Saunders Nclex-PN - Elimination, NCLEX Pre OP Care

A client receiving iron supplements is complaining of constipation and the stool that is passed is black. Which information is appropriate for the nurse to share with the client? *Select all that apply.* 1.Increase your fluid intake. 2.Include more fiber in your diet. 3.Ferrous sulfate changes the color of stool to black. 4.Iron slows colonic acid and often leads to constipation. 5.Use an enema every other day if you don't have a bowel movement. 6.Signs of constipation include not having a bowel movement every day.

(1,2,3 & 4) Rationale: As motility slows, feces are exposed to the intestinal walls and water is absorbed. Increasing fluid intake will help by adding more fluid to the intestinal contents. Fiber increases motility. Iron and several other medications slow motility. Lack of exercise or bed rest contributes to constipation. An enema should not be used every other day, usually no more frequently than on the third day. Many people do not have bowel movements every day. Constipation is not having a bowel movement in 3 days.

A client has been diagnosed with functional incontinence. Which interventions are *most appropriate* to care for this type of incontinence? *Select all that apply.* 1.Schedule toileting every 2 hours. 2.Modify clothing for easy removal. 3.Assess environment for obstacles. 4.Decrease fluid intake to 1500 mL/day. 5.Obtain prescription for catheterization to eliminate embarrassment. 6.Set up schedule of cues such as mealtimes, awakening, and bedtime.

(1,2,3 & 6) Rationale: Functional incontinence is loss of urine by factors outside the urinary tract that interfere with the ability to respond in a socially appropriate way to the urge to void. It may be an inability or unwillingness of a person with normal bladder function to get to the bathroom in time, environmental barriers (e.g., raised side rails), physical limitations (e.g., can't walk self to bathroom), or mental factors (e.g., disorientation). Interventions include such things as clothing modifications, environmental alterations, scheduled toileting, and absorbent products. Therefore, option 2 is correct because modifying clothing to use Velcro or easy fasteners can save time in reacting to urge. Option 1 is correct because toileting every 2 hours will prevent overfilling of the bladder. Option 3 is correct because environmental obstacles such as poor lighting or lack of assistive devices can make it difficult to reach the toilet in a timely manner. Option 6 is correct because establishing a schedule will provide reminders to use the toilet. Option 4 is incorrect because decreasing fluid intake to below 2000 mL will irritate the bladder and may contribute to incontinence and may increase risk of infection. Option 5, catheterization, is incorrect because it contributes to risk of infection.

The nurse is preparing to administer an enema to an adult client. Which interventions should the nurse plan to perform for this procedure? *Select all that apply.* 1.Apply disposable gloves. 2.Place the client in the right Sims' position. 3.Lubricate the enema tube and insert it approximately 4 inches. 4.Clamp the tubing if the client expresses discomfort during the procedure. 5.Hang the enema solution container 24 inches above the client's anus. 6.Ensure that the temperature of the solution is between 100° F (37.8° C) and 105° F (40.5° C).

(1,3,4 & 6) Rationale: The administration of an enema is a clean procedure, and standard precautions must be used. The nurse applies disposable gloves when administering an enema to prevent the transfer of microorganisms. To administer an enema, the nurse places the client in the left Sims' position because the enema solution will flow downward by gravity along the natural curve of the sigmoid colon and rectum, improving retention of the enema solution. The tube is lubricated for easy insertion and is inserted approximately 3 to 4 inches in an adult. If the client complains of cramping or discomfort during the procedure, the nurse clamps the tubing until the discomfort subsides. The container containing the enema solution is hung about 12 to 18 inches above the client's anus. A flow of solution that is too forceful can damage the bowel. The temperature of the solution should be between 100° F (37.8° C) and 105° F (40.5° C). Solution that is too hot will burn the client, and solution that is too cool will cause cramping.

A client is to be monitored for residual urine every 8 hours. Which are appropriate nursing actions for the nurse to complete this task? *Select all that apply.* 1.Obtain the bladder scan before the client voids. 2.Have the client void and then perform the bladder scan. 3.If residual urine is less than 100 mL, continue to monitor. 4.Reduce oral fluid intake to decrease amount of residual urine. 5.Straight catheterize the client if 100 mL of urine is viewed on the scan. 6.Notify the primary health care provider immediately if 30 mL of urine is viewed on the scan.

(2 & 3) Rationale: To obtain a residual urine, it is necessary for the client to void, then obtain a bladder scan. If less than 100 mL of urine (or the specific amount prescribed) is viewed on the scan, continuing to monitor as prescribed is appropriate. Obtaining the scan before voiding would tell the nurse how much fluid the bladder can hold. Decreasing fluids may lead to dehydration and will not affect residual urine. Notifying the primary health care provider of normal findings is inappropriate, as is catheterizing for 100 mL of residual urine.

The nurse evaluates that there is a need for further teaching on bowel elimination when the client makes which statement? 1."I walk 1 to 2 miles per day." 2."I need to decrease fiber in my diet." 3."I drink 6 to 8 glasses of water per day." 4."I have a bowel movement every other day."

(2) Rationale: Adequate dietary fiber is an important factor for improving bowel function. Dietary fiber increases fecal weight and water content and accelerates the transit of the fecal mass through the gastrointestinal (GI) tract. The retention of water by the fiber has the ability to soften stools and promote regularity. Fluid intake and exercise also facilitate bowel elimination.

