EXAM 1 Prep-U's

A client who is scheduled for knee surgery is anxious about the procedure, saying, "You hear stories on the news all the time about doctors working on the wrong body part. What if that happens to me?" What is the nurse's best response? Select all that apply. - "The client can be involved in marking the knee, the site for the surgery." - "The surgical team performs a 'time-out' prior to surgery to conduct a final verification." - "The surgeon on the team has never been involved in such a mix-up." - "The client will be involved in the verification process prior to surgery." - "Our surgical team would never make that mistake."

Answer: - "The client can be involved in marking the knee, the site for the surgery." - "The surgical team performs a 'time-out' prior to surgery to conduct a final verification." - "The client will be involved in the verification process prior to surgery."

The physician has prescribed 0.9% sodium chloride IV for a hospitalized client in metabolic alkalosis. Which nursing actions are required to manage this client? Select all that apply. - Compare ABG findings with previous results. - Maintain intake and output records. - Document presenting signs and symptoms. - Administer IV bicarbonate. - Suction the client's airway.

Answer: - Compare ABG findings with previous results. - Maintain intake and output records. - Document presenting signs and symptoms.

A nurse caring for a patient who is receiving an IV solution via a central vein suspects the complication of an air embolism. Which of the following are signs and symptoms consistent with that diagnosis? Select all that apply. - Crackles on auscultation - Cyanosis - Hypertension - Shoulder pain - Dyspnea - Tachycardia

Answer: - Cyanosis - Shoulder pain - Dyspnea - Tachycardia

A patient is complaining of a headache after receiving spinal anesthesia. What does the nurse understand may be the cause of the headache related to the spinal anesthesia? (Select all that apply.) - The patient lying in the supine position - Leakage of spinal fluid from the subarachnoid space - Size of the spinal needle used - Degree of patient hydration - An allergic reaction to the medication used

Answer: - Leakage of spinal fluid from the subarachnoid space - Size of the spinal needle used - Degree of patient hydration Rationale: Headache may be an aftereffect of spinal anesthesia. Several factors are related to the incidence of headache: the size of the spinal needle used, the leakage of fluid from the subarachnoid space through the puncture site, and the patient's hydration status. Measures that increase cerebrospinal pressure are helpful in relieving headache. These include maintaining a quiet environment, keeping the patient lying flat, and keeping the patient well hydrated. A headache is not likely to occur as the result of the patient lying in the supine position or of an allergic reaction to the medication.

The nurse assesses a client to determine if there is increased risk for complications intraoperatively or postoperatively. Which are general risk factors? Select all that apply. - nutritional status - age - physical condition - gender - health status - Ethnicity

Answer: - nutritional status - age - physical condition - health status

The nurse is aware that which of the following helps to stimulate T-cell response: A.) Arginine B.) Biotin C.) Vitamin D D.) Zinc

Answer: A.) Arginine Rationale: Arginine is necessary for collagen synthesis and deposition, increases wound strength, and stimulates T-cell response.

Which findings indicate that a client has developed water intoxication secondary to treatment for diabetes insipidus? A.) Confusion and seizures B.) Sunken eyeballs and spasticity C.) Flaccidity and thirst D.) Tetany and increased blood urea nitrogen (BUN) levels

Answer: A.) Confusion and seizures Rationale: Classic signs of water intoxication include confusion and seizures, both of which are caused by cerebral edema. Weight gain will also occur. Sunken eyeballs, thirst, and increased BUN levels indicate fluid volume deficit. Spasticity, flaccidity, and tetany are unrelated to water intoxication.

What medication should the nurse prepare to administer in the event the client has malignant hyperthermia? A.) Dantrolene sodium B.) Fentanyl citrate C.) Naloxone D.) Thiopental sodium

Answer: A.) Dantrolene sodium

Which type of healing occurs when granulation tissue is not visible and scar formation is minimal? A.) First intention B.) Second intention C.) Third intention D.) Fourth intention

Answer: A.) First intention

Nursing students are reviewing information about agents used for anesthesia. The students demonstrate understanding when they identify which of the following as an inhalation anesthetic? A.) Halothane B.) Fentanyl C.) Succinylcholine D.) Propofol

Answer: A.) Halothane Rationale: Halothane is an example of an inhalation anesthetic. Fentanyl, succinylcholine, and propofol are commonly used intravenous agents for anesthesia.

