Assessment II

A nurse is caring for a client who is recovering from surgical placement of an artificial heart valve and is to be started on warfarin (Coumadin) prior to discharge. Which of the following diagnostic tests should the nurse use to monitor the effect of this therapy?

Prothrombin time (PT)

A nurse is caring for a client who is one week postoperative following abdominal surgery. While changing the client's abdominal dressing the nurse notes the presence of serosanguineous drainage. The nurse should recognize which of the following?

Serosanguineous drainage at this time is a manifestation of possible dehiscence.

A nurse at an outpatient surgery center is providing discharge teaching for a client and his wife following surgical removal of a cataract. Which of the following should the nurse include in the teaching?

The client should wear dark glasses while outdoors

A nurse is caring for a client who is postoperative. Which of the following nonpharmacological interventions should the nurse use to promote bowel elimination for this client?

increase ambulation

A nurse is teaching a client who is preoperative how to do deep breathing exercises and cough effectively after surgery. Which client statement indicates to the nurse that the teaching has been effective?

"I'll splint my incision with a pillow to cough."

A nurse is admitting a client who is about to undergo surgery for benign prostatic hypertrophy. The client states, "I don't know what I will do if they find I have cancer." Which of the following is an appropriate nursing response?

"I'm hearing that you are concerned that it might turn out that you have cancer."

A nurse is providing preoperative teaching for a client who will undergo abdominal surgery. The nurse explains that the client will wear antiembolism stockings after the procedure. When the client asks what the stockings do, which of the following is an appropriate nursing response?

"They'll improve your circulation to keep blood from pooling in your legs"

A nurse is caring for a 4-year-old client who just had abdominal surgery. Which of the following techniques should the nurse use to get the client to take deep breaths?

"lets play game of blowing cotton balls across your table."

A charge nurse is asked to witness a surgical consent form. Upon entering the room, the client asks "Are there other options besides surgery?" Which of the following responses by the nurse is appropriate?

"several treatment options are available for your disease. Have you discussed this with your provider?"

A nurse is caring for an elderly client who is scheduled for surgery. Which of the following should the nurse be aware that the client is at risk for? (Select all that apply.)

- a decrease in the ability to communicate - a decrease in skin elasticity

A nurse is completing a neurovascular check of a client's lower extremity after surgery to reduce a fracture. Which of the following parameters should the nurse include as a part of evaluating the neurovascular status of the injured leg? (Select all that apply.)

- color - temp - sensation

A nurse is obtaining informed consent from a client prior to surgery. Which of the following is necessary for informed consent to be valid? (Select all that apply.)

- disclosure of the treatment is provided - client understands the surgical procedure - voluntary consent is given

A nurse is caring for a client who is postoperative. Which of the following statements about pain management is true? (Select all that apply.)

- each person's expression of pain may be different and individualized - pain level and pain tolerance can be assessed using a scale from 0-10

Which of the following should the nurse recognize as a sign of possible infection in a postoperative client? (Select all that apply.)

- oliguria - adventitious breath sounds - decreased level of consciousness - oral temp. of 38.3 C

A nurse is considering the risk factors for a client who has a surgical wound. Which of the following factors place the client at risk for dehiscence? (Select all that apply.)

- poor nutritional state - obesity - wound infection

A nurse is preparing to remove staples from a client's surgical incision. Identify the sequence the nurse should follow. (Move the steps of staple removal into the box on the right, placing them in the selected order of performance. All steps must be used.)

1. clean the surgical site 2. examine the incision 3. remove every other staple 4. reexamine the incision 5. remove remaining staples.

A client who is postoperative has an IV fluid prescription for 1,000 mL lactated Ringer's, then 1,000 mL dextrose 5% in 0.9% sodium chloride, then dextrose 5% in water. The three solutions are to infuse over 24 hr. The drop factor on the manual IV tubing is 10 gtt/mL. The nurse should adjust the IV flow rate to deliver how many gtt/min? (Round to the nearest whole number.)

