Med Surg 2 Exam 3

A surgical client has just been admitted to the unit from PACU with patient-controlled analgesia (PCA). What must the client require for safe and effective use of PCA? A) A clear understanding of the need to self-dose B) An understanding of how to adjust the medication dosage C) A caregiver who can administer the medication as prescribed D) An expectation of infrequent need for analgesia

A) A clear understanding of the need to self-dose The two requirements for PCA are an understanding of the need to self-dose and the physical ability to self-dose. The client does not adjust the dose and only the client himself or herself should administer a dose. PCAs are normally used for clients who are expected to have moderate to severe pain with a regular need for analgesia. Chapter 19

The nurse is preparing to administer a unit of platelets to an adult client. When administering this blood product, which of the following actions should the nurse perform? A) Administer the platelets as rapidly as the client can tolerate B) Establish IV access as soon as the platelets arrive from the blood bank C) Ensure that the client has a patent central venous catheter D) Aspirate 10 to 15 mL of blood from the client's IV immediately following the transfusion

A) Administer the platelets as rapidly as the client can tolerate The nurse should infuse each unit of platelets as fast as client can tolerate to diminish platelet clumping during administration. IV access should be established prior to obtaining the platelets from the blood bank. A central line is appropriate for administration, but peripheral IV access (22-gauge or larger) is sufficient. There is no need to aspirate after the transfusion. Chapter 32

A gardener sustained a deep laceration while working and requires sutures. The date of the client's last tetanus shot was over 10 years ago. Based on this information, the client will receive a tetanus immunization which will allow for the release of what? A) Antibodies B) Antigens C) Cytokines D) Phagocytes

A) Antibodies Immunizations activate the humoral immune response, culminating in antibody production. Antigens are the substances that induce the production of antibodies. Immunizations do not prompt cytokine or phagocyte production. Chapter 35

A nurse in the preoperative holding area is admitting a woman prior to reduction mammoplasty. What should the nurse include in the care given to this client? Select all that apply. A) Establishing an IV line B) Verifying the surgical site with the client C) Taking measures to ensure the client's comfort D) Applying a grounding device to the client E) Preparing the medications to be given in the OR

A) Establishing an IV line B) Verifying the surgical site with the client C) Taking measures to ensure the client's comfort In the holding area, the nurse reviews charts, identifies clients, verifies surgical site and marks site per institutional policy, establishes IV lines, administers medications, if prescribed, and takes measures to ensure each client's comfort. A nurse in the preoperative holding area does not prepare medications to be given by anyone else. A grounding device is applied in the OR. chapter 17

A client has been brought to the emergency department by EMS after being found unresponsive. Rapid assessment reveals anaphylaxis as a potential cause of the client's condition. The care team should attempt to assess for what potential causes of anaphylaxis? Select all that apply. A) Foods B) Medications C) Insect stings D) Autoimmunity E) Environmental pollutants

A) Foods B) Medications C) Insect stings Substances that most commonly cause anaphylaxis include foods, medications, insect stings, and latex. Pollutants do not commonly cause anaphylaxis Chapter 37

The policies and procedures on a preoperative unit are being amended to bring them closer into alignment with the focus of the Surgical Care Improvement Project (SCIP). What intervention most directly addresses the priorities of the SCIP? A) Actions aimed at increasing participation of families in planning care B) Actions aimed at preventing surgical site infections C) Actions aimed at increasing interdisciplinary collaboration D) Actions aimed at promoting the use of complementary and alternative medicine (CAM)

B) Actions aimed at preventing surgical site infections SCIP identifies performance measures aimed at preventing surgical complications, including venous thromboembolism (VTE) and surgical site infections (SSI). It does not explicitly address family participation, interdisciplinary collaboration, or CAM. Chapter 17

The nurse on the medical-surgical unit is reviewing discharge instructions with a client who has a history of glaucoma. The nurse should anticipate the use of what medications? A) Potassium-sparing diuretics B) Cholinergics C) Antibiotics D) Loop diuretics

B) Cholinergics Cholinergics are used in the treatment of glaucoma. The action of this medication is to increase aqueous fluid outflow by contracting the ciliary muscle and causing miosis and opening the trabecular meshwork. Diuretics and antibiotics are not used in the management of glaucoma. chapter 63

A client is receiving the first of two prescribed units of PRBCs. Shortly after the initiation of the transfusion, the client reports chills and experiences a sharp increase in temperature. What is the nurse's priority action? A) Position the client in high Fowler's B) Discontinue the transfusion C) Auscultate the client's lungs D) Obtain a blood specimen from the client

B) Discontinue the transfusion Stopping the transfusion is the first step in any suspected transfusion reaction. This must precede other assessments and interventions, including repositioning, chest auscultation, and collecting specimens. chapter 32

The nurse is caring for a client who is postoperative day 2 following a colon resection. While turning him, wound dehiscence with evisceration occurs. What should be the nurse's first response? A) Return the client to his previous position and call the physician. B) Place saline-soaked sterile dressings on the wound. C) Assess the client's blood pressure and pulse. D) Pull the dehiscence closed using gloved hands.

