304 exam 1 (quizizz questions)

when assessing an obese client, a nurse observes dehiscence of the abdominal surgical wound with evisceration. the nurse places the client in the low-fowler position with the knees slightly bent and encourages the client to lie still. what is the next nursing action?

obtain VS notify HCP reinsert the protruding organs using aseptic technique *cover the wound with sterile gauze soaked with NS

the nurse teaching a health awareness class identifies which situation as being the highest risk factor for the development of a DVT?

pregnancy *inactivity aerobic exercise tight clothing

a client reports feeling nauseated immediately after surgery. which action would the nurse take?

provide some dry crackers to eat *administer the prescribed antiemetic explain that this is expected after surgery encourage deep breathing until the nausea subsides

the nurse is monitoring a patient who is receiving IV fluids. which finding around the insertion site indicates that the IV has infiltrated?

red firm inflamed *edematous

which assessment finding in a client signifies a mild form of hypocalcemia?

seizures hand spasms severe muscle cramps *numbness around the mouth

you are the nurse caring for an older client recently admitted. which of the following data collected during the assessment process places the older adult patient at risk for dehydration?

skin warm, dry, intact BMI 20.5 BP 140/98 *water intake of 2 glasses per day

the client returned to the surgical unit status post total knee replacemnt. the baseline VS -99.1-88-16-124/62-96% RA. what changes in VS would the nurse suspect the patient showing initial signs of bleeding?

temp 100.2, RR 22 HR 64, BP 114/56 RR 8, SpO2 88% RA *HR 101, BP 104/52

when monitoring a client for hyponatremia, which assessment findings would the nurse consider significant? SATA

thirst *seizures erythema *confusion constipation

which process should a nurse follow when obtaining would culture from a surgical site?

thoroughly irrigate the wound before collecting the culture use a sterile and wipe the crusted area around the outside of the wound *roll a sterile swab from the center of the wound use a sterile swab starting on the outer edge of the wound

the MD orders daily weights for the purpose of evaluating a patient's fluid loss or gain. the nurse should weigh the patient

twice a day one hour before meals *at the same time each day before urinating in the morning

the nurse is receiving shift report. which patient on the nurse's assignment should contact precautions be implemented? SATA

varicella *herpes zoster *MRSA pertussis *C. diff

which clinical manifestation is associated with cellulitis?

vesicles that erupt into pustules coolness and pallor *lympthadenopathy urticaria and pruritus

which type of asepsis is the nurse using when he or she washes his or her hands before changing a client's postoperative dressing?

wound aspesis *medical asepsis surgical asepsis concurrent asepsis

3 days after bariatric surgery, the client puts the call light on and states, "i felt a 'pop' in my belly after i had a coughing spell." the nurse assesses the client's incision site for signs of dehiscence. which clinical finding supports the nurse's conclusion that the client is experiencing wound dehiscence?

wound edges approximated with loosened sutures *increase in serosanguineous drainage purplish color of the incision protrusion of organs through an open incision

the nurse is providing preoperative education to a client scheduled for orthopedic surgery at 8am the next day. which instruction would the nurses include?

"have your dinner completed by 6pm and then no food or fluids after that" "drink whatever liquids you want tonight and the only clear liquids tomorrow morning" *"consume a light meal tonight and then no food or fluids after midnight" "eat lunch today and then do not eat or drink anything until after your surgery"

the nurse is educating a client who is preparing to have surgery. which statement by the client indicates the teaching was effective?

"i will stop taking my anticoagulants and NSAIDs a month before the surgery" "there are no required tests to be done prior to the surgery" *"the surgeon will inform me of the procedure and risks associated with it prior to having surgery" "i will never be given antibiotics before, during, or after the surgery"

which client statement would cause the nurse to stop the HCP from initiating nerve block anesthesia?

