Lippincott chapter 14 the client having surgery missed question
139. The client is being transferred from the recovery room to the medical surgical unit. The nurse from the recovery room should report which information to the nurse in the medical surgical unit. Select all that apply..
-type of surgery -Current vital signs I'm out of blood loss -Fluid infusion, indicating right and type of fluid
126. The client is admitted on the day of the surgery for on orthoscope be to the left knee which nursing activities should be completed prior to administering anesthesia to the client to avoid wrong site surgery select all that apply
-verify that the surgeon has marked with a permanent maker, the correct me for the surgical site -Verbally ask the client to stay at his or her name, surgical site and procedure -Verify the correct client with the correct operative site for medical records and diagnostic report -Call a time out in the operating room to have a surgery verify the correct need before making the incision
134. The nurse has just received morning change of shift report on for clients in what order from first to last should the nurse perform that action all options must be used.
- notify the healthcare provider about the client who has a serum potassium level of 6.2. -Assess a client who has been vomiting according to the report from the Night nurse -Discuss the plan of the day with the UAP delegating as appropriate -Begin discharge paperwork for a client who has eager to go home
48. Prior to placement of an epidural catheter, what should the nurse instruct the client to do while the catheter is in place
- tell the nurse about having nausea or -Call for assistance with turning or repositioning -Inform the nurse of numbness or weakness in the legs -Call the nurse of the catheter becomes dislodged
15. On the day of surgery , a client with diabe tes who takes insulin on a sliding scale is to have nothing by mouth and all medications withheld . The client's 0600 glucose level is 300 mg / dL ( 16.7 mmol / L ) . What should the nurse do ?
3. Call the health care provider ( HCP ) for spe cific prescriptions based on the glucose level
24. When evaluating a client's preoperative cognitive - perceptual pattern , which question should the nurse ask the client ?
4. " Do you wear glasses ? "
105. After surgery, the client is receiving epidural pain management. The client wants to get out of bed and walk to the bathroom. The nurse should base that decision to Amber on which information.
A low concentration of analgesia is used with a catheter
45. A client who had a gastrectomy has been in the post anesthesia recovery room for 30 minutes when the vital signs suddenly change. The nurse checks the recovery room record. In addition to notifying the healthcare provider what action should the nurse take immediately?
Administer dantrolene
99. The nurse assesses a client who has just received morphine sulfate. The clients blood pressure is 90/50 pulse rate 58 respirations 4 what should the nurse do
Administer naloxone hydrochloride
84. I'm at the following the pelvic surgery a client has an indwelling urinary catheter which nursing action would be most helpful to prevent a catheter related urinary track infection.
Advocate for a limited use of an duration of indwelling urinary catheter
104. When an epidural catheter is used for postoperative pain management, what should the nurse do
Assess but not disturb the epidural dressing
75. Eight hours after laproscope abdominal surgery, a client has a distended bladder and is unable to void because in bed using a urinal the client can be out of bed as tolerated but has not done so yet what should the nurse do next?
Assist the client at the bedside to use the urinal
72. On the day of surgery a client has been breathing room air. The vital sense are normal and the 02 saturation is 89. What should the nurse do first
Assist the client takes several deep breaths and cough
73. The client has been able to avoid since having them down a surgery seven hours ago. What should the nurse do first
Assist the client up to the toilet should attempt to avoid
50. The nurse is assessing a client who had epidural anesthesia four hours ago. What should the nurse assess first
Bladder distention
52. The nurse is in the post anesthesia care unit notes that one of the clients pupils is larger than the other. What should the nurse do first
Check the clients baseline data
54. The surgical floor receives a client from the post anesthesia care unit. 10 minutes ago. The final assessment in the post anesthesia care. Unit indicated the client had a patent airway and stable vital signs. The clients pain level was at two. What should the nurse do next?
Check the dressing for signs of bleeding
97. The nurse empties in Jackson Pratt drainage above what nursing action insurance correct functioning of the drain.
Compressing it, and then plugging it to establish section
94. The nurses making rounds and observes the client receiving oxygen. What should the nurse do next?
Confirm the flow rate is set to deliver oxygen at 6 to 10 mL per minute
141. When taking the clients vital signs on the first post operative day the UAP reports to the nurse that the temperature is 100°F after encouraging the client to use the incentives barometer at the nurse should delegate which activity to the UAP.
Continue to monitor the client's temperature
60. And 80-year-old client has spinal anesthesia for a transurethral resection of the prostate and receive 400 mL of room temperature isotonic bladder irrigation. He now has continue an irrigation through a three-way indwelling urinary catheter. Which post offered of nursing intervention is most important to include in this plan of care.