B) Place saline-soaked sterile dressings on the wound. The nurse should first place saline-soaked sterile dressings on the open wound to prevent tissue drying and possible infection. Then the nurse should call the physician and take the client's vital signs. The dehiscence needs to be surgically closed, so the nurse should never try to close it. Chapter 19

A client is admitted to the hospital with pernicious anemia. The nurse should prepare to administer which of the following medications? A) Folic acid B) Vitamin B12 C) Lactulose D) Magnesium sulfate

B) Vitamin B12 Pernicious anemia is characterized by vitamin B12 deficiency. Magnesium sulfate, lactulose, and folic acid do not address the pathology of this type of anemia. Chapter 33

A client will be undergoing a total hip arthroplasty later in the day and it is anticipated that the client may require blood transfusion during surgery. How can the nurse best ensure the client's safety if a blood transfusion is required? A) Prime IV tubing with a unit of blood and keep it on hold. B) Check that the client's electrolyte levels have been assessed preoperatively. C) Ensure that the client has had a current cross-match. D) Keep the blood on standby and warmed to body temperature.

C) Ensure that the client has had a current cross-match. Few clients undergoing an elective procedure require blood transfusion, but those undergoing high-risk procedures may require an intraoperative transfusion. The circulating nurse anticipates this need, checks that blood has been cross-matched and held in reserve, and is prepared to administer blood. Storing the blood at body temperature or in IV tubing would result in spoilage and potential infection. Chapter 18

The nurse is assessing a new client with complaints of acute fatigue and a sore tongue that is visibly smooth and beefy red. This client is demonstrating signs and symptoms associated with what form of hematologic disorder? A) Sickle cell disease B) Hemophilia C) Megaloblastic anemia D) Thrombocytopenia

C) Megaloblastic anemia A red, smooth, sore tongue is a symptom associated with megaloblastic anemia. Sickle cell disease, hemophilia, and thrombocytopenia do not have symptoms involving the tongue. Chapter 33

The nurse is performing wound care on a postsurgical client. Which of the following practices violates the principles of surgical asepsis? A) Holding sterile objects above the level of the nurse's waist B) Considering a 1-inch edge around the sterile field as being contaminated C) Pouring solution onto a sterile field cloth D) Opening the outermost flap of a sterile package away from the body

C) Pouring solution onto a sterile field cloth Whenever a sterile barrier is breached, the area must be considered contaminated. Pouring solution onto a sterile field cloth violates surgical asepsis because moisture penetrating the cloth can carry microorganisms to the sterile field via capillary action. The other options are practices that help ensure surgical asepsis. Chapter 18

Two units of PRBCs have been prescribed for a client who has experienced a GI bleed. The client is highly reluctant to receive a transfusion, stating, "I'm terrified of getting AIDS from a blood transfusion." How can the nurse best address the client's concerns? A) "All donated blood is treated with antiretroviral medications before it is used." B) "That did happen in some high-profile cases in the 20th century, but it is no longer a possibility." C) "HIV was eradicated from the blood supply in the early 2000s." D) "The chances of contracting AIDS from a blood transfusion are exceedingly low."

D) "The chances of contracting AIDS from a blood transfusion are exceedingly low." The client can be reassured about the very low possibility of contracting HIV from the transfusion. However, it is not an absolute impossibility. Antiretroviral medications are not introduced into donated blood. The blood supply is constantly dynamic, due to the brief life of donated blood. chapter 32

Following a motorcycle accident, a 37-year-old man is brought to the ED. What physical assessment findings related to the ear should be reported by the nurse immediately? A) The malleus can be visualized during otoscopic examination. B) The tympanic membrane is pearly gray. C) Tenderness is reported by the client when the mastoid area is palpated. D) Clear, watery fluid is draining from the client's ear.

D) Clear, watery fluid is draining from the client's ear. For the client experiencing acute head trauma, immediately report the presence of clear, watery drainage from the ear. The fluid is likely to be cerebrospinal fluid associated with skull fracture. The ability to visualize the malleus is a normal physical assessment finding. The tympanic membrane is normally pearly gray in color. Tenderness of the mastoid area usually indicates inflammation. This should be reported, but is not a finding indicating urgent intervention. chapter 64

A nurse is preparing a client for allergy skin testing. What precautionary step is most important for the nurse to follow? A) The client must not have received an immunization within 7 days. B) The nurse should administer albuterol 30 to 45 minutes prior to the test. C) Prophylactic epinephrine should be given before the test. D) Emergency equipment should be readily available.