The nurse is assigned to care for a client with a serum phosphorus concentration of 5.0 mg/dL (1.61 mmol/L). The nurse anticipates that the client will also experience which electrolyte imbalance? A.) Hypocalcemia B.) Hyperchloremia C.) Hypermagnesemia D.) Hyponatremia

Answer: A.) Hypocalcemia

The nurse is caring for a client undergoing alcohol withdrawal. Which serum laboratory value should the nurse monitor most closely? A.) Magnesium B.) Calcium C.) Phosphorus D.) Potassium

Answer: A.) Magnesium Rationale: Chronic alcohol abuse is a major cause of symptomatic hypomagnesemia in the United States. The serum magnesium concentration should be measured at least every 2 or 3 days in clients undergoing alcohol withdrawal. The serum magnesium concentration may be normal at admission but may decrease as a result of metabolic changes, such as the intracellular shift of magnesium associated with intravenous glucose administration.

The nurse is caring for a client with severe diarrhea. The nurse recognizes that the client is at risk for developing which acid-base imbalance? A.) Metabolic acidosis B.) Respiratory acidosis C.) Metabolic alkalosis D.) Respiratory alkalosis

Answer: A.) Metabolic acidosis

Which of the following consequences may result if tranquilizers are withdrawn suddenly? A.) Seizures B.) Cardiovascular collapse C.) Hypotension D.) Respiratory depression

Answer: A.) Seizures Rationale: Abrupt withdrawal of tranquilizers may result in anxiety, tension, and even seizures if withdrawn suddenly. Abrupt withdrawal of steroids may precipitate cardiovascular collapse. Monoamine oxidase inhibitors increase the hypotensive effects of anesthetics. Thiazide diuretics may cause excessive respiratory depression during anesthesia due to an associated electrolyte imbalance.

A client is diagnosed with syndrome of inappropriate antidiuretic hormone (SIADH). The nurse should anticipate which laboratory test result? A.) Serum sodium level of 124 mEq/L B.) Serum creatinine level of 0.4 mg/dl C.) Hematocrit of 52% D.) Serum blood urea nitrogen (BUN) level of 8.6 mg/dl

Answer: A.) Serum sodium level of 124 mEq/L

A nurse is caring for a client who is three hours post op from open abdominal surgery. During routine assessment, the nurse notes the previously stable client now appears anxious, apprehensive, and has a blood pressure of 90/56. What does the nurse consider is the most likely cause of the client's change in condition? A.) The client is displaying early signs of shock. B.) The client is showing signs of a medication reaction. C.) The client is displaying late signs of shock. D.) The client is showing signs of an anesthesia reaction.

Answer: A.) The client is displaying early signs of shock.

The client is experiencing intractable hiccups following surgery. What would the nurse expect the surgeon to order? A.) chlorpromazine B.) metoclopramide C.) omeprazole D.) nizatidine

Answer: A.) chlorpromazine

A 17-year-old client is having same-day surgery. Solely during the intraoperative phase of perioperative care, the nurse: A.) continuously monitors the sedated client. B.) performs a complete assessment of the client. C.) obtains a surgical consent from the client's mother. D.) assesses how well the client is recovering from anesthesia.

Answer: A.) continuously monitors the sedated client.

A nurse is caring for a client who underwent a skin biopsy and has three stitches in place. This wound is healing by: A.) first intention. B.) second intention. C.) third intention. D.) fourth intention.

Answer: A.) first intention.

