EAQ- NUR 320 (1)
The nurse is providing orientation to new surgical staff employees. What does the nurse inform the employee that proper attire for the restricted area of the surgery department would include? Street clothing Surgical attire and head cover Surgical attire, head cover, and mask Surgical attire, with the addition of shoe covers
Surgical attire, head cover, and mask
An older adult patient is admitted to the hospital for hip replacement surgery. What special considerations should be followed during the surgery to prevent complications? Teach the patient about postoperative care. Ask the patient about a family history of bone diseases. Take greater care in preparing and positioning the patient. Maintain clear and concise communication with the patient. Use warming devices to prevent perioperative hypothermia.
Take greater care in preparing and positioning the patient. Maintain clear and concise communication with the patient. Use warming devices to prevent perioperative hypothermia.
A patient with a body mass index (BMI) of 45 is admitted for abdominal surgery. The nurse explains to the patient the potential complications of abdominal surgery caused by obesity. Which statements should the nurse include in the explanation? Access to the surgical site is easy. Recovery from anesthesia is faster. The risk of wound infection is higher. Anesthesia administration is more difficult. The risk of a postoperative incisional hernia may be higher.
The risk of wound infection is higher. Anesthesia administration is more difficult. The risk of a postoperative incisional hernia may be higher.
To ensure patient safety and reduce risks associated with surgical procedures, the circulating nurse calls a surgical timeout prior to surgery. Which activities should be included in the timeout? Verify patient identification. Complete a fire risk assessment. Verify surgical site and procedure. Ensure that consent for the specific procedure was obtained. Ensure that a significant other is available if needed for consultation.
Verify patient identification. Complete a fire risk assessment. Verify surgical site and procedure. Ensure that consent for the specific procedure was obtained.
The nurse is providing discharge education for a patient with heart failure about the importance of obtaining daily weights. How should the nurse instruct the patient on how to obtain the weights?
Weigh the patient on the same calibrated scale *Accurate assessment of body weight is very important and an early indicator of any shift in fluid volume. The nurse should weigh the patient on the same calibrated scale because there may be variable error in other scales. The patient should be weighed every day at the same time and in the same garments, preferably before having food. If the patient has any drainage bags, the fluid should be removed before the patient is weighed.
A patient with a history of psychosis has newly developed anxiety and is combative with the nurse. What does the nurse know may be causes of this change in behavior? Delirium Excessive sleep Hyperoxygenation Electrolyte imbalances
electrolyte imbalance
While caring for a patient with chronic obstructive pulmonary disease, the nurse finds that the patient's arterial blood gas results show a blood pH of 7.29, partial pressure of carbon dioxide (PaCO 2) of 49 mm Hg, and a bicarbonate ion (HCO 3) level of 25 mEq/L. Which condition does the nurse suspect? Metabolic acidosis Metabolic alkalosis Respiratory acidosis Respiratory alkalosis
respiratory acidosis
A patient is admitted with alcohol abuse. Laboratory data reveals a phosphate level of 1.8 mg/dL. Which assessment finding is consistent with this data? Tetany Diarrhea Weakness Seizure activity
weakness **Signs of hypophosphatemia include weakness, confusion, coma, and diminished reflexes. Seizure activity, diarrhea, and tetany are not associated with this electrolyte imbalance.
The nurse is preparing to administer a preoperative dose of cefazolin prior to an open cholecystectomy. What is the best explanation to the patient about why they are receiving this medication? "It will prevent postoperative pneumonia." "It will treat your urinary tract infection (UTI)." "It will prevent postoperative surgical-site infection." "It will remove harmful bacteria from your intestines before surgery."
"It will prevent postoperative surgical-site infection."
In the regulation of water balance, which system has a primarily antiinflammatory effect and increases serum glucose levels? Renal Cardiac Adrenal-cortical Hypothalamic-pituitary
Adrenal-cortical
An older adult patient is undergoing preoperative assessment and teaching. What nursing interventions are appropriate during the education process? (select all that apply) Administer a sedative to relieve fear and anxiety. Help the patient walk safely to the operating room. Coordinate assessment with the team of health care providers. Speak slowly when giving preoperative instructions to the patient. Understand that the patient may have sensory and cognitive deficits.
