PrepU NCLEX - Perioperative Patient

A client comes to the emergency department complaining of severe pain in the right flank, nausea, and vomiting. The physician tentatively diagnoses right ureterolithiasis (renal calculi). When planning this client's care, the nurse should assign the highest priority to which nursing diagnosis?

Acute pain Rationale: Ureterolithiasis typically causes such acute, severe pain that the client can't rest and becomes increasingly anxious. Therefore, the nursing diagnosis of Acute pain takes highest priority. Diagnoses of Risk for infection and Impaired urinary elimination are appropriate when the client's pain is controlled. A diagnosis of Imbalanced nutrition: Less than body requirements isn't pertinent at this time

The nurse is assessing a client's nutritional status before surgery. Which of the following observations would indicate poor nutrition in a 5-foot 7-inch (170.2 cm) female client who is 21 years of age?

Brittle nails.

A nurse is assessing a client with nephrotic syndrome. The nurse should assess the client for which condition?

Massive proteinuria rationale: Nephrotic syndrome is characterized by massive proteinuria caused by increased glomerular membrane permeability. Other symptoms include peripheral edema, hyperlipidemia, and hypoalbuminemia. Because of the edema, clients retain fluid and may gain weight. Hematuria is not a symptom related to nephrotic syndrome.

For which of the following clients is the nursing assessment of pain most likely to result in undertreatment?

Older adult who grimaces and states there is no pain after a gastrostomy tube placement

A 23-year-old nulliparous client visiting the clinic for a routine examination tells the nurse that she desires to use the basal body temperature method for family planning. What instructions should the nurse give the client?

Take her temperature at the same time every morning before getting out of bed.

A nurse determines that a client has 20/40 vision. Which statement about this client's vision is true?

The client can read from a distance of 20′ (6 m) what a person with normal vision can read at a distance of 40′.

Through the prevention of postoperative complications, the nurse promotes rapid convalescence. Which of the following would be most indicative of a potential postoperative complication in a client that requires further observation?

Urinary output of 20 mL/hr over 2 hours Rationale: Urine output is maintained at a minimum of 30 mL/hr in adults. Less than this for 2 consecutive hours should be reported to the physician. A low-grade fever is expected in healing and is the natural inflammatory response to surgery. Moderate drainage can be observed, and the blood pressure is still within normal parameters.

When assessing for oxygenation in a client with dark skin, the nurse should examine the client's:

buccal mucosa Rationale: The nurse should examine the buccal mucosa, along with the conjunctiva and sclera, nailbeds, palms, soles, lips, and tongue to assess for oxygenation in a client with dark skin.

To assess the effectiveness of cardiac compressions during adult cardiopulmonary resuscitation (CPR), a nurse should palpate which pulse site?

carotid artery Rationale: During CPR, the carotid artery pulse is the most accessible and may persist when the peripheral pulses (radial and brachial) are no longer palpable because of decreases in cardiac output and peripheral perfusion. Chest compressions performed during CPR preclude accurate assessment of the apical pulse.

In a care conference, the social worker is asking if a psychosocial assessment has been completed. Which areas would the nurse report on as part of this assessment?

health habits, family relationships, affect, and thought patterns

A nurse can auscultate for heart sounds more easily if the client is:

leaning forward.

Which of the following findings in a client who recently underwent a total hip replacement would require a nurse to take immediate action?

red painful area on the calf of the affected leg Rationale:Deep vein thrombosis is a complication of total joint replacement and manifestations include a red tender calf. Ecchymosis around the incision site is a normal finding. The client's diaphoresis, fluid volume deficit, and edema in the nonaffected leg should be further assessed; however, the priority is the red tender calf

A client has the following arterial blood gas results: pH 7.32; PaCO2 50; HCO3 23; SaO2 80%. The nurse would interpret the arterial blood gases to be which of the following?

resp acid

Which finding is considered normal in the neonate during the first few days after birth?

weight loss then return to birth weight rationale: Neonates lose approximately 10% of their birth weight during the first 3 or 4 days, because of loss of excess extracellular fluids and meconium and limited oral intake, until breast-feeding is established. Return to birth weight should occur within 10 days after birth. Normal birth weights range from 6 to 9 lb (2,700 to 4,000 g).