A client reports muscle cramps in the calves and feeling "tired a lot." The client is taking ethacrynic acid (Edecrin) for hypertension. Based on these symptoms, the client will be evaluated for which electrolyte imbalance? A.) hypokalemia B.) hyperkalemia C.) hypocalcemia D.) hypercalcemia

Answer: A.) hypokalemia Rationale: Hypokalemia causes fatigue, weakness, anorexia, nausea, vomiting, cardiac dysrhythmias, leg cramps, muscle weakness, and paresthesias. Many diuretics, such as ethacrynic acid (Edecrin), also waste potassium. Symptoms of hyperkalemia include diarrhea, nausea, muscle weakness, paresthesias, and cardiac dysrhythmias. Signs of hypocalcemia include tingling in the extremities and the area around the mouth and muscle and abdominal cramps. Hypercalcemia causes deep bone pain, constipation, anorexia, nausea, vomiting, polyuria, thirst, pathologic fractures, and mental changes.

Following a unilateral adrenalectomy, a nurse should assess for hyperkalemia as indicated by: A.) muscle weakness. B.) tremors. C.) diaphoresis. D.) constipation.

Answer: A.) muscle weakness.

The nurse is instructing a client with recurrent hyperkalemia about following a potassium-restricted diet. Which statement by the client indicates the need for additional instruction? A.) "Bananas have a lot of potassium in them; I'll stop buying them." B.) "I will not salt my food; instead I'll use salt substitute." C.) "I'll drink cranberry juice with my breakfast instead of coffee." D.) "I need to check to see whether my cola beverage has potassium in it."

Answer: B.) "I will not salt my food; instead I'll use salt substitute."

A client asks the nurse how an inhalant general anesthetic is expelled by the body. What is the best response by the nurse? A.) "The kidneys will eliminate the inhalant with urination." B.) "The lungs primarily eliminate the anesthesia." C.) "The skin will eliminate the anesthesia through evaporation." D.) "The liver will eliminate the inhalant anesthesia."

Answer: B.) "The lungs primarily eliminate the anesthesia."

A patient's serum sodium concentration is within the normal range. What should the nurse estimate the serum osmolality to be? A.) <136 mOsm/kg B.) 275-300 mOsm/kg C.) >408 mOsm/kg D.) 350-544 mOsm/kg

Answer: B.) 275-300 mOsm/kg

You are caring for a client preoperatively who is very anxious and fearful about their surgery. You know that this client's anxiety can cause problems with the surgical experience. What type of problems can this client have because of their anxiety and fear? A.) Anxiety and fear increases the need for anesthesia and postoperative medications. B.) Anxious clients have a poor response to surgery and are prone to complications. C.) Anxious clients need psychological counseling after surgery. D.) Anxiety and fear can affect a client positively during and after surgery.

Answer: B.) Anxious clients have a poor response to surgery and are prone to complications.

The nurse is caring for a client in heart failure with signs of hypervolemia. Which vital sign is indicative of the disease process? A.) Low heart rate B.) Elevated blood pressure C.) Rapid respiration D.) Subnormal temperature

Answer: B.) Elevated blood pressure

Which laboratory result does the nurse identify as a direct result of the client's hypovolemic status with hemoconcentration? A.) Abnormal potassium level B.) Elevated hematocrit level C.) Low white blood count D.) Low urine specific gravity

Answer: B.) Elevated hematocrit level

A client has been administered ketamine for moderate sedation. What is the priority nursing intervention? A.) Assessing for hallucinations B.) Frequently monitoring vital signs C.) Administering oxygen D.) Providing a quiet dark room for recovery

Answer: B.) Frequently monitoring vital signs

Which could be a potential cause of respiratory acidosis? A.) Vomiting B.) Hypoventilation C.) Diarrhea D.) Hyperventilation

Answer: B.) Hypoventilation

A client is receiving general anesthesia. The nurse anesthetist starts to administer the anesthesia. The client begins giggling and kicking her legs. What stage of anesthesia would the nurse document related to the findings? A.) I B.) II C.) III D.) IV

Answer: B.) II

A client has a respiratory rate of 38 breaths/min. What effect does breathing faster have on arterial pH level? A.) No effect B.) Increases arterial pH C.) Decreases arterial pH D.) Provides long-term pH regulation

Answer: B.) Increases arterial pH

Your client has a diagnosis of hypervolemia. What would be an important intervention that you would initiate? A.) Give medications that promote fluid retention. B.) Limit sodium and water intake. C.) Assess for dehydration. D.) Teach client behaviors that decrease urination.