*"im not sure how a nerve block works" "i understand that the numbness from the nerve block may not be temporary" "i signed the consent form for a nerve block" "i am aware that i will be at increased risk for falls during the nerve block"

identify the type of IV solution that will pull water into the cell expanding it

*0.45% NaCl 0.9% NS lactated ringers 3% NaCl

which priority interventions would the nurse follow when caring for a client with malignant hyperthermia? SATA

*administer 100% oxygen *stop the anesthesia continue the surgery insert an indwelling catheter *initiate cooled intravenous solution

which collaborative and nursing actions would help prevent venous thrombosis in a client during the perioperative period? SATA

*administer subcut heparin injections give intravenous thrombolytic meds *assist the client to don antiembolism stockings *apply sequential compression devices to the legs remind the client the importance of bed rest

which findings are consistent with hypercalcemia after prolonged immobility? SATA

*bone pain convulsions muscle spasms tingling of extremities *decreased DTRs

which laboratory test is required to determine accurate treatment of a client with cellulitis with purulent exudate?

*culture and sensitivity wound culture blood culture WBC count

which is most important when the nurse assess adult patients for the effects of vomiting?

*electrolyte lab values mouth conditions bowel function body weight

the nurse is caring for a client who is postoperative day 2 from an open cholecystectomy and notes the presence of dim bases bilaterally. the nurse suspects atelectasis. which nursing actions will be appropriate for this client?

*encourage turning, coughing, deep breathing exercises decrease by mouth fluid intake offer a high-potassium diet obtain a chest x-ray

the nurse is caring for a client admitted for isotonic dehydration. which lab values does the nurse anticipate to result for this client? SATA

*hematocrit 55% hemoglobin 10 gm/dL *sodium 147 mEq/L urine specific gravity 1.005 BUN 25 mg/dL

which electrolyte imbalance response would the nurse assess for in a client with dehydration?

*hypernatremia hypovolemia hyperkalemia hypoglycemia

a nurse is caring for a client who had major abdominal surgery one day ago. what factor increases the risk of this client developing a wound dehiscence?

*jackson pratt drain placement client is overweight presence of flatus *client being treated with antibiotics for a wound infection decreased mobility

a client with a 20 year history of excessive alcohol use is admitted to the hospital with jaundice and ascites. what is the priority nursing action during the first 48 hours after the client's admission?

*monitor the client's VS increase fluid intake improve nutritional status determine reasons for drinking

which statement needs correction regarding obtaining informed consent from clients?

*obtaining informed consent is an important part of the nurse-client relationship; it is a vital part of the nursing duty consent would be obtained in all situations except extraordinary circumstances a client may give consent based on the full disclosure of risks, benefits, alternatives, and consequences of refusal the primary HCP legally has to disclose facts in terms that the client is able to make an informed decision

a client is admitted with dehydration and has an IV catheter infusing at 150 mL/hr. upon assessment, the nurse notes the client's VS are: HR 76, RR 12, BP 98/62, O2 87% on RA and is coughing up pink, frothy sputum. what would be the first nursing action?

*raise the head of the bed apply oxygen at 4L/min inform the HCP turn of the IV fluids

the nurse is performing a health history of an older adult client at a wellness clinic. which vaccinations does the nurse verify have been completed? SATA

*shingles vaccine *annual flu vaccine annual pneumococcal vaccine *hepatitis b series *tdap within 10 years

a HCP is discussing the fluid balance of a postoperative client. the physician states that the client's insensible fluid loss is approx. 600 mL daily. the nurse interprets that the physician is referring to the fluid loss that is occurring through which of the following?

*skin and lungs wound drain and skin NG tube and wound drain foley catheter and NG tube

as a part of informed consent, a surgeon explains to the client scheduled for surgery the details of the surgery and related care. the nurse witnesses the informed consent. which information would the nurse ensure was provided to the client? SATA

*surgical procedure *explanation of possible risks name of staff members participation in the surgery *name of the surgeon anesthetic medication used during the procedure

a client diagnosed with electrolyte imbalance induced dysrhythmias question the need for more tomatoes and pears in the diet. what is the best information the nurse can give this client?

