Exam 1 Practice Test
An awake postoperative client received and intravenous regional nerve block (Bier block) in the arm that is now casted and elevated on pillow. What action should the nurse encourage the client to avoid until sensation returns? A) Holding the operated arm close to the face B) Holding the operated arm with the unoperated arm C) Using the unoperated arm D) Using pain medication
A) Holding the operated arm close to the face
A client is prescribed prolonged bedrest after surgery. Which complication does the nurse expect to prevent by teaching this client to avoid pressure on the popliteal space? A) Cerebral embolism B) Pulmonary embolism C) Dry gangrene of a limb D) Coronary vessel occlusion
B) Pulmonary embolism
The nurse is assessing a client recovering from anesthesia. Which of the following is an early indicator of hypoxemia? A) Somnolence B) Restlessness C) Chills D) Urgency
B) Restlessness (agitation)
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? A) Increasing restlessness B) A pulse of 86 beats/min C) Blood pressure of 110/70 D) Hypoactive bowel sounds in all four quadrants
A) Increasing restlessness
The nurse anticipates that a client who has received Propofol (Diprivan) as the induction and maintenance agent for general anesthesia will most likely experiences: A) Minimal nausea and vomiting B) Hypotension C) Slow induction of anesthesia D) Small tremors of the skeletal muscles
A) Minimal nausea and vomiting
The nurse is reviewing the chart of a 55 year old male client who is scheduled for a lumbar laminectomy. The nurse should report which of the following to the surgeon? A) Pimple on the lower back B) Abnormal ECG C) Hearing aid D) Allergy to iodine
A) Pimple on the lower back (lead to infection)
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? A) Pneumonia B) Hypoxemia C) Fluid imbalance D) Pulmonary embolism
A) Pneumonia
The nurse is reviewing a health care provider's prescription sheet for a preoperative client that states that the client must be NPO after midnight. The nurse would telephone the health care provider to clarify that which medication should be given to the client and not withheld? A) Prednisone B) Ferrous Sulfate C) Cyclobenzaprine (Flexeril) D) Conjugated estrogen (Premarin)
A) Prednisone
What action should the nurse take to avoid spreading nosocomial infections? A) Remove the face mask B) Remove the hair covering C) Wash her hands before tying the strings on the mask D) Tie the dangling strings of the mask around her neck
A) Remove the face mask
When an analgesic is titrated to manage pain, what is the priority goal? A) Titrate to the smallest dose that provides relief with the fewest side effects B) Titrate upward until the client is pain free C) Titrate downward to prevent toxicity D) Titrate to a dosage that is adequate to meet the client's subjective needs
A) Titrate to the smallest dose that provides relief with the fewest side effects
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? A) Red, hard skin B) Serous draining C) Purulent drainage D) Warm, tender skin
B) Serous draining
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? A) Urinary output of 20 ml/hr B) Temperature of 99.6 F C) Blood pressure of 100/70 D) Serous drainage on the surgical dressing
A) Urinary output of 20 ml/hr
After surgery for insertion of a coronary artery bypass graft (CABG), a client develops a temperature of 102 F. What priority concern related to elevated temperatures does a nurse consider when notifying the health care provider about the client's temperature? A) a fever may lead to diaphoresis B) A fever increases the cardiac output C) An increased temperature indicated cerebral edema D) An increased temperature may be a sign of hemorrhage
B) A fever increases the cardiac output
A client received a PRN morphine, lorazepam (Ativan), and cyclobenzaprine (Flexeril). The UAP reports that the client has a respiratory rate of 10 breaths/min. What is the priority nursing action? A) Call the physician to obtain an order for naloxone (Narcan) B) Assess the client's responsiveness and respiratory status C) Obtain a bag-valve mask and deliver breaths at 20/min D) Double-check the drug order to see what the client should have received
B) Assess the client's responsiveness and respiratory status
The nurse is assessing a client's nutritional status preoperatively. Which of the following observations would indicate poor nutrition in a 5-foot 7-inch female client who is 21 years of age? A) Poor posture B) Brittle nails C) Dull expression D) Weight of 128 pounds (58.1 kg)
B) Brittle nails
The nurse receives the preoperative blood work report for a client who is scheduled to undergo surgery. Which of the following laboratory findings should be reported to the surgeon? A) Red blood cells 4.5 million/mm3 B) Creatinine 2.6 mg/dL C) Hemoglobin 12.2 g/dL D) BUN 15 mg/dL
B) Creatinine 2.6 mg/dL
While being prepared for surgery for a ruptured spleen, a client complains of feeling light-headed. The client's color is pale and the pulse is rapid. What should the nurse conclude about the client's condition? A) Hyperventilating B) Going into shock C) Experiencing anxiety D) Developing an infection
B) Going into shock
