AH1 HESI review questions - Perioperative Care
The nurse is caring for a client with bladder cancer and bone metastasis. What signs and symptoms would the nurse recognize as indications of a possible oncological emergency? Select all that apply 1. Facial edema in the morning 2. Serum calcium level of 12 mg/dL 3. Weight loss of 20 lbs in one month 4. Serum sodium level of 136 mg/dL 5. Serum potassium level of 3.4 mg/dL 6. Numbness and tingling of the lower extremities
1, 2, and 6 Rationale: Oncological emergencies include sepsis, disseminated intravascular coagulation, SIADH, spinal cord compression, hypercalcemia, superior vena cava syndrome, and tumor lysis syndrome. Blockage of blood flow to the venous system of the head resulting in facial edema is a sign of superior vena cava syndrome. A serum calcium level of 12 mg/dL indicates hypercalcemia. Numbness and tingling of the lower extremities could be a sign of spinal cord compression. Mild hypokalemia and weight loss are not oncological emergencies. A sodium level of 136 mg/dL is a normal level.
A client who has had a abdominal surgery complains of feeling as though "something gave way" in the incisional site. The nurse removes the dressing and notes the presence f a loop of bowel protruding through the incision. Which nursing interventions should the nurse take? SELECT ALL THAT APPLY. 1. Contact the surgeon 2. Instruct the client to remain quiet 3. Prepare the client for wound closure 4. Document the findings and actions taken 5. Place a sterile saline dressing and ice packs over the wound
1,2,3,4 Contact the surgeon Instruct the client to remain quiet Prepare the client for wound closure Document the findings a actions taken Rationale: Wound dehiscences is the separation of the wound edges. Wound evisceration is protrusion of the internal organs through an incision. If would dehiscence or evisceration occurs, the nurse should call for help, stay with the client, ask another nurse to contact the surgeon and obtain needed supplies to care for the client. The nurse places the client in a low Fowler's position, and the client is kept quiet, and instructed not to cough. Protruding organs are covered with a sterile saline dressing. Ice is not applied because of its vaso constrictive effect. The treatment for evisceration is usually immediate wound closure under local or general anesthesia. The nurse also documents the findings and actions taken.
The nurse receives a telephone call from the post anesthesia care unit stating that a client is being transferred to the surgical unit. The nurse plans to take which action first on arrival of the client? 1. Assess the patency of the airway 2. Check tubes or drains for latency 3. Check dressing to assess for bleeding 4. Assess the vital signs to compare with preoperative measurements
1. Assess the patency of the airway Rationale: The first action of the nurse is to assess the patency of the airway and respiratory function. If the airway is not patent the nurse must take immediate measures of the survival of the client. The nurse then takes vital signs, followed by checking the dressing, and the tubes or drains. The other nursing actions should be performed after a patent has been established.
The nurse is caring for a client who is postoperative following a pelvic exenteration and the HCP changes the client's diet from NPO status to clear liquids. The nurse should check which priority item before administering the diet? 1. Bowel sounds 2. Ability to ambulate 3. Incision appearance 4. Urine specific gravity
1. Bowel sounds Rationale: The client is kept NPO until peristalsis returns, usually in 4-6 days. When signs of bowel function returns, clear fluids are given to the client. If no distention occurs the diet is advanced as tolerated. The most important assessment is to assess bowel sounds before feeding the client. Options 2,3, and 4 are unrelated to the data in the question.
The nurse is developing a plan of care for the client with multiple myeloma and includes which priority intervention in the plan? 1. Encouraging fluids 2. Providing frequent oral care 3. Coughing and deep breathing 4. Monitoring the RBC
1. Encouraging fluids Rationale: Hypercalcemia caused by bone destruction is a priority concern in the client with multiple myeloma. The nurse should administer fluids in adequate amounts to maintain a urine output of 1.5 - 2 L a day; this requires about 3 L of fluid intake per day. The fluid is needed not only to dilute the calcium overload but also to prevent protein from precipitating in the renal tubules. Options 2,3, and 4 maybe components of the plan of care but are not the priority in this client.
The nurse is reviewing the laboratory results of a client diagnosed with multiple myeloma. Which would the nurse expect to note specifically in this disorder? 1. Increased Calcium level 2. Increased white blood cells 3. Decreased blood urea nitrogen level 4. Decreased number of plasma cells in the bone marrow
1. Increased calcium level Rationale: Findings indicative of multiple myeloma are an increased number of plasma cells in the bone marrow, anemia, hypercalcemia caused by the release of calcium from the deteriorating bone tissue, and an elevated Blood Urea Nitrogen level. An increased WBC count may or may not be present and is not related specifically to multiple myeloma.