The nurse should recognize that which type of enema has the highest risk of water intoxication? 1. Soapsuds 2. Tap water 3. Normal saline 4. Hypertonic solution

(2) Rationale: Tap water is hypotonic, creating a lower osmotic pressure than the fluid in interstitial spaces. With repeated tap water enemas, fluid can escape from the bowel lumen into interstitial spaces and can cause circulatory overload or water intoxication if the body absorbs too much water. Normal saline enemas are the safest type of enema because of having the same osmotic pressure as fluid in the interstitial spaces around the bowel. Thus, enemas using normal saline do not cause any fluid shifts but may not be effective in evacuating the bowel. Castile soap is incorrect because it can be mixed with either water or saline, and if mixed with saline, there should not be any risk of fluid overload. Castile soap is the only safe soap to use for a soapsuds enema because harsh soaps may cause inflammation of the bowel. Hypertonic solution is incorrect because hypertonic fluids pull fluid from the interstitial spaces into the colon. Although this could have the potential for dehydration, it does not pose as high of a risk of complications as the tap water enema. A Fleets enema (commercially prepared sodium phosphate) is the most common type of hypertonic enema.

A preoperative client expresses anxiety to the nurse about the upcoming surgery. Which response by the nurse is most likely to stimulate further discussion between the client and the nurse?

"Can you share with me what you've been told about your surgery?"

A client with arthritis is scheduled for a surgical knee joint replacement. The client will be admitted to the hospital on the day of the surgical procedure, and the nurse is reinforcing instructions to the client regarding preparation for the surgical procedure. Which statement by the client indicates an understanding of the preoperative instructions?

"I cannot drink or eat anything after midnight on the night before surgery."

A client who currently underwent abdominal surgery experiences an evisceration. Which statement made by the client supports this diagnosis?

"It felt like something just slit me wide open."

A preoperative client expresses anxiety to the nurse about the upcoming surgery. Which response by the nurse is most likely to stimulate further discussion between the client and the nurse? "If it's any help, everyone is nervous before surgery." "I will be happy to explain the entire surgical procedure to you." "Can you share with me what you've been told about your surgery?" "Let me tell you about the care you'll receive after surgery and the amount of pain you can anticipate."

"Let me tell you about the care you'll receive after surgery and the amount of pain you can anticipate."

A client had an aortic valve replacement 2 days ago. This morning, the client tells the nurse, "I don't feel any better than I did before surgery." Which response by the nurse is most appropriate?

"You are concerned that you don't feel any better after surgery?"

The client has a three-way closed continuous bladder irrigation system. Which information should be included in the documentation for this client? *Select all that apply.* 1.Character of drainage 2.Presence of blood clots 3. Amount of drainage emptied 4.Client complaint of pain/spasms 5. Type and amount of irrigation fluid used 6. Frequency of emptying the drainage bag

(1,2,3,4 & 5) Rationale: Options 1, 2, 3, 4, and 5 are all correct because they all are indications of the effectiveness of the bladder irrigation. Character of drainage describes details such as color and sediment and is a means of evaluating effectiveness of irrigation. Presence and size description of blood clots, complaints of spasms, type and quantity of solution infused, and amount of solution returned all provide information as to effectiveness of procedure and client status. Option 6 is incorrect because it is not necessary to document how frequently the drainage bag was emptied, but the amount of irrigation fluid that went in and the total amount of drainage emptied should be documented so that the actual urine output can be calculated by subtracting the input from the output.

The nurse is monitoring an adult client for postoperative complications. Which is most indicative of a potential postoperative complication that requires further observation?

A urinary output of 20 mL/hour

The skin surrounding a postoperative client's abdominal wound is becoming irritated in the area where the dressing tape is being reapplied with each dressing change. Which is the appropriate nursing action?

Apply Montgomery ties.

When performing a surgical dressing change of a client's abdominal dressing, the nurse notes an increase in the amount of drainage and separation of the incision line. The underlying tissue is visible to the nurse. The nurse should plan to do which action in the initial care of this wound?

Apply a sterile dressing soaked with normal saline.

The nurse is changing the abdominal dressing on a client following abdominal surgery. The nurse notes that the incision line is separated and the appearance of underlying tissue is noted. Wound dehiscence is suspected. Which is the appropriate initial nursing action?

Apply a sterile dressing soaked with sterile normal saline to the wound.

The nurse is taking care of a client preoperatively. The client is NPO and tells the nurse that he takes detemir insulin (Levemir) and aspart insulin (NovoLog) at 0700 daily. The client's surgery is scheduled for 0900. Which is the best action for the nurse to take?

Call the health care provider for clarification.

A client's preoperative vital signs are temperature 98.6° F orally, apical pulse 80 beats per minute with a regular rhythm, respiration rate 22 breaths per minute, and blood pressure 168/94 mm Hg in the right arm. Based on the interpretation of these findings, which action should the nurse take first?

Compare these values to those recorded previously.

The nurse is assisting in providing surgical instructions to a preoperative client. Which instruction would be most appropriate to include in the preoperative plan of care?

Coughing and deep breathing exercises

A client is admitted to the surgical unit postoperatively with a wound drain in place. Which nursing action should the nurse avoid in the care of the drain?

Curl the drain tightly and tape it firmly to the body.