A client who has undergone preadmission testing has had a blood drawn for serum laboratory studies including a complete blood count, coagulation studies and electrolytes and creatinine levels. Which laboratory results should be reported to the surgeon's office by the nurse, knowing that it could cause surgery to be postponed? A) Sodium 141 mEq/L B) Hemoglobin, 8.0 g/dL C) Platelets, 210,000/mm3 D) Serum creatinine 0.8 mg/dL
B) Hemoglobin, 8.0 g/dL
The nurse assesses a client who has just received morphine sulfate. The client's blood pressure is 90/50 mmHg, pulse rate 58 bpm, respiration rate 4 breaths/min. The nurse should check the client's chart for an order to administer? A) Flumazenil (Romazicon) B) Naloxone hydrochloride (Narcan) C) Doxacurium (Neuromax) D) Remifentanily (Ultiva)
B) Naloxone hydrochloride (Narcan)
The client has a latex allergy. What should the nurse teach the client to do before having surgery at a free-standing surgery center? Select all that apply A) Determine that there will be a latex-safe environment for surgery B) Report symptoms experienced with the latex allergy (e.g. rhinitis, conjunctivitis, flushing) C) Notify the health care providers at the surgery center D) Wear a stainless steel medical alert bracelet into the surgical suite E) Ask to have the surgery at the hospital
A) Determine that there will be a latex-safe environment for surgery B) Report symptoms experienced with the latex allergy (e.g. rhinitis, conjunctivitis, flushing) C) Notify the health care providers at the surgery center
A client will receive IV midazolam hydrochloride (versed) during surgery. Which of the following should the nurse determine as a therapeutic effect? A) Amnesia B) Nausea C) Mild agitation D) Blurred vision
A) Amnesia
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? A) Assess the patency of the airway B) Check tubes or drains for patency C) Check the dressing to assess for bleeding D) Assess the vital signs to compare with preoperative measurements
A) Assess the patency of the airway
The nurse assesses vital signs on a client who has had epidural anesthesia. For which of the following should the nurse assess next? A) Bladder distention B) Headache C) Postoperative pain D) Ability to move the legs
A) Bladder distention
The surgical floor receives a new postoperative client from the post anesthesia care unit. Assessment reveals that the client has a patent airway and stable vital signs. The nurse should next: A) Check the dressing for signs of bleeding B) Empty any peri-incisional drains C) Assess the client's pain level D) Assess the client's bladder
A) Check the dressing for signs of bleeding
A client who has had abdominal surgery complains of feeling as though "something gave way" in the incisional site. The nurse removes the dressing and notes the presence of a loop of bowel protruding through the incision. Which nursing interventions should the nurse take? Select all that apply A) Contact the surgeon B) Instruct the client to remain quiet C) Prepare the client for wound closure D) Document the findings and actions taken E) Place a sterile saline dressing and ice packs over the wound F) Place the client in a supine position without a pillow under the head
A) Contact the surgeon B) Instruct the client to remain quiet C) Prepare the client for wound closure D) Document the findings and actions taken
A client returns to the medical-surgical floor from the post-anesthesia recovery room after a colon resection for adenocarcinoma. The client has comorbidities of stage 2 hypertension and a previous myocardial infarction. The first set of postoperative viral signs are recorded are pulse rate of 110 bpm, respiration rate of 20/min, blood pressure of 130/86 mmHg, and temperature of 98 F. The surgeon calls to ask if the client needs a unit of packed red blood cells. The nurse's response should be based on which data? Select all that apply A) Cyanotic mucous membrane B) Warm, dry skin C) Vital sign changes D) Oxygen saturation E) Intake and output
A) Cyanotic mucous membrane C) Vital sign changes D) Oxygen saturation E) Intake and output
When the nurse is conducting a preoperative interview with a client who is having a vaginal hysterectomy, the client states that she forgot to tell her doctor that she had a total hip replacement 3 years ago. The nurse communicates this information to the perioperative nurse because: A) The prosthesis may cause a problem with the electrosurgical unit used to control bleeding B) The client should not have her hip externally rotated when she is positioned for the surgery C) The perioperative nurse can inform the rest of the team about the total hip replacement D) There is not enough time to notify the surgeon and not this finding on the history and physical examination
B) The client should not have her hip externally rotated when she is positioned for the surgery
A client is admitted on the day of surgery for an arthroscopy of the left knee. Which nursing activities should be completed to avoid wrong-site surgery? Select all that apply A) Ask the surgeon preoperatively to mark with a permanent marker the correct knee for the surgical site B) Verbally ask the client with the correct operative site by medical records and radiographic diagnostic reports C) Verify the correct client with the correct operative site by medical records and radiographic diagnostic reports D) Call a "time-out" in the operating room to have the surgeon verify the correct knee before making the incision E) Show the client an anatomical model of the surgery site