Which statement regarding heart sounds is correct?

S1 is loudest at the apex, and S2 is loudest at the base Rationale: The S1 sound — the "lub" sound — is loudest at the apex of the heart. It sounds longer, lower, and louder there than the S2. The S2 — the "dub" sound — is loudest at the base. It sounds shorter, sharper, higher, and louder there than the S1.

Which of the following is a priority nursing assessment of a reddened heel in a bed-ridden client?

Test for blanching to the affected area.

An adult male client has been unable to void for the past 12 hours. The best method for the nurse to use when assessing for bladder distention in a male client is to check for:

a rounded swelling above the pubis The best way to assess for a distended bladder in either a male or female client is to check for a rounded swelling above the pubis. This swelling represents the distended bladder rising above the pubis into the abdominal cavity. Dullness does not indicate a distended bladder. The client might experience tenderness or pressure above the symphysis. No urine discharge is expected; the urine flow is blocked by the enlarged prostate

A client is transferred to the acute stroke unit. The nurse initiates a neurologic flow sheet to provide ongoing data about the recovery phase of care and is aware this information indicates which of the following regarding a client's clinical status?

changes in level of consciousness or responsiveness as evidence by movement and orientation to time, place and person Rationale: This is the correct choice, as it offers specific measurable data about the client. The other choices are not complete neurologic assessments.

When assessing an older adult, the nurse finds the apical impulse below the fifth intercostal space. The nurse should further assess the client for:

left ventricular enlargement

A client is on complete bed rest. The nurse should assess the client for risk for developing which of the following complications?

thrombophlebitis

The nurse is receiving over the telephone a laboratory results report of a neonate's blood glucose level. The nurse should:

write down the results, read back the results to the caller from the laboratory, and receive confirmation from the caller that the nurse understands the results.

Upon hearing a blood pressure reading of 146/96 mm Hg, a 58-year-old client asks whether medication will be necessary. Which of the following would be the best response by the nurse?

"A single elevated blood pressure does not confirm hypertension. You will need to have your blood pressure reassessed several times before a diagnosis can be made."

A nurse is helping to plan a teaching session for a client who will be discharged with a colostomy. Which statement describes a healthy stoma?

"At first, the stoma may bleed slightly when touched." explanation: The surgical site remains fresh for up to 1 week after a colostomy and touching the stoma normally causes slight bleeding. However, profuse bleeding should be reported immediately. A dark stoma with a bluish hue indicates impaired circulation; a normal stoma should appear red, similar to the buccal mucosa. Swelling should decrease in 6 weeks, leaving a stoma that protrudes slightly from the abdomen; continued swelling suggests a blockage. A burning sensation under the faceplate is abnormal and indicates skin breakdown.

The nurse is obtaining a blood sample for a PTT test ordered for a client who is taking heparin. It is 5 AM. When drawing the blood, the nurse should do which of the following? Select all that apply.

Awake the client/ Ask the client to state their name/ Check the armband for client id number and compare with order/ Labelthe sample vialin front of the client. rationale: When obtaining blood samples, the nurse must use 2 acceptable sources of identification (the client states his/her name; the nurse verifies the client's name and identification number of the armband); verifying a room number is not acceptable as client's can be easily reassigned to other rooms. The client must be awake to state his/her name. Blood samples must be labeled in front of the client.

What would be important environmental assessments for the home care nurse to explore with a client who is being discharged home?