Cover the client with warm blankets
110. The client who had a cholecystectomy has a biliary drainage tube in place what color of the drainage is expected
Dark yellow, orange
80. A client had a collect me 8 1/2 hours ago and has received 1500 mL of dextrose 5% and water with normal saline. The client has just use a patient controlled pump to administer morphine for pain has been repositioned for comfort and has stable, pollse rate, respiration, and blood pressure. What should the nurse do next?
Dim the lights in the room
132. On the second day after surgery the nurse assesses an older client. The nurse finds blood pressure is 148/92 heart rate 9802, 88 on 4 mL of oxygen breath sounds are coarse and wet bilaterally with loose, productive cough, the client has with it 100 mL very dark, concentrated turn the last four hours bilateral pitting pedal edema using the S bar the nurse recommend which prescription
Diuretic medication
24. When evaluating a clients pre-operative, cognitive perceptual pattern, which question should the nurse asked the client
Do you wear glasses?
66. On the first day after abdominal surgery the nurse auscultates a clients afternoon for bowel sounds. They are none. What should the nurse do
Document assessment finding in the clients medical record
91. The nurse is teaching a client how to take care of an incision at home what should the nurse tell the client
Don't be concerned about uneven lumps under the suture line
103. After surgery, a client was treated for postoperative nausea and vomiting and now experiencing hypertension and tachycardia. The nurse should review and medication record and determine if the client is received medication.
Droperidol
113. How often should the clients temperature be assessed during the first 24 hours after surgery
Every four hours
1. A client tells the nurse on admission that she is uneasy about having to leave her children with a relative while being in the hospital for surgery . What should the nurse do ?
Gather more information about the clients feelings about the childcare arrangements
135. While making rounds, the nurse observes at the clients primary bag of IV solution is light yellow so we leave on the IV bag says the solution is D5W. What should the nurse do first
Hang a new bag of D5W and completed incident report
30. When administering IV midazolam hydrochloride to the client, what should the nurse do?
Have the client take deep breaths
62. Prior having a broken arm cast of the client receives an intravenous regional nerve block. Following surgery, the Cassett arms elevated on a pillow. What action should the nurse encourage the client to avoid until sensation returns
Holding the operated arm close to the face
55. A client with impaired cardiac functioning is having abdominal surgery. Sodium with the pencil is being used during anesthesia induction. What should the nurse monitor the client for during surgery?
Hypotension
117. The nurse is teaching a client about deep breathing techniques which statement from the client indicates the need for additional education.
I should take four deep breasts, and then cough deeply from my lungs
32. Metoclipramide is prescribed as a pre-medication for a client to undergo a GastroDuidenoscooy. What expected therapeutic affect of this drug should the nurse assess in the client?
Increased gastric emptying
56. A client receive propofol as the induction and Maintenance agent for general anesthesia. What outcome of this drug should the nurse expect?
Minimal nausea and vomiting
118. The client had a nasogastric tube connected to low end or middle section. What is the client at risk for?
Muscle cramping
38. The nurse learns that the client who is scheduled for a tonsillectomy has been taking 40 mg of oral prednisone daily for the last week for poison ivy on the leg. What should the nurse do first
Notify the anesthesiologist of the prednisone administration
58. The nurse is assessing a client recovering from anesthesia. Which finding is an early indicator of hypoxemia.
Restlessness
64. When administering naoloxone nurse should monitor the surgical client closely for which clinical manifestations.
Restlessness
53. A client is admitted to the post anesthesia care unit following a hip replacement in the left hip. The initial nursing assessment is as follows temperature 96, pulse 90 respiration 14 and blood pressure 120/80. The client only responds with moaning when spoken what is the first thing that I should do.
Position the client on the right side
136. A client informs the nurse that the Vinny puncture site hurts. The nurse should assess the site for which findings select all that apply.
Redness, pain, coolness, blanching, firmness, edema
5. When we're moving protective covering, what action should the nurse take to avoid spreading nosocomial infections?
Remove the facemask
115. My client has been positioned in the lithotomy position under general anesthesia for a pelvic procedure in which anatomic area made a client expect to experience post operative discomfort.
Shoulders
83. A client had a total abdominal hysterectomy and bilateral offer up to be for ovarian carcinoma. Yesterday she received 2 mg of morphine sulfate IV by PCA 10 minutes ago. The nurse was assisting her from bed to chair when the client felt dizzy and fell into the chair. What should the nurse do next?
Take the clients blood pressure
57. A 250 pound male client is recovering from general anesthesia. The clients vital signs are pulse 150 blood pressure 95/50 respiratory 28 tympanic temperature 99. The client has rigid muscles. How should the nurse interpret these findings?
The client is in an early stage of Maui, Jim hyperthermia. The nurse should obtain emergency medication and notify the anesthesiologist.