B) Verbally ask the client with the correct operative site by medical records and radiographic diagnostic reports C) Verify the correct client with the correct operative site by medical records and radiographic diagnostic reports D) Call a "time-out" in the operating room to have the surgeon verify the correct knee before making the incision
On the day of surgery a client with diabetes who takes insulin on a sliding scale is ordered to have nothing by mouth and all medications withheld. The client's 6 AM glucose level is 300 mg/dL. The nurse should: A) Withhold all medications as ordered B) Administer the insulin dose indicated by the sliding scale C) Call the physician for specific orders based on the glucose level D) Notify the surgery department
C) Call the physician for specific orders based on the glucose level
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? A) If it is any help, everyone is nervous before surgery B) I will be happy to explain the entire surgical procedure to you C) Can you share with me what you've been told about your surgery D) Let me tell you about the care you'll receive after surgery and the amount of pain you can anticipate
C) Can you share with me what you've been told about your surgery
The physician has ordered a placebo for a client with chronic pain. You are a newly hired nurse and you feel very uncomfortable administering the medication. What is the first action that you should take? A) Prepare the medication and hand it to the physician B) Check the hospital policy regarding the use of a placebo C) Follow a personal code of ethics and refuse to participate D) Contact the charge nurse for advice
D) Contact the charge nurse for advice (generally considered unethical to give a placebo)
Which of the following nursing interventions is most important in preventing postoperative complications? A) Progressive diet planning B) Pain management C) Bowel and elimination monitoring D) Early ambulation
D) Early ambulation
A client had a cholecystectomy 8.5 hours ago. She has received 1,500 mL of dextrose 5% in water with normal saline solution. The client has just used a patient-controlled analgesia pump to administer morphine for pain, has been repositioned for comfort and has stable pulse rate, respirations, and blood pressure. What should the nurse do next? A) Check that the family is comfortable B) Assess vital signs following use of morphine C) Dim the lights in the room D) Increase nasal oxygen from 2 to 3 L
C) Dim the lights in the room (comfort leads to pain decrease)
The nurse is preparing to administer a preoperative medication. Which of the following actions should the nurse take first? A) Have the family present B) Ensure that the preoperative shave is completed C) Have the client empty his bladder D) Make sure the client is covered with a warm blanket
C) Have the client empty his bladder
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? A) Avoid oral hygiene and rinsing with mouthwash B) Verify that the client has not eaten for the last 24 hours C) Have the client void immediately before going into surgery D) Report immediately any slight increase in blood pressure or pulse
C) Have the client void immediately before going into surgery
The client is admitted to the surgical floor after having bowel surgery. The nurse observes that the client's urine output has decreased from 50 to 20 mL/hr. Which of the following is the most likely cause? A) Bowel obstruction B) Adverse effect opioid analgesics C) Hemorrhage D) Hypertension
C) Hemorrhage (assess for the cause when urine output less than 30 mL/hr
Following abdominal surgery a client refuses to deep breath and cough every 2 hours as ordered. The nurse should do which of the following first? A) Ask the client's wife to insist that the client take the deep breaths every 2 hours B) Respect the client's wishes and turn the client from side to side more frequently C) Suggest that the client increase daily fluid intake to at least 2,500 ml D) Explain the risks of not expanding the lungs and why the exercise is important
D) Explain the risks of not expanding the lungs and why the exercise is important
You are the charge nurse. A client with chronic pain reports to you that the nurses have not been responding to requests for pain medication. What is your initial action? A) Check the MAR for the past several days B) Ask the nurse educator to provide in-service training about pain management C) Perform a complete pain assessment on the client and take a pain history D) Have a conference with the nurses responsible for the care of this client
D) Have a conference with the nurses responsible for the care of this client
Family members are encouraging your client to "tough out the pain" rather than risk drug addiction to narcotics. The client is stoically abiding. You recognize that the sociocultural dimension of pain is the current priority for the client. Which question will you ask? A) Where is the pain location and does it radiate to other parts of your body? B) How would you describe the pain, and how is it affecting you? C) How is the pain affecting your activity level and your ability to function? D) What information do you need about pain, healing, and addiction?
C) How is the pain affecting your activity level and your ability to function?