Coordinate assessment with the team of health care providers. Speak slowly when giving preoperative instructions to the patient. Understand that the patient may have sensory and cognitive deficits.
An older adult patient has a complication after a cardiac catheterization and has to remain in the intensive care unit (ICU) for an extra three days. For what is the patient most at risk? Delirium Depression Alcohol withdrawal Aggressive behaviors
Delirium
When caring for older patients, the nurse should watch for signs of dehydration due to decreased fluid intake. Which factors contribute to dehydration in older patients? Decreased taste sensation Disorientation and confusion Inability to hold a cup or glass Decrease in thirst mechanisms Fear of stomach bloating and discomfort
Disorientation and confusion Inability to hold a cup or glass Decrease in thirst mechanisms
A patient with a history of deep vein thrombosis is recovering in the postanesthesia care unit (PACU) after an abdominal surgery. Considering that the patient is at risk of developing pulmonary embolism (PE), what signs should the nurse watch out for? Dyspnea Tachypnea Tachycardia Coarse crackles Noisy respirations
Dyspnea Tachypnea Tachycardia
The nurse is caring for a patient and observes with a serum potassium of 2.8 mEq/L. What is the greatest risk for this patient that the nurse should monitor for? Dysrhythmias Acute renal failure Metabolic alkalosis Malignant hypertension
Dysrhythmias
The nurse is providing care to a patient whose serum potassium level is 5.1 mEq/L. Which change should the nurse make to the plan of care to address this finding? Monitoring for digitalis toxicity Adding bananas to the list of approved fruits Implementing continuous monitoring of urine output Ensuring that intravenous calcium gluconate is available at all times
Ensuring that intravenous calcium gluconate is available at all times
The nurse is reviewing the laboratory reports of a patient during a follow-up visit and finds that the blood sugar level has decreased to 150 mg/dL from 210 mg/dL. Which movement between intracellular fluid and extracellular fluid can support the effectiveness of treatment? Osmosis Diffusion Active transport Facilitated diffusion
Facilitated diffusion **Facilitated diffusion is a process that involves the movement of molecules from higher concentrations to lower concentrations by a protein carrier across the membrane. It is a passive process in which the glucose molecules are transported into the cell by combining with the carrier molecule from extracellular fluid to intracellular fluid.
A patient who normally takes an oral antidiabetic agent twice a day, at morning and at bedtime, asks the nurse what to do about the dose the morning of the surgery. What is the best response by the nurse? Skip taking the drug the morning of surgery. Take the medication with a small sip of water. Eat a light snack for breakfast and take the medication. Get instructions from the health care provider for any special instructions.
Get instructions from the health care provider for any special instructions.
The perioperative nurse is explaining legal considerations regarding surgical team performance. The nurse tells the team that to whom or what does the surgical technologist need access at all times? Surgeon Computer Anesthesiologist Registered nurse
RN *If the circulating nurse is not an RN, the licensed practical/vocational nurse or surgical technologist must have access to an RN at all times pg. 317
The nurse receives an unconscious postoperative patient in the post anesthesia care unit (PACU). What position would be the safest to place this patient immediately after the operation? Supine Lateral Semi-Fowler's High Fowler's
lateral
The nurse is documenting a patient's skin turgor assessment. After pinching a fold of skin over the sternum, it takes approximately 22 seconds for the pinched skin to return to normal after being released. How would the nurse most accurately document this finding? Poor Lagged Normal Decreased
poor
A nurse working in the emergency department is taking care of a patient with respiratory alkalosis. Which statements would be appropriate for the nurse to give as an explanation of the cause of this imbalance to the patient and family? . "This imbalance is never caused by central nervous system disorders." "Hyperventilation can occur without any physiologic need from pain or anxiety." "This imbalance can be caused by hyperventilation, which can occur from fevers." "The primary cause is hypoxemia from acute pulmonary disorders, such as pneumonia." "The primary cause is hypercarbia from an acute pulmonary disorder, such as a pulmonary embolism."
