CCC4 exam 3

The nurse has received a prescription to add 30 MEQ of potassium chloride to 1000 ML bottle of IV fluid. The nurse has a 40 ML, multiple does vial of potassium chloride. The label reads 2 MEQ/ML how many milliliters should the nurse add to the IV fluid? record as a whole number

15 O:30MEQ A:2MEQ/ML O/A: 30/2=15

patient asked about risks of surgical procedure one hour before hand. What does the nurse do?

Contact provider to speak with patient

Clients need to understand their operation and what the doctor tells them before signing. If they do not.:

Contact the provider

Which of the following interventions will improve pulmonary function and decrease the risk of pneumonia? Select all that apply. Cough and deep breathing exercises Use of an incentive spirometer device 10 times every one to two hours while awake Early ambulation Resting quietly in bed Repositioning every 3 to 4 hours

Cough and deep breathing exercises Use of an incentive spirometer device 10 times every one to two hours while awake Early ambulation

Clients using an incentive spirometer should inhale _____ through the mouthpiece while keeping the ball _______?

Deeply afloat

Patient says my incision opened up, what is the medical term for this??

Dehiscence

Giving a client a back rub is using what pain control method

Distraction

Initial vitals versus reassessment vitals, what do you do?

Document as normal

Measures to prevent thrombophlebitis DVT. Select all that apply.

Early ambulation at least three times a day Blood thinners like Lovenox Leg exercises SCDs/TED hose Hydration

Patient should not _____ prior to surgery. If they report they did, then notify surgical team

Eat

Which of these food choices are best one promoting a healthy immune system? -Eggs and beans -Celery and water -Pasta and bread -Olive oil, and peanuts

Eggs and beans

Patient has a DVT you need to ___ the leg?

Elevate

What is the first response with severe chest pain?

Evaluate pain/assess patient

For the first 24 hours following surgery how frequently should the wound dressing be evaluated?

Every hour

Measures to prepare a client psychologically for surgery

Fear/ anxiety Alleviating fears by teaching about what will happen prior to during and after surgery

Best indicator that peristalsis is returning?

Gas/flatus

Vital signs are as follows Blood pressure 130/70 Heart rate 90 Respiration rate 22 and labored Oxygen saturation on room air, 82% What do you do?

Give oxygen

Best way to prevent cross contamination?

Hand hygiene

An infection developed while in the hospital is called?

Hospital acquired/healthcare acquired

Non-from a logical pain treatment:

Hot/cold -Reposition -Distraction -Herbals -Massage

What is the medical term for a fever?

Hyperthermia

Which of these are signs of fluid volume deficit? -Heart rate 85 -Blood pressure 112/72 -Hypoactive bowel sounds -Increasing restlessness

Hypoactive bowel sounds Increasing restlessness

Septic shock vitals/LOC

Hypotension Tachycardia Hyperthermia Tachypnea Hypoxia Lethargy

Patience on TPN need BS checks because the TPN can cause the patient BG to?

Increase

Patient diagnosed with sepsis, which finding is most concerning? Elevated BP Dry cough Cloudy Urine Increased lethargy

Increased lethargy

Early symptoms of shock and older adults?

Increasing restlessness/confusion

Pain management should be _____ to the patient?

Individualize

What acid base imbalance is a septic patient at risk for and what is trying to compensate for it and how?

Metabolic acidosis The lungs Increased rate and depth of respiration

If gauze it difficult to remove:

Moisten it

What should be available if patient is receiving morphine or any opioids?

Naloxone/ Narcan

Phantom pain is what type of pain?

Neuropathic

Can immunocompromise patients have artificial nails?

No

A client is ordered to receive a blood transfusion, but they have a fever. Can the patient still receive the blood?

No delay, notify the provider

Our time outs part of the preop checklist

No timeouts are part of the intraoperative process done in the OR

Client had abdominal surgery 10 hours ago. What finding should be reported? -30ml of green emesis -Pain, 5/10 -no urine output since surgery -Strong cough

No urine output since surgery

What is the most appropriate time to offer pain medication to a client?

When they ask for it

Best time to apply antiembolism stockings?

Before rising in the morning

Client has sepsis, and you received the following order: antibiotics, blood cultures, CBC, chem 7. What do you implement first?

Blood cultures

Priority assessment after epidural?

Blood pressure

If a patient is effectively using an incentive spirometer, they will be able to _____ easier

Breathe

Sepsis pharm treatment

Broad-spectrum antibiotics

Order 0.2mg/kg, available 20mg/ml Wt 90lbs round to nearest 10th

0.4 O: 0.2mg/kg x 40.909= 8.18mg A: 20mg/ml Wt: 90lbs/2.2= 40.909kg O/A= 8.18/20= 0.409= 0.4

Order 0.25 g, available 100mg. How many tablets will you give?

2.5 tablets. O: 0.25g= 250mg A: 100mg O/A: 250/100= 2.5

Antiembolism stockings should be removed. How often?

20 minutes every shift

when should a patient be medicated for pain prior to wound care?

30 minutes

The nurse is caring for a client at risk for septic shock from a wound infection to prevent systemic inflammatory response syndrome. The nurses priority is to monitor which of the following?

Clients, pulse rate and quality

Common side effects of narcotics?

Constipation

24 hour urine output of 300 ML is _____ and requires?