The nurse is monitoring the status of a postoperative client. The nurse would become most concerned with which sign that could indicate an evolving complication? 1. Increasing restlessness 2. A pulse of 86 beats/minute 3. Blood pressure of 110/70 mm Hg 4. Hypoactive bowel sounds in all four quadrants
1. Increasing restlessness. Rationale: Increasing restlessness is a sign that requires continuous and close monitoring because it could indicate a potential complication, such as hemorrhage, shock, or pulmonary embolism. A blood pressure of 110/70 mm Hg with a pulse of 86 beats/minute is within normal limits. Hypoactive bowel sounds heard in all four quadrants are a normal occurrence.
A postoperative client asks the nurse why it is so important to deep breathe and cough after surgery. When formulating a response, the nurse incorporates the understanding that retained pulmonary secretions in a postoperative client can lead to which condition? 1. pneumonia 2. hypoxemia 3. fluid imbalance 4. pulmonary embolism
1. Pneumonia Rationale: Postoperative respiratory problems are atelectasis, pneumonia, and pulmonary embolism. Pneumonia is the inflammation flung tissue that causes productive fought, dyspnea, and lung crackles and can be caused by retained pulmonary secretions. Hypoxemia is an inadequate concentration of oxygen in arterial blood. Fluid imbalance can be a deficit or excess related to fluid loss or overload. Pulmonary embolus occurs as a result of a blockage of the pulmonary artery that disrupts blood flow to one or more lobes of the lung; this is usually due to clot formation.
The nurse is reviewing a HCP's prescription sheet for a preoperative client that states that the client must be NPO after midnight. The nurse would telephone the HCP to clarify that which medication should be given to the client and not withheld? 1. Prednisone 2. Ferrous sulfate 3. Cyclobenzaprine (Flexeril) 4. Conjugated estrogen (Premarin)
1. Prednisone Rationale: Prednisone is a corticosteroid. With prolonged use corticosteroids cause adrenal atrophy, which reduces the ability of the body to withstand stress. When stress is severe, corticosteroids are essential to life. Before and during surgery, dosages may be increased temporarily. Ferrous sulfate is an oral iron preparation used to treat iron deficiency (anemia). Clyclobenzaprine is a skeletal muscle relaxant. Conjugated estrogen is an estrogen used for hormone replacement therapy in post menopausal women. These last three medications may be withheld before surgery without undue effects on the client.
The home health care nurse is caring for a client with cancer who is complaining of acute pain. The most appropriate determination of the client's pain should include which assessment? 1. The client's pain rating 2. Non verbal cues from the client 3. Nurse's impression of the client's pain 4. Pain relief after appropriate nursing intervention
1. The client's pain rating Rationale: The client's self report is a critical component of pain assessment. The nurse should ask the client to describe the pain and listen carefully to the words the patient uses to describe the pain. Nonverbal cues from the client are important but not the most appropriate pain assessment measure. The nurse's impression of the client's pain is not appropriate in determining the client's level of pain. Assessing pain relief is an important measure but this option is not related to the subject of the question.
The nurse has just reassessed the condition of a postoperative client who was admitted 1 hour ago to the surgical unit. The nurse plans to monitor which parameter most carefully during the next hour? 1. Urinary output of 20 mL/hour 2. Temperature of 37.6 C (99.6F) 3. Blood pressure of 100/70 mm Hg 4. Serous drainage on the surgical dressing
1. Urinary output of 20 ml/hour Rationale: Urine output should be maintained at a minimum of 30 mL/hour for an adult. An output of less than 30 mL for each of 2 consecutive hours should be reported to the HCP. A temperature higher than 37.7 C(100F) or lower than 36.1C (97F) and a falling systolic blood pressure, lower than 90 mm HG, are usually considered reportable immediately. The client's preoperative or baseline blood pressure is used to make informed postoperative comparisons. Moderate or light serous drainage from the surgical site is considered normal.