21 gtt/min

A nurse is totaling the number of milliliters of fluid a client received during a 9 hr major abdominal surgery. What is the total milliliters of fluid? Lactated ringers at 150 ml/hour Cefazolin sodium (Ancef) 2 gm IV piggyback in 100 ml of normal saline Two units of packed RBCs at 275 ml and 250 ml Bolus of 250 ml normal saline every four hours Ranitidine (Zantac) 50 mg IV in 50 ml D5W over 30 minutes milliliters

2525 mL

A nurse is assigned four postoperative clients. Which of the following clients should the nurse address first?

A client whose blood pressure at 0800 was 128/86 mm Hg and at 1200 is 106/60 mm Hg

A postoperative client is prescribed an IV infusion of D5 Ringer's Lactate at 120 mL/hr. The tubing has a drop factor of 20 gtt/mL. The nurse should set the IV flow rate to how many gtt/min?

40 gtt/min

A nurse is caring for a client who had a mastectomy and returns to the surgical unit immediately following surgery. Which of the following is the priority action by the nurse?

Assess vital signs on the client's non-affected arm

A nurse is caring for a client who is immediately postoperative following thoracic surgery. The nurse administers a narcotic analgesic to the client frequently for pain. Which of the following should the nurse recognize as the primary reason for this action?

It facilitates the client's deep breathing

​A nurse is assessing a client who will undergo abdominal surgery in 2 hr. The nurse finds that the client has mild anxiety about the surgery, last had food and fluids at 2330 the previous evening, and signed the surgical consent 2 days ago. Which of the following is an appropriate nursing action regarding these findings?

Document the findings in the client's medical record.

A nurse is talking with a client who is about to undergo hip arthroplasty. The nurse explains that the surgeon will prescribe anticoagulant therapy to prevent deep-vein thrombosis postoperatively. The nurse should explain that the client will not require frequent clotting time determinations because the surgeon plans to prescribe which of the following medications?

Enoxaparin (lovenox)

A nurse is completing discharge teaching to a client about nutrition therapy for wound healing following major surgery. Which of the following vitamins promote wound healing and should be included in the teaching? (Select all that apply.)

Vitamin A Vitamin C

A nurse is preparing a client for surgery. She should begin preoperative teaching by exploring

What the client knows about the surgery.

A float nurse from the PACU is assigned to the medical-surgical unit. Which of the following client assignments is the most appropriate?

a client post-lobesctomy with a chest tube

A nurse is completing the preoperative teaching for a client who is to undergo a gastrectomy. Which of the following information should the nurse include in prevention of postoperative complications?

apply a sequential compression device

A nurse is caring for a group of clients on a surgical unit. Which of the following should be the nurse's initial action?

assessing a client who experiences unilateral calf pain when ambulating

Following a suicide bombing at a shopping mall, an unidentified, unconscious client is admitted to the emergency department with an acute intra-abdominal hemorrhage. The nurse should recognize that consent for the surgery

can be inferred since the client is in critical condition

An adult client is scheduled for surgery. Which of the following sites should the nurse assess for possible placement of an IV catheter? (Select all that apply.)

cephalic vein basilic vein

A nurse is caring for a client on the second day following abdominal surgery and observes wound evisceration. Which of the following is the first action by the nurse?

cover the area with a sterile dressing, moistened with saline.

A client who had abdominal surgery 24 hr ago suddenly reports a pulling sensation and pain in his surgical incision. The nurse checks the client's surgical wound and finds an evisceration. Which of the following interventions is appropriate?

cover the area with saline-soaked sterile dressings

A nurse is caring for a client who is postoperative and is at risk for development of thrombophlebitis. The nurse should instruct the client to avoid which of the following unsafe actions while sitting in a chair?

crossing the legs

A nurse is caring for a client who returns to the nursing unit from the recovery room after a sigmoid colon resection for adenocarcinoma. The client had an episode of intraoperative bleeding. Which finding indicates to the nurse that the client may be developing hypovolemic shock?

increase in the heart rate from 88 to 110 beats per minute.