The nurse is collecting data from a client who is scheduled for surgery in 1 week in the ambulatory care surgical center. The nurse notes that the client has a history of arthritis and has been taking acetylsalicylic acid (aspirin). The nurse reports the information to the health care provider and anticipates that the provider will prescribe which?

Discontinue the aspirin 48 hours before the scheduled surgery.

The nurse is reinforcing instructions to a client and family regarding home care following cataract removal from the left eye. The nurse should provide the client with which instruction regarding positioning in the postoperative period?

Do not sleep on the left side.

The nurse is preparing the client for transfer to the operating room (OR). The nurse should take which action in the care of this client at this time? Ensure that the client has voided. Administer all the daily medications. Practice postoperative breathing exercises. Verify the time that the client last ate or drank. Assist the client by contacting family members the client wants notified.

Ensure that the client has voided. Verify the time that the client last ate or drank. Assist the client by contacting family members the client wants notified.

The nurse monitors a postoperative client for signs of complications. Which signs/symptoms should the nurse determine to be indicative of a potential complication?

Increasing restlessness

When positioning for a surgical procedure, the nurse understands that the client's respiratory system is most at risk for dysfunction when in which position?

Lithotomy

The nurse is getting a postoperative client out of bed for the first time since surgery. The nurse raises the head of the bed, and the client complains of dizziness. Which action should the nurse take first?

Lower the head of the bed slowly until the dizziness is relieved.

During a surgical procedure, the nurse prevents a client's extremities from dangling over the sides of the table, knowing that this action may cause what?

Nerve and muscle damage

The student nurse is changing an abdominal dressing on a client with an open incision and notes the presence of sanguineous drainage. Which nursing action would be appropriate?

Notify the registered nurse.

The nurse is caring for a postoperative client who is being monitored by pulse oximetry. Which is an expected measurement determined by the pulse oximeter?

Oxygen saturation 95% to 100%

The nurse is caring for a client following a total abdominal hysterectomy. The nurse anticipates that which postoperative outcome will be the priority in the first 24 hours following surgery?

Pain

The nurse monitors the postoperative client frequently, knowing that accumulated secretions can lead to which problem?

Pneumonia

The nurse is caring for a postoperative client who had a pelvic exenteration. The health care provider has changed the client's diet from nothing by mouth (NPO) to clear liquids. The nurse checks which before administering the clear liquids? Incision appearance Pain rating of 3 or less Presence of bowel sounds Urinary output of 30 mL per hour Whether the client has passed flatus

Presence of bowel sounds Urinary output of 30 mL per hour Whether the client has passed flatus

The nurse is assigned to assist in caring for a client who recently returned from the operating room. On data collection, the nurse notes that the client's vital signs are as follows: blood pressure (BP) 102/62 mm Hg, pulse 91 beats per minute, respirations 16 breaths per minute. Preoperative vital signs were BP 124/78 mm Hg, pulse 74 beats per minute, respirations 20 breaths per minute. Which action should the nurse plan to take first?

Recheck the vital signs in 15 minutes.

A client has returned to the nursing unit following abdominal hysterectomy. To most effectively gather data on the client's postoperative bleeding, the nurse would implement which intervention?

Rolling the client to one side to view bedding

The nurse reinforces preoperative teaching to a client who will wear an abdominal binder postoperatively following abdominal surgery. Which instruction should the nurse reinforce in the preoperative teaching plan? Sit up for coughing while splinting the incision. Remove the binder before assisting the client to ambulate. Remove the binder only when the primary health care provider is present. Apply the binder over the abdominal dressing as tight as possible. Remove the binder to change the abdominal dressing as prescribed and reapply.

Sit up for coughing while splinting the incision. Remove the binder to change the abdominal dressing as prescribed and reapply.

The nurse, caring for a client with a postoperative abdominal wound, observes that the dressing has Montgomery ties in place. The nurse determines this intervention will decrease the risk of which complication? Dehiscence Paralytic ileus Wound infection Skin irritation surrounding the wound

Skin irritation surrounding the wound

The nurse is caring for a postoperative client who has been NPO and the health care provider has prescribed a clear liquid diet. In planning to initiate this diet, which priority item should the nurse place at the client's bedside?

Suction equipment

Which equipment should the nurse plan to have at the bedside when initiating a clear liquid diet for a postoperative client who has had general anesthesia?

Suction equipment

Which equipment should the nurse plan to have at the bedside when initiating a clear liquid diet in a postoperative client who has had general anesthesia?

Suction equipment

A client is being advanced to a full liquid diet on the second postoperative day. Which foods are allowed for this client? Select all that apply. Tea Crackers Ice cream Scrambled eggs Cream of tomato soup Cream of wheat cereal

Tea Crackers Ice cream Cream of tomato soup Cream of wheat cereal

The nurse checks the sternotomy incision of a client on the second postoperative day after cardiac surgery. The incision shows some slight "puffiness" along the edges and is non-reddened with no apparent drainage. The client's temperature is 99° F (37.2° C) orally. The white blood cell (WBC) count is 7500 cells/mm3. Which interpretation does the nurse make of these findings?

The incision line is slightly edematous but shows no active signs of infection.

The nurse checks the client's surgical incision for signs of infection. Which is indicative of a potential infection?

The presence of purulent drainage

The nurse is reviewing the preoperative prescriptions of a client with a colon tumor who is scheduled for abdominal perineal resection. The nurse notes that the health care provider has prescribed neomycin sulfate (Mycifradin) for the client. Which is the rationale for prescribing this medication?