"Hyperventilation can occur without any physiologic need from pain or anxiety." "This imbalance can be caused by hyperventilation, which can occur from fevers." "The primary cause is hypoxemia from acute pulmonary disorders, such as pneumonia."
A patient is instructed not to have anything to eat or drink eight hours prior to surgery. When arriving to the preoperative holding area, the patient informs the nurse they ate eggs and toast about 2 hours ago. What is the best response by the nurse? "We will do the surgery, but it will increase your risk of complications." "You were provided with strict instructions on what to do before surgery." "We will keep you in the hospital overnight to be sure you don't do that again." "I will inform the anesthesia care provider and surgeon to see what the options are."
"I will inform the anesthesia care provider and surgeon to see what the options are."
The family of a patient being treated for acute pancreatitis hears the nurse referring to "third spacing" during the assessment and asks the nurse what that means. Which explanation provides the best description for the family? "This is just a term that we use to describe edema." "Third-spacing refers to how the fluids both inside and outside of the cells are distributed." "Third-spacing describes the places where fluids can be found in the cells, blood vessels, and lymph system." "The fluid normally in the cells becomes trapped in between the cells and has difficulty moving back into the cells."
"The fluid normally in the cells becomes trapped in between the cells and has difficulty moving back into the cells."
The nurse is educating a patient regarding skin care management. What statement made by the patient indicates to the nurse that further education is required? "Avoid extreme temperatures." "Apply moisturizers even at night." "Wash hands and legs frequently with soap." "Change your position regularly while at rest."
"Wash hands and legs frequently with soap."
A child is brought to the emergency room for the surgical reduction of a displaced shoulder. The parents ask the nurse if the child will undergo anesthesia. Which is the most appropriate response by the nurse? "Your child will most likely be moderately sedated for the procedure." "There is no need for anesthesia because the reduction does not involve an incision." "Due to your child's age, your child will likely be given a general anesthetic before reduction." "The primary care provider will most likely use an epidural or spinal block to numb the area for the procedure."
"Your child will most likely be moderately sedated for the procedure."
The nurse is caring for a patient with hyponatremia associated with heart failure and liver cirrhosis. What drug does the nurse anticipate administering to treat this patient? Amiloride Tolvaptan Kayexalate Pamidronate
-Tolvaptan *Tolvaptan is used to treat hyponatremia associated with heart failure and liver cirrhosis. It acts by blocking the activity of antidiuretic hormone. Amiloride is a potassium-sparing diuretic that is not effective in treating hyponatremia. Kayexalate is an ion-exchange resin used to treat hyperkalemia. Pamidronate is used to treat hypercalcemia.
A nurse is preparing a patient for cataract surgery. The nurse needs to instill different eye drops into the patient's eyes. How many minutes should the nurse wait between each set of eye drops?
5 minutes
The nurse is caring for a patient with hypercalcemia. Which nursing interventions are appropriate when caring for a patient for this patient?
Administer furosemide. Administer bisphosphonates. Administer isotonic saline infusions. *Hypercalcemia is treated by hydrating the patient and promoting urinary excretion of calcium. Therefore the nurse should administer loop diuretics such as furosemide to promote diuresis and should keep the patient hydrated by administering isotonic saline infusions. The nurse can also administer bisphosphonates to inhibit the activity of osteoclasts. The patient should be encouraged to drink at least 3000 to 4000 mL of fluid to promote calcium excretion and prevent kidney stones. The patient is encouraged to breathe into a paper bag if signs of hypocalcemia are evident.
An asthmatic patient underwent a splenectomy. During surgery, the patient is administered ketamine as an anesthetic, with ranitidine. Postoperatively, the patient's family members report that the patient is behaving strangely and talking to people who are not present. The patient has a history of depression. The nurse suspects that what is the most probable reason for this behavior? Exacerbation of asthma Administration of ketamine Administration of ranitidine Manifestation of depression
Administration of ketamine
The nurse is caring for a patient in the postanesthesia care unit (PACU), when the blood pressure drops from 110/60 mm HG to 92/58 mm Hg. What actions should the nurse take? Assess ECG tracing. Inspect the surgical site. Administer pain medication. Administer prescribed metoprolol. Have the patient take deep breaths. Administer intravenous (IV) fluid bolus per protocol.