*tomatoes and pears are high in magnesium tomatoes and pears are high in potassium tomatoes and pears are low in sodium tomatoes and pears are high in fiber

the nurse has just reassessed the condition of a post operative patient admitted 1 hour ago to the surgical unit. the nurse plans to monitor which parameter most carefully during the next hour?

*urine output of 20mL/hr temp 99.6F BP 110/70 small amount of sanguineous drainage on the surgical dressing

a client has redness, warmth, and increased drainage along the surgical incision. what condition does the nurse suspect?

*wound infection dehiscence DVT hemorrhage

the nurse is caring for a patient with an isotonic fluid volume deficit. which types of intravenous solutions does the nurse expect the health care provider to prescribe? SATA

3% normal saline 0.45% normal saline *5% dextrose in water 5% dextrose in NS *lactated ringers

which members of the surgical team are sterile during surgical procedures?

anesthesiologist circulating nurse *scrub nurse *surgeon *surgical assistant

the nurse notes tachycardia, tetany, hyperreflexia, and dysrhythmias. which medication does the nurse anticipate being prescribed?

calcium carbonate *magnesium sulfate normal saline bolus potassium chloride

an older adult client with postherpetic neuralgia reports deep tissue pain. which infection does the nurse expect to observe in the client's EMR?

cellulitis *herpes zoster herpes simplex virus candidiasis

the nurse is preparing to discharge a client with cellulitis. which discharge instructions does the nurse anticipate providing?

continue IV antibiotics for the next 2 weeks *complete the 7-10 day course of oral antibiotics do not eat dairy productions expect the area to remain red for several weeks

a client is scheduled to have surgery to remove an organ that is not working and replace it with a new organ. what type of surgery is this?

cosmetic palliative diagnostic *transplant

3 days after abdominal surgery a client has not passed flatus and there continue to be no bowel sounds. paralytic ileus is suspected. what does the nurse conclude is the most likely cause of the ileus?

decreased blood supply *impaired neural functioning perforation of the bowel wall obstruction of the bowel lumen

which nursing intervention would be most effective to improve comfort for a client with herpes zoster?

direct sunlight dry heating pad *cool compress warm, moist dressing

a client reports to the ED with increased pain, tenderness, and redness to upper thigh where poison ivy skin reaction has been for the past week. the client reports diaphoresis and a temperature of 38.7C. what treatment does the nurse anticipate the HCP to order?

discharge with steroids and oral antibiotics discharge with diphenhydramine and steroids admission with droplet precautions with IV antibiotics and steroids *admission with standard precautions with IV antibiotics and antibiotics

in reviewing the record of a client, a nurse notes that the physician has documented the presence of Chvostek sign. based on this documentation, which of the following would the nurse expect to note on assessment of the client?

discoloration of the abdomen and periumbilical area is present carpal spasm is elicited by compressing the upper arm and causing ischemia to the nerves distally *a spasm of the facial muscles is elicited by tapping the facial nerve in the region of the parotid gland the epidermal skin layer can be rubbed off by slight friction

which intervention would the nurse include in the plan of care for a client admitted with herpes zoster? SATA

droplet precautions *cool compresses *gabapentin *acyclovir outline redness with a skin marker

a nurse is caring for an older adult client at risk for fluid and electrolyte imbalance. which assessment finding would be the first indication to the nurse to take action for this problem?

fever poor skin turgor *mental status changes elevated BP

the nurse assessing a client notes a bounding pulse quality, neck vein distention when supine, presence of crackles in the lungs, and increasing peripheral edema. the nurse should provide interventions for which condition?

fluid volume deficit *fluid volume excess fluid homeostasis fluid dehydration

the nurse is educating a client about hydrochlorothiazide. which symptom identified by the client needs to be reported to the HCP indicated effective teaching?

insomnia nasal congestion increased thirst *generalized weakness