Answer: B.) Limit sodium and water intake.

Which is a classic sign of hypovolemic shock? A.) Dilute urine B.) Pallor C.) High blood pressure D.) Bradypnea

Answer: B.) Pallor

A nurse is caring for a client with acute renal failure and hypernatremia. In this case, which action can be delegated to the nursing assistant? A.) Monitor for signs and symptoms of dehydration. B.) Provide oral care every 2-3 hours. C.) Teach the client about increased fluid intake. D.) Assess the client's weight daily for trends.

Answer: B.) Provide oral care every 2-3 hours.

A 55-year-old patient arrives at the operating room. The nurse is reviewing the medical record and notes that the patient has a history of osteoporosis in her lower back and hips. The patient is scheduled to receive epidural anesthesia. Which of the following nursing diagnoses would be a priority for this patient? A.) Risk for injury related to effects of anesthetic agents B.) Risk for perioperative positioning injury related to operative position C.) Anxiety related to the surgical experience D.) Disturbed sensory perception related to sedation

Answer: B.) Risk for perioperative positioning injury related to operative position Rationale: Although any of the nursing diagnoses might apply for this patient, the priority would be risk for perioperative positioning injury related to the patient's history of osteoporosis. The bone loss associated with this condition necessitates careful manipulation and positioning during surgery.

A client with excess fluid volume and hyponatremia is in a comatose state. What are the nursing considerations concerning fluid replacement? A.) Restrict fluids and salt for 24 hours. B.) Correct the sodium deficit rapidly with salt. C.) Administer small volumes of a hypertonic solution. D.) Monitor the serum sodium for changes hourly.

Answer: C.) Administer small volumes of a hypertonic solution.

A client reports tingling in the fingers as well as feeling depressed. The nurse assesses positive Trousseau's and Chvostek's signs. Which decreased laboratory results does the nurse observe when the client's laboratory work has returned? A.) Potassium B.) Phosphorus C.) Calcium D.) Iron

Answer: C.) Calcium

Which would be included as a responsibility of the scrub nurse? A.) Obtaining and opening wrapped sterile equipment B.) Keeping all records and adjusting lights C.) Handing instruments to the surgeon and assistants D.) Coordinating activities of other personnel

Answer: C.) Handing instruments to the surgeon and assistants

Which stage of anesthesia is referred to as surgical anesthesia? A.) II B.) I C.) III D.) IV

Answer: C.) III Rationale: Stage III may be maintained for hours with proper administration of the anesthetic. Stage I is beginning anesthesia, where the client breathes in the anesthetic mixture and experiences warmth, dizziness, and a feeling of detachment. Stage II is the excitement stage, which may be characterized by struggling, singing, laughing, or crying. Stage IV is a state of medullary depression and is reached when too much anesthesia has been administered.

The nurse recognizes that written informed consent is required for insertion of a(n): A.) Nasogastric tube. B.) Urinary catheter. C.) Peripherally-inserted central catheter. D.) Oral airway.

Answer: C.) Peripherally-inserted central catheter.

Which method of wound healing is one in which wound edges are not surgically approximated and integumentary continuity is restored by granulation? A.) Primary-intention healing B.) First-intention healing C.) Second-intention healing D.) Third-intention healing

Answer: C.) Second-intention healing

A nurse is teaching a client about diaphragmatic breathing. What client action indicates that further teaching is needed? A.) The client places the hands on the lower chest to feel the rise and fall with breathing. B.) The client performs diaphragmatic breathing in a semi-Fowler's position. C.) The client exhales forcefully with a short expiration. D.) The client breathes in deeply through the nose and mouth.