Assess ECG tracing. Inspect the surgical site Have the patient take deep breaths. Administer intravenous (IV) fluid bolus per protocol.
A patient who is scheduled for thyroid surgery reports amenorrhea that began two months ago. How should the nurse ensure the patient is not pregnant? By taking an x-ray By checking hematocrit level By checking international normalized ratio level By checking human chorionic gonadotropin level
By checking human chorionic gonadotropin level
A patient that is an alcoholic had a hernia operation and is restless and irritable. On assessment, the nurse finds that the patient has auditory hallucinations. What is the most appropriate nursing action? Conclude that these effects are due to alcohol withdrawal. Consider the situation normal, due to the anesthetic drugs. Conclude that the patient suffers from a psychotic disorder. Infer that the patient is suffering from pain and suggest using pain killers.
Conclude that these effects are due to alcohol withdrawal.
A patient's potassium level is 2.9 meq/L. Which health care provider order should the nurse expect? Continuous ECG monitoring Increase digoxin (Lanoxin) to 0.25 mg every day Add 20 meq KCL to the present IV bag hanging and give over four hours 40 meq KCL in 100 cc D5W intravenous piggyback (IVPB) to infuse over 30 minutes
Continuous ECG monitoring
A patient asks the nurse whether it is alright to take regularly scheduled insulin on the morning of surgery. What is the most appropriate nursing action? Inform the patient to skip the insulin dose on the morning of surgery. Tell the patient to take half the usual dose on the morning of surgery. Tell the patient to take the same dose as he or she is currently taking every day. Inform the surgeon of the patient's insulin use and ask whether the dose needs to be adjusted.
Inform the surgeon of the patient's insulin use and ask whether the dose needs to be adjusted.
Which is a priority nursing action when providing care to a patient who is being treated for hypernatremia that developed slowly over several days? Initiating seizure precautions Administering prescribed diuretics Monitoring the patient's weight each day Restricting the patient's dietary sodium intake
Initiating seizure precautions **A rapid reduction in the sodium level can cause a rapid shift of water back into the cells, resulting in cerebral edema and neurologic complications. This risk is greatest in a patient who developed hypernatremia over several days or longer. The priority nursing action in this case is to implement seizure precautions due to the risk of neurologic complications. Monitoring the patient's weight each day, restricting dietary sodium intake, and administering prescribed diuretics are all appropriate nursing actions; however, these are not the priority given this patient's risk for neurologic complications.
The nurse has been administering magnesium sulphate I.V. to a patient with preeclampsia. When observing signs of toxicity, what medication should the nurse administer to counter the effects of the magnesium? Intravenous calcium chloride Intravenous magnesium sulfate Intravenous potassium chloride Intravenous 3% sodium chloride
Intravenous calcium chloride **Magnesium toxicity can be treated by administering intravenous calcium chloride to antagonize the effects of magnesium on the cardiac muscles. Intravenous magnesium sulfate can further increase magnesium toxicity. Intravenous potassium chloride is used to treat hypokalemia, but it does not reverse magnesium toxicity. A solution of 3% intravenous sodium chloride is used to treat hyponatremia.
The nurse is admitting a patient reporting abdominal pain, nausea, and vomiting. A bowel obstruction is suspected. The patient is assessed for which anticipated primary acid-base imbalance if the obstruction is high in the intestine? Metabolic acidosis Metabolic alkalosis Respiratory acidosis Metabolic respiration
Metabolic alkalosis
While reviewing a patient's laboratory reports, the nurse finds the plasma concentration of calcium to be 11.2 mg/dL. Which clinical manifestations does the nurse anticipate observing? (select all that apply) Polyuria Seizures Nephrolithiasis Chvostek's sign Trousseau's sign
Nephrolithiasis Polyuria **Plasma concentration of calcium greater than 10.2 mg/dL indicates hypercalcemia, which results in increased concentration of calcium in the urine. This impairs sodium and water reabsorption and causes polyuria. Hypercalcemia can cause kidney stones, or nephrolithiasis, because an increased concentration of calcium in the urine deposits crystals in the kidney, which combine to form kidney stones. Seizures, Chvostek's sign, and Trousseau's sign are clinical manifestations of hypocalcemia.