When completing the preoperative checklist on the nursing unit, the nurse discovers an allergy that the client has not reported. What should the nurse do first? A) Administer the prescribed pre-anesthetic medication B) Note this new allergy prominently at the front of the chart C) Contact the scrub nurse in the operating room D) Inform the nurse anesthetist
D) Inform the nurse anesthetist
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 (aspirin). The nurse determines that the client needs additional teaching if the client makes which statement? A) Aspirin can cause bleeding after surgery B) Aspirin can cause my ability to clot blood to be abnormal C) I need to continue to take the aspirin until the day of surgery D) I need to check with my healthcare provider about the need to stop the aspirin before the scheduled surgery
C) I need to continue to take the aspirin until the day of surgery
On the admission to same-day surgery, the nurse reviews the chart to verify the client's identification documentation. Which of the following is most important? A) Admitting record B) Addressograph labels C) Identification bracelet D) Location of family
C) Identification bracelet
The nurse is preparing a preoperative teaching plan for a client who is undergoing a bilateral breast reduction. Which aspect of the plan is the priority? A) Reduction of risk potential B) Physiologic adaptation C) Psychosocial integrity D) Health promotion and maintenance
C) Psychosocial integrity (body image changes)
When assessing a client who had spinal anesthesia, which of the following would the nurse expect to find? A) The client feels pain before moving the legs B) The blood pressure is significantly increased C) Sensation returns to the toes first, then progresses to the perineal area D) The client complains of a headache while in the lying position
C) Sensation returns to the toes first, then progresses to the perineal area
A client who is to receive general anesthesia has a serum potassium level of 5.8 mEq/L. What should be the nurse's first response? A) Call the surgeon B) Send the client to surgery C) Make a note on the front of the chart D) Notify the anesthesiologist
D) Notify the anesthesiologist (places client at risk for arrhythmias)
A client had a total abdominal hysterectomy and bilateral oophorectomy for ovarian carcinoma yesterday. She received 2 mg of morphine sulfate IV by patient-controlled analgesia 10 minutes ago. The nurse was assisting her form the bed to the chair when the client felt dizzy and fell into the chair. The nurse should: A) Discontinue the PCA pump B) Administer oxygen C) Take the client's blood pressure D) Assist the client back to bed
C) Take the client's blood pressure (orthostatic hypotension)
During preadmission testing for same-day surgery, a client states that she has had two cloves of garlic each day to her diet to help control her blood pressure. The nurse should further inquire about which of the following? A) The type of surgery the client is having B) What her blood pressure has been running C) The amount of garlic she is eating D) Her preference for the type of anesthesia
C) The amount of garlic she is eating (garlic has anticoagulant properties)
A client is eligible for patient controlled analgesia (PCA) when: A) A family member is able to assist with self-dosing B) There is a court-appointed advocate to assist with dosing C) The client has the ability to self-dose D) There is a nurse to assist with self-dosing
C) The client has the ability to self-dose
When attempting to check the pupils of a client scheduled to receive general anesthesia, the nurse notices that the client has trouble tilting his head back. Which of the following does the nurse recognize as the primary concern related to this finding? A) The client has limited movement of his neck B) The client is at risk for postoperative neck pain C) The client is at risk for difficult intubation D) The ability to assess the client's pupils is limited
C) The client is at risk for difficult intubation
In application of the principles of pain treatment, what is the first consideration? A) Treatment is based on client goals B) A multidisciplinary approach is needed C) The client's perception of pain must be accepted D) Drug side effects must be prevented and managed
C) The client's perception of pain must be accepted
A client arrives from surgery to the post anesthesia care unit. Which of the following respiratory assessments should the nurse complete first? A) Oxygen saturation B) Respiration rate C) Breath sounds D) Airway flow
D) Airway flow (abc's)
The client has returned to the surgery unit from the Post Anesthesia Care Unit. The client's respirations are rapid and shallow, the pulse is 120. and the blood pressure is 88/52. The client's level of consciousness is deteriorating. The nurse should do which of the following first? A) Call the PACU B) Call the primary care physician C) Call the respiratory therapist D) Call the rapid response team
D) Call the rapid response team
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? A) Obtain a court order for the surgery B) Have the charge nurse sign the informed consent immediately C) Send the client into surgery without the consent form being signed D) Obtain a telephone consent form a family member following agency policy
D) Obtain a telephone consent form a family member following agency policy
A nurse in the post-anesthesia care unit is caring for a client who received a general anesthetic. Which finding should the nurse report to the health care provider? A) Client pushes the airway out B) Client has snoring respirations C) Respirations of 16 breaths/min are shallow D) Systolic blood pressure drops from 130 to 90 mmHg
D) Systolic blood pressure drops from 130 to 90 mmHg
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? A) Inhale as rapidly as possible B) Keep a loose seal between the lips and mouthpiece C) After maximum inspiration, hold breath for 15 seconds and exhale D) The best results are achieved when sitting up or with the head of the bed elevated 45 to 90 degrees
D) The best results are achieved when sitting up or with the head of the bed elevated 45 to 90 degrees