To decrease the bacteria in the bowel

The nurse just reassessed the condition of a postoperative client who was admitted 1 hour ago to the surgical unit. The nurse plans to carefully monitor which parameter during the next hour?

Urinary output of 20 mL/hr

The nurse is preparing a client for surgery. Which would be a component of the plan of care? Verify the preoperative laboratory studies were drawn. Report any increases in blood pressure (BP) on the day of surgery. Verify that the client has received nothing by mouth (NPO) for 24 hours before surgery. Instruct the client not to swallow water with oral hygiene on the morning of surgery. Document that any medications the client was instructed to take before surgery are given.

Verify the preoperative laboratory studies were drawn. Instruct the client not to swallow water with oral hygiene on the morning of surgery. Document that any medications the client was instructed to take before surgery are given.

A client returns from the recovery room following an abdominal surgical procedure. Following the arrival of the client to the nursing unit, Which is the initial nursing assessment?

Vital signs

The nurse is assisting in providing surgical instructions to a preoperative client who will have abdominal surgery. Which instructions would be appropriate to include in the preoperative plan of care? Select all that apply. Wound care Personal hygiene Activity restrictions Frequent assessment of vital signs Coughing and deep breathing exercises Pain monitoring and medications to relieve pain

Wound care Frequent assessment of vital signs Coughing and deep breathing exercises Pain monitoring and medications to relieve pain

The nurse is explaining the universal protocol for preventing wrong site, wrong procedure, and wrong person surgery to a group of nursing students. Which action does site marking involve?

The surgeon marking the area of the operative procedure

The nurse administers scopolamine as prescribed to a client in preparation for surgery. The nurse monitors the client for side effects related to the administration of this medication. Which should the nurse determine is an expected side effect of this medication?

Client complaints of a dry mouth

The nurse is explaining the concept of time-out in the perioperative area to a group of nursing students. What is the purpose of a time-out?

To allow the surgical team a chance to verbally verify their agreement on the client's name, surgical procedure, and site

Which types of nourishment should the nurse include when initiating a prescribed clear liquid diet for a postoperative client who has a gag reflex after surgery under general anesthesia? Select all that apply. Coffee Ice chips Beef broth Plain yogurt Tea with milk Lemon flavored gelatin

Coffee Ice chips Beef broth Lemon flavored gelatin

The nurse is reinforcing instructions to a client following mastectomy who will be discharged with an axillary drain in place. The client will be receiving home care visits from a nurse to monitor drainage and perform dressing changes. Which statement by the client indicates a need for further teaching?

"I need to begin full range-of-motion (ROM) exercises to my upper arm as soon as I get home."

Intravenous (IV) lactated Ringer's (LR) solution is prescribed for a postoperative abdominal surgery client. A nursing student is caring for the client, and the nursing instructor asks the student about why this IV solution is prescribed? Which is a correct response by the student?

"Lactated Ringer's solution is isotonic to plasma."

The nurse in the health care provider's office is measuring vital signs on a postoperative client who underwent mastectomy of her right breast 2 weeks ago. The client tells the nurse that she is very concerned because she has numbness in the area of the surgery and along the inner side of the arm from the armpit to the elbow. Which statement is appropriate for the nurse to tell the client?

"These sensations dissipate over several months and usually resolve after 1 year."

The nurse is inserting an indwelling urinary catheter into a male client. As the catheter is inserted into the urethra, urine begins to flow into the tubing. When should the nurse inflate the balloon? 1.Immediately inflate the balloon. 2.Insert the catheter 2.5 cm to 5 cm and inflate the balloon. 3.Advance the catheter to the bifurcation and inflate the balloon. 4.Insert the catheter until resistance is met and inflate the balloon.

3.Advance the catheter to the bifurcation and inflate the balloon. Rationale: Urinary catheterization is a sterile procedure. When inserting an indwelling catheter, the nurse should ensure the balloon is in the bladder before inflating it. If the balloon is inflated in the urethra of the male client, trauma may occur. When catheterizing a male client, the nurse observes the tubing for the flow of urine and then continues to advance the catheter to the point of bifurcation and then inflates the balloon. The nurse then pulls the catheter back until slight resistance is felt and applies a tube holder onto the thigh to hold the catheter in place. The balloon should not be inflated when urine is first observed, after advancing several more centimeters or when resistance is felt.

The nurse receives a client in the surgical unit who was transferred from the postanesthesia care unit. The nurse checks the client for what data first?

A patent airway

The nurse is changing the abdominal dressing on a client following a suprapubic prostatectomy. A wound drain is in place in the abdominal wound. Which nursing action would be appropriate during the dressing change?

Checking the wound site for drainage from the drain

The nurse is monitoring a postoperative client on an hourly basis. The nurse notes that the client's hourly urine output is 25 mL. Based on this finding, what should be the nurse's first action? Increase the rate of the IV fluid. Call the primary health care provider. Administer a 250-mL bolus of normal saline (0.9%). Check the client's overall intake and output record. Gather data about the urinary catheter and check for patency.

Check the client's overall intake and output record. Gather data about the urinary catheter and check for patency.

The nurse is caring for a postoperative client who has a drain inserted into the surgical wound. Which action should the nurse avoid in the care of the drain? Check the drain for patency. Check that the drain is decompressed. Observe for bright red, bloody drainage. Maintain aseptic technique when emptying. Empty the drain when it is half full and every 8 to 12 hours. Secure the drain by curling or folding it and taping it firmly to the body.