109. A client has a Jackson Pratt drainage tube in place the first day after surgical repair of a ruptured diverticulum. The client has a nurse the purpose of the drain. What should the nurse tell the client
The drain is used to prevent infection on the peritoneal cavity
107. Three days after surgery a client continues to take hydrocodone 7.5 mg and acetaminophen 500 mg for postoperative pain. What should the nurse asked the client before administering the pain medication
When did you last have a bowel movement?
89. A client who had a left thoroughscope you substained injury secondary to the surgery position. The nurse should assess the client for which sign.
Tingling in the arm
122. The nurse is helping to prepare a client for a non-emergency surgery. What should the nurse to
Verify that the client understands informed consent
96. Two days following abdominal surgery a client is refusing to take narcotic pain medication even though the pain rating is an eight on a 0 to 10 scale. The client tells the nurse I don't want to get dependent on the stuff. Which response from the nurse is most appropriate.
You will recover more quickly and more effectively if you take your pain medication now
16. The nurse is preparing a preoperative teach ing plan for a client who is undergoing a bilateral breast reduction . Which aspect of the plan is the priority ?
3. psychosocial integrity
28. The nurse receives the preoperative blood report for a client who is scheduled to undergo surgery. Which laboratory findings should the nurse report to the surgeon and anesthesiologist.
Creatinine 2.6.
59. When administering flumazenil IV for reversal of sedation, what should the nurse to select all that apply?
-give them medication undiluted in incremental doses -Be alert for shivering and hypotension -
138. The client is in the operating room having surgery through a place a hip. Prior to starting the surgery there is confusion about the view of the hip on the x-ray. The surgical team requested time out and stops the surgery. When can surgery. Continue select all that apply.
-The surgeon verifies the correct procedure -The surgeon verify is the correct surgical site -The surgical team identifies the client using two sources of identification
124. The nurse should review the glucose level of which clients were going to surgery today so I did all that apply.
-A client with diabetes control by diet -A client with high stress response to surgery -A client receiving corticosteroids for the past three months
36. During the pre-operative interview, the nurse obtains information about the clients medication history. Which information is not necessary to record about the client.
All drugs taken in the last 18 months
146. A nurse is caring for a group of clients. After receiving shift report, the nurse should make rounds on the client in which order placed an order the highest to lowest priority.
-The female client has 34 years of age and just returned from the recovery room following an abdominal hysterectomy, Ivy running at 50 drops per minute with 100 mL remaining -Client who is 79 years old of age 2 days post operative for removal of cancer of the colon who's had a tracheostomy for four years -The client is 75 years old with a fractured hip of four days who needs to be turned frequently -The client is 50 years of age and diagnosed with diabetes three days ago, who is learning to administer insulin
47. A client is to receive medication by a continuous nerve block route. Prior to insertion of the catheter by the anesthesiologist, what information must the nurse document select all that apply?
-Vital science, weakness and numbness, location of pain, allergies
148. A client who has had abdominal dressing has asked to use the urinal a nurse drops to clean glove on the floor while attempting to Don the glove which order from first to last should the nurse proceed.
-apply new cleaning gloves -Assess the client surgical dressing -Reposition the clients urinal -Dispose of the glove on the floor
69. A client requests in a Kartic shortly after the oncoming nurse receives change of shift report the nurse is leaving report. The client had received morphine 10 mg two hours ago and what order from first to last should the nurse perform the actions
-assess the client pain using a pain scale -Take the clients vital signs -Determine the client sedation level using the opioid induced sedation scale -Review the prescription for those and frequency of administration
140. A client with the history of mitocardial infarction three years ago was admitted at 7 AM. The client has been NPO since midnight at 8:30. The client reports having chest pain at seven the clients vital signs were a pulse 80 respirations 14 blood pressure 110/70 at 8:30 the nurse takes her vital signs pulse is 110 blood pressure is 90/60. The nurse called the surgeon and using the S bar communication protocol. Should the nurse discuss information with the surgeon select all that apply.
-history of my myocardial infarction in current report of chest pains -The change in vital signs -Request for ECG -Request to administer nitroglycerin
71. The client who is a Jehovah's Witness consented to surgery only and not to receive any blood products including auto transfusion. During surgery, the client lost blood and a blood pressure dropped and two units of blood were administered following surgery during handoff the nurses inform the blood had been administered in which order from first to last to the nurse complete the task.
-initiate the ethics consultation -Notify the unit manager -Complete an incident report Informed the next oncoming nurse during hand off of care report
85. The nurse is instructing a client who had abdominal surgery that day to do deep breathing exercise in which order from first to last should the nurse teach the client to perform diaphragmatic, breathing and coughing.
-splint the incision site -Inhale through the nose -Exhale through Pierce lips -Cough deeply from lungs