When caring for a client with an internal radiation implant, the nurse should observe which principles? SELECT ALL THAT APPLY 1. Limiting the time with the client to one hour per shift 2. Keeping pregnant women out of the client's room 3. Placing the client in a private room with a private bath 4. Wearing a lead shield when providing direct client care 5. Removing the dosimeter film badge when entering the client's room. 6. Allowing individuals younger than 16 years old in the room as long as they are 6 feet away from the client
2,3,4 Rationale: The time that the nurse spends in a room of a client with an internal radiation implant is 30 minutes per eight hour shift. The client must be placed in a private room with a private bath. The nurse should wear a lead shield to reduce the transmission of radiation. The dosimeter film badge must be worn when in the client's room. Children younger than 16 year of age and pregnant women are not allowed in the client's room.
A client who has undergone pre admission testing has had blood drawn for serum laboratory studies, including a complete blood count, coagulation studies, and electrolytes and creatinine levels. Which laboratory result should be reported to the surgeon's office by the nurse knowing that it could cause surgery to be postponed? 1. Sodium, 141 mEq/L 2. Hemoglobin, 8.0 g/dL 3. Platelets, 210,000/mm3 4. Serum Creatinine, 0.8 mg/dL
2. Hemoglobin, 8.0 g/dL Routine screening tests include a complete blood count, serum electrolyte analysis, coagulation studies, and a serum creatinine test. The complete blood count includes the hemoglobin analysis. All these values are within normal range except for hemoglobin. If a client has a low hemoglobin level, the surgery likely could be postponed by the surgeon.
The nurse assesses a client's surgical incision for signs of infection. Which finding by the nurse would be interpreted as a normal finding at the surgical site? 1. Red, hard skin 2. Serous drainage 3. Purulent drainage 4. Warm, tender skin
2. Serous drainage Rationale: Serous drainage is an expected finding at a surgical site. The other options indicate signs of wound infection. Signs and symptoms of infection include warm, red, and tender skin around the incision. Wound infection usually appears 3 - 6 days after surgery. The client also may have a fever and chills. purulent material may exit from drains or form separated wound edges. Infection may be caused by poor aseptic technique or a contaminated would before surgical exploration; existing client condition such as diabetes mellitus or immunocompromise may place the client at risk.
A preoperative client expresses anxiety to the nurse about upcoming surgery. which response by the nurse is most likely to stimulate further discussion between the client and the nurse? 1. "If it's any help, everyone is nervous before surgery" 2. "I will be happy to explain the entire surgical procedure to you" 3. "Can you share with me what you've been told about your surgery?" 4. "Let me tell you about the care you'll receive after surgery and the amount of pain you can anticipate"
3. "Can you share with me what you've been told about your surgery?" Rationale: Explanations should begin with the information that the client knows. By providing the client with individualized explanations of care and procedures, the nurse can assist the client in handling the anxiety and fear for a smooth preoperative experience. Clients who are calm and emotionally prepared for surgery withstand anesthesia better and experience fewer postoperative complications. Option 1 does not focus on the client's anxiety. Explaining the entire surgical procedure may increase the client's anxiety. Option 4 avoids the client's anxiety and is focuses on postoperative care.
The nurse has conducted preoperative teaching for a client scheduled for surgery in 1 week. The client has a history of arthritis and has been taking acetylsalicylic acid (aspirin). The nurse determines that the client needs additional teaching if the client makes which statement? 1. "Aspirin can cause bleeding after surgery" 2. "Aspirin can cause my ability to clot blood to be abnormal" 3. "I need to continue to take the aspirin until the day of surgery" 4. "I need to check with my HCP about the need to stop the aspirin before the scheduled surgery"
3. "I need to continue to take the aspirin until the day of surgery" Rationale: Anticoagulants alter normal clotting factors and increase the risk of bleeding after surgery. Aspirin has properties that can alter the clotting mechanism and hold be discontented at least 48 hours before surgery. However, the client should always check with his or her HCP regarding when to stop taking the aspirin when a surgical procedure is scheduled. Options 1,2, and 4 are accurate client statements.
The nurse should plan to implement which intervention in the care of a client experiencing neutropenia as a result of chemotherapy? 1. Restrict all visitors 2. Restrict fluid intake 3. Teach the client and family about the need for hand hygiene. 4. Insert an indwelling urinary catheter to prevent skin breakdown
3. Teach the client and family about the need for hand hygiene. Rationale: In the neutropenic client meticulous hand hygiene education is implemented for the client, family, visitors, and staff. Not all visitors are restricted, but the client is protected from persons with known infections. Fluids should be encouraged. Invasive measures such as indwelling urinary catheters should be avoided to prevent infections.