Check the drain for patency. Check that the drain is decompressed. Observe for bright red, bloody drainage. Maintain aseptic technique when emptying. Empty the drain when it is half full and every 8 to 12 hours.

Which ostomy location would most likely need to be irrigated? Refer to figure. A) Asending B) Proximal Transverse C) Distal Transverse D) Descending

D Rationale: The ostomy located at the juncture of the descending and sigmoid colon would be most likely to need irrigating because the effluent would be the most solid. Effluent in the ascending colon would be mostly liquid, and would become more solid as fluid is absorbed during passage through the transverse colon.

The nurse is caring for a client following an abdominal hysterectomy performed 1 day ago. An intravenous (IV) line is infusing and a nasogastric (NG) tube is in place and attached to low intermittent suction. The nurse monitors the client and notes that the bowel sounds are absent. The nurse should perform which action? Increase the amount of suction on the NG tube. Ask the client whether he has passed any flatus. Encourage the client to take frequent sips of water. Document the finding and continue to check for bowel sounds. Immediately notify the registered nurse or primary health care provider.

Document the finding and continue to check for bowel sounds. Ask the client whether he has passed any flatus. Immediately notify the registered nurse or primary health care provider.

The nurse has admitted a client to the clinical nursing unit following a right mastectomy. The nurse plans to place the right arm in which position? Elevate the right arm on one or two pillows. Do not check the radial pulse in the right arm. Use small-gauge needles if the IV is initiated in the left arm. Instruct the client to avoid bending the fingers of the right hand. Ensure that no venipunctures or blood pressures (BPs) are done in the right arm.

Elevated on one or two pillows Do not check the radial pulse in the right arm. Ensure that no venipunctures or blood pressures (BPs) are done in the right arm.

A client has been taking prednisone for 3 years to treat symptoms of lupus erythematosus. She is scheduled for abdominal hysterectomy because of menorrhagia. The nurse plans care realizing that postoperatively the client is at risk for which condition? Hypoglycemia Increased risk for dehiscence Excessive bleeding at the surgical incision Increased likelihood of surgical site infection Very early wound healing, causing excessive scarring

Increased likelihood of surgical site infection Increased risk for dehiscence

The nurse is monitoring the status of the postoperative client. The nurse should become most concerned with which sign(s) that could indicate an evolving complication?

Increasing restlessness Blood pressure of 104/66 mm Hg with a pulse of 106 beats per minute

The nurse is assisting in caring for a client immediately following an abdominal surgical procedure who lost a significant amount of blood during surgery. Which finding would indicate a sign of a potential complication? Absent bowel signs Increasing restlessness A pulse rate of 108 beats per minute A blood pressure (BP) of 88/58 mm Hg Increasing pain unrelieved by analgesics

Increasing restlessness A pulse rate of 108 beats per minute A blood pressure (BP) of 88/58 mm Hg Increasing pain unrelieved by analgesics

The nurse is reinforcing instructions to a client and family regarding home care following cataract removal with lens implantation in the left eye. The nurse should provide the client with instructions to contact the surgeon promptly for which signs or symptoms? Select all that apply. New floaters Improvement in vision clarity Increasing redness in the eye Sensation of mild grittiness in the eye Pain relieved by acetaminophen 500 mg

New floaters Increasing redness in the eye

A client arrives to the surgical nursing unit after surgery. What should be the initial nursing action after surgery?

Patency of the airway

The nurse is explaining the concept of a time-out in the perioperative area. Which statement best describes the purpose of a time-out?

To allow the surgical team a chance to verbally verify its agreement about the client's name, the surgical procedure, and the site

The nurse is assisting in caring for a client in transfer from the postanesthesia care unit following nasal surgery. Nasal packing and a mustache dressing are in place. The nurse places the client in which position to best reduce swelling?

Semi-Fowler's

The nurse is reinforcing instructions to a client about the use of an incentive spirometer in the postoperative period. The nurse should include which information in discussions with the client?

The best results are achieved when sitting at least halfway or fully upright.

The nurse checks the postoperative client for signs of infection. Which observations are indicative of a potential infection? Select all that apply. Slight redness along the incision The presence of purulent drainage A temperature of 98.8° F (37.1° C) The client states that he feels cold. The client states that the incision itches. Tender firmness palpable around the incision

The presence of purulent drainage Tender firmness palpable around the incision

The nurse is explaining The Joint Commission's (TJC's) universal protocol for preventing wrong-site, wrong-procedure, and wrong-person surgery to a group of nursing students. The nurse explains that site marking involves which action? The surgeon marking the area of the operative procedure The circulating nurse marking the area of the operative procedure Marking the site of the operative procedure during the "time-out" period Marking the site of the operative procedure at the completion of the procedure to measure any increase in swelling

The surgeon marking the area of the operative procedure

A client who had knee surgery 4 days ago reports to the home health nurse that he has not had a bowel movement since before the surgery. Which question would assist the nurse in the collection of data regarding the client's problem? "How often do you usually move your bowels?" "How often do you usually take a laxative?" "Have you been eating meat on a daily basis?" "What have you been eating and drinking since the surgery?" "Have you been experiencing any urge to move your bowels?" "What kind and how often have you been taking medications for pain?"