The nurse asks the patient scheduled for a total hip replacement to sign the operative permit as directed in the health care provider's preoperative prescriptions. The patient states that the health care provider has not really explained what is involved in the surgical procedure. What is the most appropriate action by the nurse? Ask family members to clarify the information for the patient. Have the patient sign the form and explain the procedure to the patient. Notify the health care provider about the conversation with the patient and delay the signature. Have the patient sign the consent form and ask the health care provider to discuss again before surgery.
Notify the health care provider about the conversation with the patient and delay the signature.
The circulating nurse is providing orientation to a group of nurses who are new to the perioperative setting. What should the nurse emphasize to the nurses that the role of the circulating nurse is? Ongoing assessment of the patient during the surgical procedure Implementing specific tasks related to surgical policies and procedures Ensuring that the patient has been assessed for safe administration of anesthesia Performing a preoperative history and physical assessment to identify patient needs
Ongoing assessment of the patient during the surgical procedure
An older patient is having problems with concentration and memory after extensive surgery to repair an abdominal aortic aneurysm. What determines if this is a factor of delirium or postoperative cognitive dysfunction? Preexisting dementia identified before surgery Ability of the patient to state name, location, and date Ability to ambulate in the halls and follow commands An undisturbed sleep-wake cycle in the critical care unit
Preexisting dementia identified before surgery **Dementia should be assessed preoperatively so interventions can be established after surgery to help the patient meet outcomes.
In which phase of general anesthesia are H 2 blockers used? Induction phase Emergence phase Preinduction phase Maintenance phase
Preinduction phase
An unconscious patient needs to undergo emergency surgery. There are no family members or friends available. What action should the nurse take regarding obtaining consent for the surgery? Call the local magistrate to get consent for the surgery. Obtain consent from a legally appointed representative. Avoid giving any treatment because it is illegal to treat without consent. Proceed with plans for surgery; consent is not required for a true medical emergency.
Proceed with plans for surgery; consent is not required for a true medical emergency.
The nurse is caring for a patient postoperatively after major abdominal trauma sustained during a motor vehicle crash. The patient begins to pick at the air and asks the nurse why there are so many bugs in the room. Which nursing actions are a priority at this time? Provide a calm, quiet environment. Obtain an order for a benzodiazepine. Monitor the patient for increased heart rate and blood pressure. Assess the patient for cardiopulmonary and respiratory depression. Observe the patient for transient skeletal muscle movements (myoclonia).
Provide a calm, quiet environment. Obtain an order for a benzodiazepine. Monitor the patient for increased heart rate and blood pressure.
The nurse is monitoring a patient who is about to be transferred to the clinical unit from the postanesthesia care unit (PACU). Which assessment data require the most immediate attention? Oxygen saturation of 94% Pulse rate 128 beats/minute Respiratory rate of 13/minute Temperature of 99.8° F (37.7° C)
Pulse rate 128 beats/minute
A patient inadvertently received a large amount of intravenous fluid. The nurse assesses that the patient has reduced oxygen saturation, crackles on auscultation, and infiltrates on chest x-ray. How should the nurse relieve the patient's breathing discomfort and promote oxygen saturation? Restrict fluids. Administer diuretics. Administer oxygen therapy. Administer bronchodilators. Implement anticoagulant therapy.
Restrict fluids. Administer diuretics. Administer oxygen therapy.
A pregnant woman reports headaches and shortness of breath to the nurse. The nurse auscultates crackles and a bounding pulse. What is the appropriate nursing action? Applying hot and cold compresses Restricting the intake of dietary sodium Asking the patient to sit and then stand Providing ice chips to hydrate the patient
Restricting the intake of dietary sodium
