nursing 327 exam 1

A postoperative client is being discharged home after a minor surgery. The PACU nurse is reviewing discharge instructions with the client and the client's spouse. What actions by the nurse are appropriate? Select all that apply.

- Educate on limitations - Wound care - Spouse on when to call the doctor - Health promotion

The nurse is caring for a female client who has been diagnosed with neisseria gonorrhoeae. The nurse is aware that if this client had not received treatment, what other serious issues could have resulted from this disease? Select all that apply

- Increased chance of HIV - Infection and scarring of the fallopian tubes - Infection of infants eyes

A postanesthesia care unit nurse is caring for a client with the following assessment data pale, cool, moist skin, thready pulse of 122, blood pressure 78/60, urine output of 25 mg/h, temperature 99.2 F. what interventions by the nurse are appropriate? Select all that apply

- Maintain the airway - Monitor neurologic - Administer oxygen - Administer blood products

The client has suffered an injury to his right leg and is reporting pain at the level of "5" on a scale of 0 to 10. The client has a history of peripheral arterial disease. The client requests nonpharmacologic interventions. The nurse does all of the following

- Massage the clients back -Teach slow rhythmic breathing -Turn tv on to distract patient

A nurse would implement droplet precautions for a client with which condition? Select all that apply

- Pertussis - Mumps - Bv19

The nurse determines that a patient is at risk for the development of thrombophlebitis. What interventions can the nurse provide to prevent this? Select all that apply

-Assist Pt. with exercises -Encourage ambulation -Avoiding placement of rolls under the knees

Why should the nurse be vigilant with assessment of perioperative risks on the older adult client? Select all that apply

-Ciliary action decreases -Fatty tissue increases -Liver size decreases

A nurse caring for a patient who is receiving an IV solution via a central vein suspects the complication of an air embolism. Which of the following are signs and symptoms consistent with the diagnosis? Select all that apply

-Cyanosis -Shoulder pain -Dyspnea -Tachycardia

The nurse is reviewing a preoperative informed consent when preparing the client for surgery. Which contents of the informed consent are required? Select all that apply.

-Explain the surgery , -How long it will take , -Risks involved -Benefits -Description of alternatives

The nurse is assessing a client for local complications of intravenous therapy. Which are local complications? Select all the apply.

-Extravasation -Hematoma -Phlebitis

The nurse is reviewing lab work on a newly admitted client. Which of the following diagnostic studies confirm the nursing diagnosis of deficient fluid volume? Select all the apply

-Hematocrit -Electrolyte imbalance

A patient is complaining of a headache after receiving spinal anesthesia. What does the nurse understand may be the cause of the headache related to the spinal anesthesia?

-Leakage of spinal fluid -Size of the needle -Degree of hydration

The nurse suspects the client is developing postoperative pneumonia. Which clinical manifestation would support the nurse's conclusion? Select all that apply.

-Tachypnea -Chills -Crackles in the lungs

The nurse is providing preoperative care to a client who is anxious about total hip replacement surgery. "What if i can never walk again? I don't want to end up like my father!" what are some ways the nurse might help alleviate the client's anxiety? Select all that apply.

-Understand what will happen -Listen empathetically -Review the client's postoperative goals -Ask if they want to see a clergy person

A client with legionnaires disease is prescribed azithromycin, 500 mg on the first day and then 250 mg on days 2 through 5. After completing the therapy, how many grams of the drug has the client received?

1.5 grams

A 75 year old client had surgery for a hip fracture yesterday. The client is under stress because of the pain, the medications, sleep deprivation, and hospital surroundings. Which nursing intervention to treat the client's pain should the nurse question when ordered by the doctor?

Advil

A client has just returned from the postanesthesia care unit following left tibia open reduction internal fixation. The client is reporting pain, and the nurse is preparing to administer the client's first scheduled dose of hydromorphone. Prior to administering the drug, you would prioritize what assessment?

Allergy status

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

Ambulate client as soon as possible

The client takes naproxen for arthritic pain and is now prescribed warfarin for persistent atrial fibrillation. Due to the interactions of the medications, what is the nurse's best response?

Asses the client for color of stool

The client is prescribed 2 mg of intravenous morphine every 2 hours as needed for pain. The nurse administers the medication. Thirty minutes later, the client reports the pain level remains at a "6" on a pain intensity scale of 0 to 10. The nurse first...

Assess the client's mental status and vital signs

The client, newly admitted to the hospital, is unsure of home medication and is wearing a transdermal fentanyl patch. What is the priority intervention the nurse will take?

Check patch from home for date and time

The health care provider ordered an IV solution for a dehydrated patient with a head injury. Select the IV solution that the nurse knows would be contradicted.