"What have you been eating and drinking since the surgery?" "Have you been experiencing any urge to move your bowels?" "What kind and how often have you been taking medications for pain?"

A client who had abdominal surgery complains of feeling as though "something gave way" in the incisional site. The nurse removes the dressing and notes the presence of a loop of bowel protruding through the incision. Which nursing interventions should the nurse take? Select all that apply. Notify the registered nurse immediately. Document the client's complaint with the exact times. Place a sterile saline dressing and ice packs over the wound. Prepare the client for wound closure by notifying surgery department. Place the client in a supine position without a pillow under the head. Instruct the client to remain quiet and reassure the situation is being taken care of.

1. Notify the registered nurse. 2. Document the client's complaint. 3. Instruct the client to remain quiet. 4. Prepare the client for wound closure. 6. Instruct the client to remain quiet and reassure the situation is being taken care of.

The primary health care provider prescribes a three-way bladder irrigation of normal saline. Over an 8-hour shift, 250 mL has infused from the normal saline. There is 1850 mL in the collection receptacle at the conclusion of the 8-hour shift. Which is the client's true urine output for the shift? *Fill in the blank.* ____ mL

250mL Rationale: 200 mL × 8 hr = 1600 mL, which is the amount of normal saline infused. 850 − 1600 = 250 (total in receptacle minus irrigation)

Which is the most appropriate catheter for a male client with severe urinary retention, a history of urinary tract infections, and a stage 4 pressure injury on the coccyx? 1 2 3 4

3 Rationale: Long-term indwelling catheters are used with severe urinary retention, recurrent urinary tract infections, and when wounds are irritated by contact with urine. Silicon is preferred because it can stay in place for 2 to 3 months. Size 14 to 16 are standard sizes, and only sterile water should be used to inflate the balloon. Saline will crystallize in the balloon. Intermittent and short-term catheterization would not solve the issue of severe urinary retention and would require repeated catheterization, increasing risk of infection. A condom catheter will not remedy urinary retention and does not have a balloon.

Which nursing action would avoid pressure on the popliteal nerve when applying the safety strap across the client's legs on the operating table?

Apply the safety strap 2 inches above the knees.

The nurse obtains the vital signs on a postoperative client who just returned to the nursing unit. The client's blood pressure (BP) is 100/60 mm Hg, the pulse is 90 beats per minute, and the respiration rate is 20 breaths per minute. On the basis of these findings, which nursing action should be performed? Ask if the client is thirsty and assist with drinking a glass of water. Ask how the client feels and inquire about any feelings of dizziness. Review the client record to determine time and type of analgesia last received. Review the client record to determine whether the client has voided postoperatively. Assist the client to perform leg exercises and then recheck the blood pressure and pulse rate. Review the client record to note the vital signs taken in the Post Anesthesia Care Unit (PACU).

Ask how the client feels and inquire about any feelings of dizziness. Review the client record to determine time and type of analgesia last received.gns. Review the client record to note the vital signs taken in the Post Anesthesia Care Unit (PACU).

The nurse is caring for a client who is scheduled for surgery. The client is concerned about the surgical procedure. Which action should alleviate the client's fears and misconceptions about surgery?

Ask the client to discuss information known about the planned surgery.

A surgeon is performing an abdominal hysterectomy. Before the surgery is completed, the operating room nurse counts the sponges and notes that the sponge count is not correlating with the preoperative count. Which action by the nurse is important?

Informing the surgeon of the situation

The nurse is collecting data from a client who is scheduled for surgery in 1 week in the ambulatory care surgical center. Which client data are pertinent and should be reported to the primary health care provider before the surgery? Select all that apply. Is allergic to penicillin Quit smoking 3 months earlier History of tonsillectomy at the age of 7 years Wonders if the surgery could cause incontinence Takes daily multivitamin and calcium supplements. History of deep venous thrombosis in right leg 10 years earlier

Is allergic to penicillin Quit smoking 3 months earlier Wonders if the surgery could cause incontinence Takes daily multivitamin and calcium supplement. History of deep venous thrombosis in right leg 10 years earlier

The nurse is admitting a client to the hospital who has been scheduled for gastrointestinal (GI) surgery. When asking the client whether the client takes over-the-counter medications, which statement should concern the nurse? "Yes, I take a full-strength aspirin every day." "Yesterday I took a daily multiple vitamin medication." "I have stopped the medications my doctor told me to stop taking." "I have taken my medication for my blood pressure this morning." "I took the bowel preparation medications as prescribed starting 2 days ago."

"Yes, I take a full-strength aspirin every day." "I have taken my medication for my blood pressure this morning."

The nurse is observing a client who is independently performing the application of an ostomy appliance for the first time. Which actions observed demonstrate the *need for further teaching? Select all that apply.* 1.Assess the stoma and skin. 2.Remove the used pouch and barrier. 3.Perform hand hygiene and don gloves. 4.Lightly scrub the stoma with soap and water. 5.Press the adhesive backing of the pouch against the skin. 6.Cut the opening on the appliance ½ inch larger than stoma.

(4 & 6) Rationale: The client washes the hands and dons gloves before removing the pouch and barrier. The peristomal area is cleansed with warm water to remove residue and improve visualization. The stoma is assessed for color, and the skin is checked for irritation. The appliance is measured and cut 1/16 inch larger than stoma to prevent strangulation of stoma, or too much room for skin irritation between the stoma and appliance. The adhesive backing of the appliance is pressed against the skin avoiding wrinkles to achieve seal.