Abnormal Intervention

You enter your patients room at a long-term care facility and find your patient is diaphoretic, minimally, responsive, with a weak thready pulse. What do you do?

Activate emergency response

Methods to encourage return of peristalsis and post surgical patient? Select all that apply. Insert a NG tube attached to intermittent suction Administer IV fluids Encourage ambulation Maintain NPO Monitor intake and output

Administer IV fluids Encourage ambulation Maintain NPO Monitor intake and output

Priority assessment, and immediate post care phase?

Airway

Methods to relieve abdominal discomfort, postop

Ambulate

Post op exercise that can help decrease the risk of DVT, even if patient can't ambulate

Ankle pumps

Blood cultures, If ordered, should always be drawn before?

Antibiotics

What type of medication will be used to treat septic shock?

Antibiotics

How often should SCDs be on the patient?

Anytime they are in bed

Client recovering from surgery and has the following vitals: heart rate, 120 Blood pressure 70/52 with cool and clammy skin What do you do?

Call for help/notify provider

Older adults may be under treated for pain because of an inability to?

Cant afford

Which of these is most concerning a few hours after a knee replacement surgery? Pain eight out of 10 Right foot warm to touch Swelling in the knee Cap refill of seven seconds and toes

Cat refill of seven seconds and toes

What action helps you assess wound drainage overtime?

Circle drainage on dressing

which quality and safety education for nurses competency focus on the client as the source of control and full partner in providing compassionate and coordinated care, based on respect for clients, preference, value, and needs?

Client centered care

Eviscerated bowel interventions. Select all that apply. Notify surgeon Cover incision in a sterile dressing, soaked in sterile water Vital signs Instruct the client to remain still Document, finding/actions taken Push on exposed bowel and abdomen Use ice packs

Notify surgeon Cover incision with sterile dressing, soaked in sterile water Vital signs Instruct the client to remain still Document, finding/'s actions taken

Which of the following actions are regulated by the state boards of nursing? Select all that apply. Nurse licensure Disciplinary actions NCLEX style questions Hospital policy and procedure Scope of practice for nursing

Nurse licensure Disciplinary actions Scope of practice for nursing

As an advocate for the client, the nurse must make sure that safe effective care is provided within the confines of which of the following

Nurse practice act NPA

Ordered to give 0.4 mg available is 10 mg/20 ML round to the nearest hundredth.

O: 0.4mg A: 10mg/20ml= 0.5mg/ml O/A= 0.4/0.5 = 0.8

Best intervention for preventing pneumonia after surgery?

Offered pain medication before having the client deep breath/use IS

What is the primary purpose of the PACU?

Ongoing evaluation and stabilization of client

A client describes their pain level as a five on a scale of 0 to 10. What other questions with the nurse asked the client. Select all that apply.

Onset Location Duration Characteristics Aggravating Relieving Timing Severity OLDCARTS

Which of these IV therapy is has the greatest increase in oxygen carrying capacity for the patient? -Lactated ringers -Hetastarch -Fresh, frozen plasma -Packed red blood cells

Packed red blood cells

Patient with output less than minimum, first thing to do?

Palpate the bladder for distention

QSEN recognizes that the use of the national patient safety, goals, places and additional focus on safety. How are the NPSGS determined and adjusted each year?

Panel of experts review the previous years sentinel events to determine updated goals

Laryngectomy priority?

Patent airway

TPN should never be administered via a

Peripheral Always use central catheter

Using incentive spirometer helps prevent?

Pneumonia

What macronutrient helps promote wound healing?

Protein

Who is responsible for obtaining surgical informed consent?

Provider/surgeon

Prevent sirs, by monitoring ______ & ______ closely?

Pulse rate and quality

Thick, yellow drainage is called

Purulent

what early signs of sepsis, when recognize and treated have a good recovery rate? Localized erythema and edema Low white blood cell count Low oxygen saturation Reduce urinary output

Reduce urinary output

Serious adverse effects of morphine?

Respiratory depression

What is the medical term for bloody drainage?

Sanguinous

Safest positioning for post surgical patient who is still lethargic and minimally responsive?

Semi Fowlers At risk for aspiration

Pale, red, watery drainage is defined as:

Serosanguinous

Expected drainage type from wounds

Serous

What is the medical term for clear/yellow watery drainage?

Serous

Typical duration for acute pain

Six months

Patients should use _____ to decrease abdominal discomfort during coughing/deep breathing?

Splint

Nurse practice act as what type of law?

Statutory

Transfusion reaction. What do you do first?

Stop it

Description of pain is a _____ assessment?

Subjective

Pain is _______ to the patient?

Subjective

Three early symptoms of septic shock?

Tachycardia Fever Tachypnea

Communication between members of the healthcare team can be identified as part of which QSEN competency?

Teamwork and collaboration

Best source to determine a clients tolerance of pain and pain control?

The client

Which of the following documentation entries is most correct? -The client complains stomach pain following every meal -The client reports that long hours of standing worsens the abdominal pain -The client reports a sharp pain in the abdomen -The client reports sharp pain in the lower abdomen when standing

The client reports sharp pain in the lower, abdomen one standing

What is the rationale for use of a PCA?

Therapeutic level of analgesia

Anabiotic should be given for how long?

Till they are complete

Redness at PICC line (catheter site), what do you check?

Vital signs

What vitamin best promotes wound healing

Vitamin C

The beginning of the postop I period is, when:

When surgery is complete and they've been transferred to the PACU