Checking access to the home with a walker, access and safety measures in the bathroom, and access to food preparation in the kitchen, and ensuring safety in the sleeping environment rationale: Safety and access in the client's home are important to assess before discharge to ensure that the client can manage at home

The nurse is removing the client's staples from an abdominal incision when the client sneezes and the incision splits open, exposing the intestines. Which of the following actions should the nurse take next?

Cover the abdominal organs with sterile dressings moistened with sterile normal saline.

A nurse notes that a client's I.V. insertion site is red, swollen, and warm to the touch. Which action should the nurse take first?

Discontinue the I.V. infusion Rationale: Because redness, swelling, and warmth at an I.V. site are signs of infection, the nurse should discontinue the infusion immediately and restart it at another site. After doing this, the nurse should apply warmth to the original site. Checking infusion patency isn't warranted because assessment findings suggest infection and inflammation, not infiltration. Heat, not cold, is the appropriate treatment for inflammation.

A client with myasthenia gravis is receiving continuous mechanical ventilation. When the high-pressure alarm on the ventilator sounds, what should the nurse do?

Suction the client's artificial airway. rationale: A high-pressure alarm on a continuous mechanical ventilator indicates an obstruction in the flow of oxygen from the machine to the client. The nurse should suction the client's artificial airway to remove respiratory secretions that could be causing the obstruction. The sounding of a ventilator alarm has no relationship to the apical pulse. Increasing the oxygen percentage and ventilating with a handheld mechanical ventilator wouldn't correct the airflow blockage.

The nurse is conducting a health history of a child. The mother states that the client continually has a cold all winter with a runny nose, is not doing well in school, and is itching all the time. The nurse suspects the child has which of the following?

allergies rationale: In children, many symptoms of allergies are often vague and general. They revolve around frequent cold-like symptoms, allergic rhinitis, and pruritus. These symptoms are distracting to children and can affect their ability to concentrate in school. The "itching all the time" descriptor lends itself to allergies and histamine release rather than sinusitis, ringworm, and fifth disease.

The nurse caring for a client admitted with a deep vein thrombosis is reviewing the client's prepackaged medications delivered by the pharmacy. The nurse suspects a pharmacy omission when medication from which of the following classifications is missing?

anticoagulant rationale: The nurse should anticipate the use of an anticoagulant for this medical condition. The other options would be used for other conditions such as an infection, hypertension, or an elevated cholesterol level. The client may receive these medications, but the classification related to deep vein thrombosis is the anticoagulant.

The client with bipolar disorder, manic phase, appears at the nurse's station wearing a transparent shirt, miniskirt, high heels, 10 bracelets, and eight necklaces. Her makeup is overdone and she is not wearing underwear. The nurse should

escort the client to her room and assist with choosing appropriate attire rationale: The nurse escorts the client to her room and assists with choosing appropriate attire to preserve the client's dignity and self-esteem and prevent ridicule from others on the unit. It is common for a client with bipolar disorder, manic phase, to exhibit poor judgment, provocative behavior, and hyperactivity. The client in the manic phase commonly dresses inappropriately and changes clothes many times throughout the day. The nurse needs to assist the client with hygiene, grooming, and proper attire until her judgment improves. Telling the client to dress appropriately while out of her room may be perceived by the client as an attack. Additionally, the client may be incapable of making that decision. Asking the client to put on hospital pajamas until she can dress appropriately is punitive and demeaning. Because of the client's cognitive difficulties, the client may not understand the instructions to go to her room to change clothes. Additionally, the client may become distracted by stimuli on the unit and may not reach her room.

The nurse is assessing a client's activity tolerance. Which report from a treadmill test indicates an abnormal response?

respiratory rate decreased by 5 breaths/minute rationale: The normal physiologic response to activity is an increased metabolic rate over the resting basal rate. The decrease in respiratory rate indicates that the client is not strong enough to complete the mechanical cycle of respiration needed for gas exchange. The postactivity pulse is expected to increase immediately after activity but by no more than 50 bpm if it is strenuous activity. The diastolic blood pressure is expected to rise but by no more than 15 mm Hg. The pulse returns to within 6 bpm of the resting pulse after 3 minutes of rest.