The nurse is developing a plan of care for a client scheduled for surgery. The nurse should include which activity in the nursing care plan for the client on the day of surgery? 1. Avoid oral hygiene and rinsing with mouthwash 2. Verify that the client has not eaten for the last 24 hours 3. have the client void immediately before going into surgery 4. Report immediately any slight increase in blood pressure or pulse
3. have the client void immediately before going into surgery Rationale: The nurse would assist the client to void immediately before surgery so that the bladder will be empty. Oral hygiene is allowed, but the client should not swallow any water. The client usually has a restriction of food and fluids for 6-8 hours before surgery instead of 24 hours. A slight increase in blood pressure and pulse is common during the preoperative period and is usually the result of anxiety.
During the admission assessment of the client with advanced ovarian cancer, the nurse recognizes which symptom as typical of the disease? 1. Diarrhea 2. Hypermenorrhea 3. Abnormal Bleeding 4 Abdominal distention
4. Abdominal distention. Rationale: Clinical manifestation of ovarian cancer include abdominal distention, urinary frequency, and urgency, pleural effusion, malnutrition, pain from pressure caused by the growing tumor and the effects of urinary or bowel obstruction, constipation, ascites with dystnea, and ultimately general severe pain. Abnormal bleeding often resulting in hypermenorrhea is associated with uterine cancer.
A client is admitted to the hospital with a suspected diagnosis of Hodgkin's disease. Which assessment finding would the nurse expect to note specifically in the client? 1. Fatigue 2. Weakness 3. Weight gain 4. Enlarged lymph nodes
4. Enlarged lymph nodes Rationale: Hodgkin's disease is a chronic, progressive neoplastic disorder of lymphoid tissue. Characterized by the painless enlargement of lymph nodes with progression to extra lymphatic sites such as the spleen and liver. Weight loss is most likely to be noted. Fatigue and weakness may occur but are not related significantly to the disease.
A client with a perforated gastric ulcer is scheduled for surgery. The client cannot sign the operative consent form because of sedation from opioid analgesics that have been administered. The nurse should take which most appropriate action in the care of this client? 1. Obtain a court order for the surgery 2. Have the charge nurse sign the informed consent immediately. 3. Send the client to surgery without the consent form being signed 4. Obtain a telephone consent from a family member, following agency policy.
4. Obtain a telephone consent from a family member, following agency policy Rationale: Every effort should be made to obtain permission from a responsible family member to perform surgery if the client is unable to sign the consent form. A telephone consent must be witnessed by two persons who hear the family member's oral con set. The two witnesses then sign the consent with the name of the family member, noting that an oral consent was obtained. Consent is not informed if it is obtained from a client who is confused, unconscious, mentally incompetent, or under the influence of sedatives. In an emergency, a client may be unable to sign and family members may not be available. In this situation, a health care provider is permitted legally to perform surgery without consent, but in this case it is not an emergency. Options 1 and 3 are not appropriate in this situation. Also agency policies regarding informed consent should always be followed.
While giving care to a client with an internal cervical radiation implant, the nurse finds the implant in the bed. The nurse should take which initial action? 1. Call the HCP 2. Reinsert the implant into the vagina 3. Pick up the implant with gloved hands and flush it down the toilet 4. Pick up the implant with long handled forceps and place in lead container
4. Pick up the implant with long had led forceps and place in lead container. Rationale: In the event that a radiation source becomes dislodged, the nurse would first encourage the client to lie still until the radioactive source has been placed in a safe, closed container. The nurse would use long handled forceps to place the source in lead container that should be in the client's room. The nurse should then call the radiation oncologist and then document the event and the actions taken. It is not within the scope of nursing practice to insert a radiation implant.
The nurse is conducting preoperative teaching with a client about the use of an incentive spirometer. The nurse should include which piece of information in discussions with the client? 1. inhale as rapidly as possible 2. keep a loose seal between the lips and the mouthpiece 3. After maximum inspiration, hold the breath for 15 seconds and exhale. 4. the best results are achieved when sitting up or with the head of the bed elevated 45 to 90 degrees
4. The best results are achieved when sitting up or with the head of the bed elevated 45 to 90 degrees Rationale: For optimal lung expansion with the incentive spirometer, the client should assume the semi-Fowler's or high Fowler's position. The mouthpiece should be covered completely and tightly while the client inhales slowly, with a constant flow through the unit. the breath should be held for 5 seconds before exhaling slowly