A client has an intravenous infusion (IV) started before surgery for a right below-the-knee amputation. In addition to the intravenous infusion, blood is drawn and a surgical skin preparation is done. The nurse anticipates that the client is likely to experience which psychosocial problem in the preoperative period? Pain Anger Grief Anxiety Altered body image

Grief Anxiety Altered body image

The nurse is developing a plan of care for a client who is scheduled for surgery. The nurse should include which activity in the nursing care plan for the client on the day of surgery? Have the client void before surgery. Avoid oral hygiene and rinsing with mouthwash. Verify that the client has not eaten for the last 24 hours. Determine that the client has signed the informed consent for the surgical procedure. Report immediately any slight increase in blood pressure or pulse from the client's baseline vital signs.

Have the client void immediately before surgery. Verify that the client has not eaten for the last 24 hours. Determine that the client has signed the informed consent for the surgical procedure.

The nurse is monitoring the status of the postoperative client after abdominal surgery earlier in the day. Which signs or symptoms noted by the nurse would indicate an evolving complication associated with hypovolemia? Select all that apply. Increasing restlessness Capillary refill of 3 seconds in all extremities Hypoactive bowel sounds in all four quadrants White blood cell (WBC) count 9,500 mm3 (9.5 × 109/L) Blood pressure of 104/66 mm Hg with a pulse of 106 beats per minute

Increasing restlessness Hypoactive bowel sounds in all four quadrants Blood pressure of 104/66 mm Hg with a pulse of 106 beats per minute

The nurse is checking a client's surgical incision and notes an increase in the amount of drainage, a separation of the incision line, and the appearance of underlying tissue. Which should be the initial action by the nurse? Turn the client to the side with the knees bent. Apply a sterile dressing soaked with normal saline to the wound. Notify the registered nurse (RN) and primary health care provider (PHCP) at once. Explain to the client that obesity is a risk factor and weight loss should be a future goal. Gently explore the wound with a cotton-tipped applicator to determine whether evisceration has occurred.

Apply a sterile dressing soaked with normal saline to the wound. Notify the registered nurse (RN) and primary health care provider (PHCP) at once. Gently explore the wound with a cotton-tipped applicator to determine whether evisceration has occurred.

The client is to receive a soapsuds enema. Which is the *best* position for administering an enema? a left sidelining b prone c lithotomy d knee chest

(1) Rationale: The Sims, or left lateral position, is the position of choice for enema administration facilitating fluid to pass farther in the intestine. Many clients cannot tolerate the prone position. The lithotomy position is impractical for the procedure, and knee chest is too uncomfortable.

An older client complains of chronic constipation. Which instructions should the nurse reinforce with the client? *Select all that apply.* 1.Include rice and bananas in the diet. 2.Increase the intake of sugar-free products. 3.Increase fluids to at least eight glasses a day. 4.Increase various potassium-rich foods in the diet. 5.Respond in a timely manner to the urge to defecate.

(3,5) Rationale: Increase of fluid intake and dietary fiber will help change the consistency of the stool and make it easier for the client to pass. Clients should respond to the feeling of peristalsis involved with urge to defecate. Some older clients with mobility issues may not respond to the urge. Increasing the intake of rice and bananas will increase constipation. Increasing sugar-free products and potassium in the diet will not be beneficial to the client.

Which factors contribute to the problem of stress incontinence? *Select all that apply.* 1.Obesity 2.Sneezing 3.Nulliparity 4.Performing Kegel exercises 5.Voiding at frequent intervals

(1 & 2) Rationale: Obesity contributes to stress incontinence by causing increased intra-abdominal pressure. Sneezing or laughing also often cause leakage of urine due to sudden increased intra-abdominal pressure. Nulliparity refers to never having given birth and is not a factor of stress incontinence; rather, a history of having three or more vaginal births is associated with stress incontinence due to the weakening of the pelvic floor muscles. Performing Kegel exercises is actually a means of strengthening muscle tone. Voiding at frequent intervals, such as every 2 hours decreases the volume of urine in the bladder, thus decreasing the stretch and pressure in the bladder, and lessening the chance of incontinence.

The nurse observes a student nurse using a bladder scanner to determine a postoperative hysterectomy client's post-void residual (PVR). Which actions observed demonstrate the need for further teaching? *Select all that apply.* 1.Placing the scan head on the symphysis pubis and aiming toward the bladder 2.Pressing and holding the done button to display the volume measurement and print results 3.Applying a generous amount of transmission/conductivity gel across the client's abdomen 4.Pressing the gender button to select the male setting and wiping the scan head with an alcohol pad 5.Turning on the scanner by pressing the on/off button and then the scan button to turn on the scanning screen 6.Assisting the client to a supine position with head elevated on a pillow and exposing the client's lower abdomen

(1 & 3) Rationale: A bladder scan is a portable ultrasound used to estimate the amount of urine in the bladder. The student nurse should apply the conductivity gel 2.5 to 4 cm above the symphysis pubis, not across the abdomen. The scan head is placed in this area and aimed toward the client's head and slightly downward toward the coccyx, not downward on the symphysis pubis. The supine position is correct. The scanner is turned on and the male setting is used with a female client without a uterus (status post hysterectomy). The scan head is cleansed with alcohol before the scan. Once the scanner head is positioned the button is pushed to display the urine in the bladder. The nurse observes the picture on the scanner to make sure the picture on the screen correctly depicts the urine. The volume measurement is printed or noted and documented in the client's medical record. The client needs to be placed in the proper position before the scanner is turned on and gender is selected. After applying gel, the bladder can be scanned. Once the bladder is scanned, the volume measurement should be displayed and the results printed.