DW 5%

A medical student scheduled to observe surgery enters the unrestricted surgical zone wearing jeans, a tshirt, and tennis shoes. What is the best action by the nurse?

Educate the medical student on the required PPE for each zone

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 client? Select all that apply.

Establish IV, Verify site with patient, Ensure comfort

The nurse is preparing an elderly client 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 client?

Hypothermia

When caring for a client who has risk factors for fluid and electrolyte imbalances, which assessment findings is the highest priority for the nurse to follow up?

Irregular heart rate

The intraoperative nurse is transferring a client from the OR to the PACU after replacement of the right knee. The client is an 83 year old woman. The nurse should prioritize which of the following actions?

Keeping the client warm

A clinic nurse is caring for a male client diagnosed with gonorrhea who has been prescribed ceftriaxone and doxycycline. The client asks why he is receiving two antibiotics. What is the nurse's best response?

Many people have gonorrhea are infected with chlamydia as well

A client in the emergency department is diagnosed with a communicable disease. When complications of the disease are discovered, the client is admitted to the hospital and placed in respiratory isolation. Which infection warrants airborne isolation?

Measles

The nurse is caring for a client admitted to the medical unit 72 hours ago with pyloric stenosis. A nasogastric tube placed upon admission has been on low intermittent suction ever since. Upon review of the morning's blood work, the nurse notices that the client's potassium is below the reference range. The nurse should assess for signs and symptoms of what imbalance?

Metabolic alkalosis

During the preoperative assessment, the client mentions allergies to avocados, bananas, and hydrocodone. What is the priority action by the nurse?

Notify surgery about latex base allergy

A client is administered succinylcholine and propofol for induction of anesthesia. One hour after administration, the client demonstrates muscle rigidity with a heart rate of 180. What should the nurse do first?

Notify the surgical team

The nurse has just received report on a client who is coming to the unit from the emergency department with a torn meniscus. The nurse reviews the PRN medications and sees that an NSAID (ibuprofen) is prescribed every 6 hours. HOw should the nurse best implement preventive pain measures?

Offer the medication every 6 hours until discharge

The nurse is giving an analgesic to an older adult patient. Why is it important for the nurse to assess the patient carefully?

Older clients are more sensitive to drugs

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

Pulmonary embolism

An obese client is scheduled for open abdominal surgery. What priority education should the nurse provide to this client?

Prevention of respiratory complication

The nurse is providing preoperative teaching to a client scheduled for surgery. The nurse is instructing the client the use of deep breathing, coughing, and the use of incentive spirometry when the client states, "I don't know why you're focusing on my breathing, My surgery is on my hip, not my chest." what rationale for these instructions should the nurse apply?

Promote optimal lung expansion

The nurse is caring for a patient who experienced trauma in a workplace accident. The patient is complaining of having trouble breathing. ABG reveals the following results pH 7.28, PaCO2 50 mmhg. HCO325 mEq/l. The nurse should recognize the likelihood of what acid base disorder?

Respiratory acidosis

An elderly client with significant dementia is brought to emergency care triage stating that she believes people are invading her bedroom several times a night trying to take her purse. The caregiver is concerned about a stroke because the client complains of a constant tingling in her lips and fingertips. The client has the following arterial blood gas (ABG) values pH7.55, ; partial pressure of arterial oxygen (PaO2) 27 mmhg, and bicarbonate (HCO3) 24 meq/l. Based on these values, the nurse suspects:

Respiratory alkaloids

What action during a surgical procedure requires immediate intervention by the circulating nurse?

Scrub nurse calling the blood bank to obtain blood products

After attending a conference at a hotel for several days, a patient is having symptoms suspected of being elated to legionnaires disease. When making a bed assignment for this patient, how should the assignment be made?

Semi Private

When a hospitalized client is in contact precautions, what action is necessary?

Should be placed in a private room if possible

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

Tachycardia

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

The client shouldnt drive home

The nurse is doing preoperative client education with a 61 year old male client who has a 40 pack year history of cigarette smoking. The client 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 client?

The patient should be smoke free for at least a month preop

A client with chronic renal failure has a serum potassium level of 6.8 meq/l. What should the nurse assess first?

The patient's pulse

The nurse is caring for an unconscious trauma victim who needs emergency surgery. The client 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 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 fiance. Who should be asked to sign surgery consent form?

The son

A newly graduated nurse is admitting a client with a long history of emphysema. The nurse learns that the client's PaCO2 has been between 56 and 64 mmhg for several months. What should the nurse be cautious administering oxygen?

Using O2 may result in the client developing CO2 necrosis and hypoxemia