A nurse is caring for a client who has developed atelectasis postoperatively. Which of the following findings should the nurse expect?

increasing dyspnea

A client who has just had abdominal surgery returns to the unit from the postanesthesia care unit with an IV fluid infusion and an NG tube in place. Which of the following is the assessment priority for the nurse who is caring for the client?

the surgical dressing

A nurse on a surgical floor is preparing a client for a surgical procedure. The nurse understands that preoperative vital signs are taken for which of the following reasons?

to establish a postoperative baseline

A nurse is caring for a client following surgery who has antiembolism stockings in place. Which of the following is the purpose for this device?

to prevent venous stasis

A nurse in a postanesthesia recovery unit is admitting a client who is postoperative following a tonsillectomy. Which of the following actions should the nurse take to prevent aspiration?

withhold fluids until the client demonstrates a gag reflex

A client is about to undergo an elective surgical procedure. Which of the following is the role of the nurse providing preoperative care regarding informed consent?

witness the client's signature

A nurse is caring for a client who is preoperative. The nurse signs as a witness on the client's procedural consent forms. By signing as a witness, the nurse is verifying that

it was the client who signed the consent form.

A nurse is caring for a postoperative client. Which of the following comfort measures should the nurse recognize as appropriate to include in the care? (Select all that apply.)

keep bed linens smooth monitor transcutaneous electrical nerve stimulation (TENS) Give a back massage Teach relaxation techniques, such as guided imagery.

A nurse is assisting a client who is postoperative following abdominal surgery with morning care and identifies a loop of bowel through an opening in the surgical incision. After calling for help, which of the following actions should the nurse take first?

apply moistened sterile gauze to the site

A client who is about to undergo abdominal surgery states that he is very anxious about the operation. Which of the following is an appropriate nursing response?

ask him to describe what he is feeling

A nurse assessing a client who is 2 days postoperative auscultates bilateral breath sounds but absent breath sounds in the bases. The nurse should suspect which of the following postoperative complications?

atelectasis

A nurse is caring for a client who is postoperative and has developed pneumonia. Which of the following is a possible complication of the pneumonia?

atelectasis

A nurse is caring for a client following an abdominal surgery. The client has a Penrose drain in place under the surgical dressing. The dressing is to be changed every 4 hr and as needed. Which of the following objects should the nurse use to reduce skin irritation around the incision area?

montgomery straps

A nurse is caring for a client who is postoperative following abdominal surgery. Which of the following client findings indicates to the nurse that peristalsis is returning?

passage of flatus

A nurse is reinforcing teaching with a client who is 2 days postoperative following colon resection. Which of the following should the nurse include in the teaching to reduce respiratory complications?

splint the incision to support coughing every 2 hr

A nurse is caring for a client who is 1 day postoperative following a left radical mastectomy for breast cancer. Which of the following behaviors should alert the nurse to the possibility that the client is having difficulty adjusting to the loss of her breast?

refusing to look at the sing or surgical incision

A nurse in the ambulatory surgery center is caring for a client who had a dilation and curettage (D&C) this morning following a spontaneous miscarriage. The client has returned from the operating room to the recovery area. Upon awakening, the client asks the nurse when she can eat. Which of the following is the appropriate action by the nurse?

auscultate the client's abdomen

A nurse is preparing to care for a surgical client in the post anesthesia care unit who has received an anesthetic with a neuromuscular blocker. Which of the following equipment should be available to the nurse?

bag valve mask device

A client who is postoperative has an NG tube that has drained 2,500 mL in the past 6 hr. Because of this, the nurse should monitor the client for which of the following electrolyte imbalances?

decreased potassium level

A nurse is conducting a preoperative interview with a client that is scheduled for surgery. The client states that he takes acetylsalicylic acid (Aspirin) 81 mg by mouth daily. Prior to the client's upcoming surgery, the nurse should instruct the client to do which of the following?