Answer: C.) The client exhales forcefully with a short expiration. Rationale: Diaphragmatic breathing should be performed gently and fully. Placing the hands on the lower chest to feel the rise and fall with breathing, performing diaphragmatic breathing in a semi-Fowler's position, and breathing deeply through the nose and mouth are all aspects of diaphragmatic breathing.

What is the most important postoperative instruction a nurse must give to a client who has just returned from the operating room after receiving a subarachnoid block? A.) "Avoid drinking liquids until the gag reflex returns." B.) "Avoid eating milk products for 24 hours." C.) "Notify a nurse if you experience blood in your urine." D.) "Remain supine for the time specified by the physician."

Answer: D.) "Remain supine for the time specified by the physician."

A client who is semiconscious presents with restlessness and weakness. The nurse assesses a dry, swollen tongue; body temperature of 99.3 °F; and a urine specific gravity of 1.020. What is the most likely serum sodium value for this client? A.) 110 mEq/L B.) 130 mEq/L C.) 145 mEq/L D.) 165 mEq/L

Answer: D.) 165 mEq/L

The Emergency Department (ED) nurse is caring for a client with a possible acid-base imbalance. The physician has ordered an arterial blood gas (ABG). What is one of the most important indications of an acid-base imbalance that is shown in an ABG? A.) PaO2 B.) PO2 C.) Carbonic acid D.) Bicarbonate

Answer: D.) Bicarbonate

Which of the following actions by the nurse is appropriate? A.) Touching the edges of an open sterile package B.) Touching sterile items with a clean-gloved hand C.) Reaching over the sterile field D.) Discarding an object that comes in contact with the 1-inch border

Answer: D.) Discarding an object that comes in contact with the 1-inch border

The surgical client has been intubated and general anesthesia has been administered. The client exhibits cyanosis, shallow respirations, and a weak, thready pulse. The nurse recognizes that the client is in which stage of general anesthesia? A.) Stage I B.) Stage II C.) Stage III D.) Stage IV

Answer: D.) Stage IV Rationale: Stage IV: medullary depression is characterized by shallow respirations, a weak, thready pulse, dilated pupils that do not react to light, and cyanosis.

Nursing assessment findings reveal that the client is afraid of dying during the surgical procedure. Which surgical team member would be most helpful in addressing the client's concern? A.) Anesthesiologist B.) Circulating nurse C.) Registered nurse first assistant D.) Surgeon

Answer: D.) Surgeon

A client develops malignant hyperthermia. What client symptom would the nurse most likely observe as the first indicator of the disorder? A.) body temperature increase of 1 °C to 2 °C (2 °F to 4 °F) B.) tetanus-like jaw movements C.) generalized muscle rigidity D.) heart rate over 150 beats per minute

Answer: D.) heart rate over 150 beats per minute

Early signs of hypervolemia include A.) a decrease in blood pressure. B.) thirst. C.) moist breath sounds. D.) increased breathing effort and weight gain.

Answer: D.) increased breathing effort and weight gain. Rationale: Early signs of hypervolemia are weight gain, elevated blood pressure, and increased breathing effort. Eventually, fluid congestion in the lungs leads to moist breath sounds. One of the earliest symptoms of hypovolemia is thirst.

A nurse is providing an afternoon shift report and relates morning assessment findings to the oncoming nurse. Which daily assessment data is necessary to determine changes in the client's hypervolemia status? A.) vital signs B.) edema C.) intake and output D.) weight

Answer: D.) weight Rationale: Daily weight provides the ability to monitor fluid status. A 2-lb (0.9 kg) weight gain in 24 hours indicates that the client is retaining 1 L of fluid. Also, the loss of weight can indicate a decrease in edema. Vital signs do not always reflect fluid status. Edema could represent a shift of fluid within body spaces and not a change in weight. Intake and output do not account for unexplainable fluid loss.