The ear canal of an infant or young child:

slants upward Rationale: The ear canal slants up in a younger child and down in an older child or adult.

When assessing a dark-skinned client for cyanosis, the nurse should examine which of the following?

the client's oral mucous membranes

When a client of Mexican descent tells the nurse that she treated her infection by drinking milk, the nurse interprets the client's remark as:

use of the hot disease concept explanation: The nurse interprets the client's statement as use of the hot disease concept in the Mexican culture, where the belief of a hot and cold balance of the body exists. A hot disease such as an infection is treated with the opposite, a cold food such as milk. The nurse should focus on the cultural differences and be sensitive to the cultural diversity.

When giving a client a tube feeding the nurse should:

verify position of the tube before beginning the feeding rationale: The position of the tube should be verified before the feeding is implemented. Warming the solution is not necessary or desirable because it can encourage bacterial growth. The client should be lying down with the head elevated or sitting upright during administration of the feeding. Gastric residual should be aspirated and then reinstilled to prevent electrolyte losses.

The nurse is receiving over the telephone a laboratory results report of a neonate's blood glucose level. The nurse should:

write down the results, read back the results to the caller from the laboratory, and receive confirmation from the caller that the nurse understands the results. Rationale: To ensure client safety, the nurse should first write the results on the medical record, then read them back to the caller and wait for the caller to confirm that the nurse has understood the results. Using scrap paper increases the risk of losing the results as well as transcription errors. The nurse may receive results by telephone, and while electronic transfer to the client's medical record is appropriate, the nurse can also accept the telephone results if the laboratory has called the results to the nursery. Sending client information via e-mail is unacceptable due to potential security and privacy issues

Question: A client with a gastrointestinal bleed has vomited 600 mL of frank red blood and is now pale and diaphoretic. Vital signs are BP 88/50 mm Hg, HR 120 bpm, RR 24 breaths/min. What are the priority nursing interventions for this client? Place in order of priority. Use all options.

Position the client on the left side. Initiate two large-bore intravenous lines. Notify the physician. Reassess vital signs and oxygen saturation. Prepare the client for the operating room. Explanation: The client would immediately be placed on his/her side to avoid aspiration of bloody vomitus. Next, IVs would need to be inserted as the BP has decreased and the client is in danger of hypovolemic shock. The physician would be notified, followed by reassessment of vital signs and preparing the client for surgery.

A nurse is assessing a client's pulse and notices a weak and thready pulse in both lower extremities. How should the nurse document this finding?

Pulse amplitude +1 bilateral lower extremities

A nurse prepares to auscultate a client's carotid arteries for bruits. For this procedure, the nurse should:

use the bell of the steth Rationale : with the client holding his breath, the nurse uses the bell of the steth to auscultate the carotid arteries for bruits. Having the client inhale would interfere with the nurses's ability to detect sound. Palpating the radial artery wouldn't yield significant info and could interfere w/the nurse's ability to listen w/o interruptions or distractions. Palpating both carotid arteries simultaneously would stop blood flow to the brain

A graduate nurse is asked to present a case study, during interdisciplinary rounds, on a client who has compartment syndrome from a leg injury. What would be the best approach by the graduate nurse to ensure a good comfort level with the topic? Select all that apply.

• Research the condition and present what was learned. • Review the client's chart to obtain assessment findings and treatment. Explanation: This is an opportunity for new learning about a complication that pertains to the client and an important safety consideration when assessing and performing care measures. Presenting this case would also provide a professional growth opportunity. As a new professional on a unit, it is important to go beyond one's normal comfort zone. Attending rounds will be a learning experience, but not a challenging growth experience, as will deferring to a more experienced nurse. Approaching the nurse manager provides excuses rather than confronting the insecurity and facing these insecurities.