The nurse is discharging a postoperative female client who had a urinary tract infection (UTI) after surgery. Which essential issues about UTIs should the nurse reinforce in the discharge instructions? Select all that apply. 1. Maintain adequate fluid intake of 2 quarts. 2. Urinate regularly every 8 hours during the day. 3. Avoid vaginal douches and/or harsh soaps, bubble baths, powders, and sprays in the perineal area. 4. Take all discharge medication as prescribed including antibiotics, and notify your primary health care provider if symptoms or signs of a UTI reappear. 5. Use good hygiene including cleaning the perineum by separating the labia, cleaning with warm soapy water after a bowel movement, and wiping from front to back after urinating.

(1, 3, 4 & 5) Rationale: Besides taking all discharge medications as prescribed, including antibiotics, and notifying the primary health care provider if symptoms/signs of a UTI reappear, it is also important for the client to take adequate fluid amounts and use appropriate hygiene to prevent microorganisms from entering the bladder. Vaginal douches need to be avoided along with other products that can potentially irritate the perineal area. The client must be told to urinate at least every 4 to 6 hours.

Which information should the nurse include when reinforcing client teaching regarding ostomy care? Select all that apply. 1.Change the appliance daily. 2.Empty pouch when ⅓ to ½ full. 3.The stoma should be a dry pale pink. 4.The stoma should be moist and pink to red. 5.The skin barrier should be within 1⁄16 to ⅛ inch of the stoma. 6.Change the appliance about every 3 days, or sooner, if it is leaking effluent.

(2,4,5 & 6) Rationale: The pouch should be emptied when ⅓ to ½ full to prevent the weight of contents from loosening the seal. The stoma should be moist and pink to red in color. Keeping the skin barrier to within 1⁄16 to ⅛ inch of the base of the stoma prevents effluent from irritating the skin. With an adequate seal, changing the appliance every 3 days is adequate and may be done as infrequently as 2 weeks. Changing the appliance daily would damage the skin around the stoma. A dry pale pink is indicative of an unhealthy stoma and possibly dehydration.

The nurse is administering a cleansing enema to a client with a fecal impaction. Before administering the enema, the nurse asks the client to assume a left Sims' position. The nurse explains that this positioning is preferred because of which reason? 1.The nurse is right handed. 2.The rectal sphincter will relax. 3.The enema will flow into the bowel easily. 4.The client is more likely to retain the enema solution.

(3) Rationale: When administering an enema, the client is placed in a left Sims' position so that the enema solution can flow by gravity in the natural direction of the colon. The anatomy of the colon consists of ascending on the right, transverse across, with descending on the left leading to the sigmoid and rectum. If the client lies on the left side, the enema solution will flow easily into the bowel. The hand dominance of the nurse is not a factor. The nurse assists the client to relax the rectal sphincter by asking the client to take a deep breath. The nurse assists the client to retain the enema solution by administering the enema slowly. The nurse should also use teach-back to determine client's understanding about the reason for the enema.

The nurse just reassessed the condition of a postoperative client who was admitted 1 hour ago to the surgical unit after abdominal surgery. The client has an indwelling urinary catheter in place. The vital signs are temperature 99.6° F (37.6° C), pulse 104 beats per minute, respirations 16 breaths per minute, and blood pressure (BP) 100/70 mm Hg. Urinary output is 20 mL for the past hour. Based on this data, which actions should the nurse take before notifying the registered nurse? Select all that apply. Auscultate breath sounds. Review vital signs from previous hour. Observe the urinary catheter for patency and flow. Observe the IV site for patency and correct flow rate. Review when the client last received pain medication.

Review vital signs from previous hour. Observe the urinary catheter for patency and flow. Observe the IV site for patency and correct flow rate. Review when the client last received pain medication.

After having a transurethral resection of the prostate (TURP), a client has a continuous bladder irrigation (CBI) postoperatively. The nurse notes that fluid is entering the bladder, but none appears to be draining. Select the appropriate nursing interventions. *Select all that apply.* 1.Check the bladder for distention. 2.Review intake and output record. 3.Check to ensure drainage tubing is not kinked. 4.Ask the client about bladder spasms and discomfort. 5.Raise the drainage bag to the height of the bladder. 6.Deflate the balloon of the catheter, advance the catheter 2 cm, and reinflate the balloon.

(1,2,3 & 4) Rationale: A continuous bladder irrigation is often prescribed after a TURP to prevent blood clot formation that will obstruct the catheter. A drainage tube that is kinked will not allow the bladder irrigation solution to exit the body and can be done quickly while observing the system setup. Assessing the bladder for distention would follow because a clot may be preventing drainage. Asking the client if there is any discomfort or spasms may indicate improper drainage. Reviewing the intake and output record is done because the nurse can see that fluid is entering the system but not leaving. Raising the drainage bag will cause the urine to backflow into the bladder or stop flow. Deflating the balloon and advancing the catheter should not be done because this will introduce bacteria into the system.