discontinue the dose 2 weeks before surgery

A nurse is caring for a client who is receiving a transfusion with one unit of packed cells because of blood loss during surgery. Thirty minutes after the unit of blood is hung, the client reports chills and back pain. The client's blood pressure is 80/64 mm Hg. Which of the following is the first action the nurse should take?

stop the infusion of blood

A nurse is assessing a client who is postoperative following abdominal surgery. Which of the following findings should make the nurse suspect deep-vein thrombosis (DVT)?

unilateral leg edema

A nurse is caring for a client who is 1 day preoperative for elective surgery. The client takes routine medications daily for asthma management. When transcribing the client's prescriptions, the nurse notes that the provider has omitted the client's routine asthma medication. The nurse, after attempting to contact the provider, tells the client to self-administer the asthma medication that was brought from home. This action by the nurse

violates the medical practice act

A nurse is caring for a client who had abdominal surgery two days ago. Which of the following findings by the nurse requires immediate attention?

wound has thick yellow-green drainage

A nurse is caring for a client who has a fractured right hip and a Jackson-Pratt (JP) drain in place after surgery for an open reduction and internal fixation. The nurse should understand that the purpose of this device is to

prevent fluid from accumulating in the wound

A nurse is assigned a group of postoperative clients. Which of the following findings should be of most concern to the nurse?

pulse oximetry 88%

A client who has just had surgery for an open femur fracture has previously developed anaphylaxis in response to penicillin. Postoperatively, the client's surgeon prescribes cefazolin (Ancef). Which of the following actions should the nurse take?

request that the surgeon prescribe a different antibiotic

A nurse is talking with a client who will undergo surgery to repair retinal detachment. Which of the following preoperative instructions should the nurse include?

restrict head movement

A nurse is caring for a client who is postoperative following vascular surgery. Which of the following signs should indicate to the nurse that the client has developed a thrombus?

dull, aching calf pain

A client who is postoperative is receiving IV fluids and a unit of whole blood. The nurse should observe the client for which of the following as an early sign of circulatory overload?

dyspnea

A nurse is caring for a client who is scheduled to have surgery. In preparing the client for surgery, which of the following actions is considered outside the responsibility of the nurse?

explain the operative procedure, risks, and benefits

A nurse is caring for a client who expresses anxiety about his impending surgery. Which of the following is the appropriate action by the nurse?

explore the client's feelings

A nurse is assessing a client who is postoperative and has anemia due to excess blood loss during surgery. The nurse should expect which of the following findings?

fatigue

A nurse is caring for a client who is returning to the surgical floor following a procedure that required spinal anesthesia. Which of the following findings indicates the client is experiencing a complication of the anesthesia?

headache

A client who has a mandible fracture has had her jaws wired. How should the nurse position the client during the immediate postoperative period?

lateral

A nurse is caring for a client with a compression fracture of a spinal vertebra. Just prior to an hour-long transport to the hospital, the client was medicated with intravenous morphine sulfate (Duramorph). On arrival, the neurosurgeon determines that urgent surgical intervention is indicated for the fracture. The nurse realizes that consent for the surgery

must be obtained from a relative of the client

A nurse is caring for a preoperative client who is sedated and awaiting surgery. While reviewing the client's preoperative forms, the nurse notes that the consent form has been signed by the client but has not been witnessed. The nurse should

notify the nurse manager and the provider

The nurse is caring for a client on the third day following abdominal surgery and assesses the absence of bowel sounds, abdominal distention, and the client passing no flatus. These findings indicate the client is experiencing which of the following postoperative complications?

paralytic ileus

A nurse is caring for a client who has returned from the surgical suite following surgery for a fractured mandible. The client has had intermaxillary fixation to repair and stabilize the fracture. The nurse should recognize that the most important goal in the immediate postoperative period is to do which of the following?

prevent aspiration