D) Emergency equipment should be readily available. Emergency equipment must be readily available during testing to treat anaphylaxis. Immunizations do not contraindicate testing. Neither epinephrine nor albuterol is given prior to testing. Chapter 37

A client with multiple food and environmental allergies tells the nurse that he is frustrated and angry about having to be so watchful all the time and wonders if it is really worth it. What would be the nurse's best response? A) "I can only imagine how you feel. Would you like to talk about it?" B) "Let's find a quiet spot and I'll teach you a few coping strategies." C) "That's the same way that most clients who have a chronic illness feel." D) "Do you think that maybe you could be managing things more efficiently?"

A) "I can only imagine how you feel. Would you like to talk about it?" To assist the client in adjusting to these modifications, the nurse must have an appreciation of the difficulties encountered by the client. The client is encouraged to verbalize feelings and concerns in a supportive environment and to identify strategies to deal with them effectively. The nurse should not suggest that the client has been mismanaging his health problem and the nurse should not make comparisons with other clients. Further assessment should precede educational interventions. Chapter 37

The surgical nurse is preparing to send a client from the presurgical area to the OR and is reviewing the client's informed consent form. What are the criteria for legally valid informed consent? Select all that apply. A) Consent must be freely given. B) Consent must be notarized. C) Consent must be signed on the day of surgery. D) Consent must be obtained by a provider. E) Signature must be witnessed by a professional staff member.

A) Consent must be freely given. D) Consent must be obtained by a provider. E) Signature must be witnessed by a professional staff member. Valid consent must be freely given, without coercion. Consent must be obtained by a provider and the client's signature must be witnessed by a professional staff member. It does not need to be signed on the same day as the surgery and it does not need to be notarized. Chapter 17

The nurse is discharging a client home from an outpatient surgery center. The nurse has reviewed all of the discharge instructions with the client and her caregiver. What else should the nurse do before discharging the client from the facility? Select all that apply. A) Provide all discharge instructions in writing. B) Provide the nurse's or surgeon's contact information. C) Give prescriptions to the client. D) Irrigate the client's incision and perform a sterile dressing change. E) Administer a bolus dose of an opioid analgesic.

A) Provide all discharge instructions in writing. B) Provide the nurse's or surgeon's contact information. C) Give prescriptions to the client. Before discharging the client, the nurse provides written instructions, prescriptions and the nurse's or surgeon's telephone number. Administration of an opioid would necessitate further monitoring to ensure safety. A dressing change would not normally be ordered on the day of surgery. Chapter 19

A client diagnosed with arthritis has been taking aspirin and now reports experiencing tinnitus and hearing loss. What should the nurse teach this client? A) The hearing loss will likely resolve with time after the drug is discontinued. B) The client's hearing loss and tinnitus are irreversible at this point. C) The client's tinnitus is likely multifactorial, and not directly related to aspirin use. D) The client's tinnitus will abate as tolerance to aspirin develops.

A) The hearing loss will likely resolve with time after the drug is discontinued. Tinnitus* and hearing loss are signs of ototoxicity, which is associated with aspirin use. In most cases, this will resolve upon discontinuing the aspirin. Many other drugs cause irreversible ototoxicity. *Tinnitus is when you experience ringing or other noises in one or both of your ears. chapter 63

Several residents of a long-term care facility have developed signs and symptoms of viral conjunctivitis. What is the most appropriate action of the nurse who oversees care in the facility? A) Arrange for the administration of prophylactic antibiotics to unaffected residents B) Instill normal saline into the eyes of affected residents two to three times daily C) Swab the conjunctiva of unaffected residents for culture and sensitivity testing D) Isolate affected residents from residents who have not developed conjunctivitis

D) Isolate affected residents from residents who have not developed conjunctivitis To prevent spread during outbreaks of conjunctivitis, health care facilities must set aside specified areas for treating clients diagnosed with or suspected of having conjunctivitis. Antibiotics and saline flushes are ineffective and normally there is no need to perform testing of individuals lacking symptoms. chapter 63

A client with rheumatic disease has developed a gastrointestinal bleed. The nurse caring for the client should further assess the client for the adverse effects of what medications? A) Corticosteroids B) Immunomodulators C) Antimalarials D) Salicylates

D) Salicylates GI bleeding is an adverse effect that is associated with salicylates (e.g., aspirin). Steroids, antimalarials, and immunomodulators do not normally have this adverse effect.