Med Surg Exam 3
A patient is transferred from the postanesthia care unit (PACU) to the clinical unit. Which action by the nurse on the clinical unit should be performed first?
Take the patient's vital signs
When admitting a patient with stage III pressure ulcers on both heels, which information obtained by the nurse will have the most impact on wound healing?
The patient takes insulin daily.
When examining an older patient in the home, the home health nurse notices irregular patterns of bruising at different stages of healing on the patient's body. Which action should the nurse take first?
Talk with the patient alone and ask about what caused the bruising.
A patient received inhalation anesthesia during surgery. Postoperatively the nurse should monitor the patient for which complication?
Laryngospasm
What measure is important in managing hypercalcemia in a child who is immobilized?
Provide adequate hydration
Which information will the nurse include when teaching an older patient about skin care?
Use warm water and a moisturizing soap when bathing
The surgical unit nurse has just received a patient with a history of smoking from the post anesthesia care unit. Which action is most important at this time?
Auscultate for adventitious breath sounds
What is a physiologic effect of immobilization on children?
Circulatory stasis can lead to thrombus and embolus formation
What condition can result from the bone demineralization associated with immobility?
Osteoporosis
Using knowledge of child development, what approach is best when preparing a toddler for a procedure?
Demonstrate on a doll how the procedure will be done
The nurse assesses that the oxygen saturation is 89% in an unconscious patient who was transferred from surgery to the post anesthesia care unit (PACU) 15 minutes ago. Which action should the nurse take first?
Increase the oxygen flow rate.
The nurse should plan to use a wet-to-dry dressing for which patient?
A patient who has a wound with purulent drainage and dry brown areas
A nurse assists a patient on the first postoperative day to ambulate, cough, deep breathe, and turn. Which action by the nurse is most helpful?
Administer ordered analgesic medications before these activities.
The nurse will perform which action when doing a wet-to-dry dressing change on a patient's stage III sacral pressure ulcer?
Administer the ordered PRN hydrocodone (Lortab) 30 minutes before the dressing change.
A patient who had knee surgery received intramuscular ketorolac (Toradol) 30 minutes ago and continues to complain of pain at a level of 7 (0 to 10 scale). Which action is best for the nurse to take at this time?
Administer the prescribed PRN IV morphine sulfate.
On admission of a patient to the post anesthesia care unit (PACU), the blood pressure (BP) is 122/72. Thirty minutes after admission, the BP falls to 114/62, with a pulse of 74 and warm, dry skin. Which action by the nurse is most appropriate?
Continue to take vital signs every 15 minutes.
The nurse reviews the laboratory results of a patient on the first postoperative day after a hiatal hernia repair. Which finding would indicate to the nurse that the patient is at increased risk for poor wound healing?
Albumin level 2.2 g/dL
While in the holding area, a patient reveals to the nurse that his father had a high fever after surgery. What action by the nurse is priority?
Alert the anesthesia care provider of the family member's reaction to surgery.
The nurse notes the presence of white lesions that resemble milk curds in the back of a patient's throat. Which questions by the nurse is appropriate at this time?
Are you taking any medications at present?
A young male patient who is paraplegic has a stage II sacral pressure ulcer and is being cared for at home by his mother. To prevent further tissue damage, what instructions are most important for the nurse to teach the mother?
Change the patient's position at least every 2 hours.
After receiving change-of-shift report about these postoperatvie patients, which patient should the nurse assess first?
Obese patient who had abdominal surgery 3 days ago and whose wound edges are separating
A patient who has diabetes and uses insulin to control blood glucose has been NPO since midnight before having a knee replacement surgery. Which action should the nurse take?
Obtain a blood glucose measurement before any insulin administration.
The nurse interviews a patient scheduled to undergo general anesthesia for a hernia repair. Which information is most important to communicate to the surgeon and anesthesiologist before surgery?
The patient's father died after receiving general anesthesia for abdominal surgery.
Which topic is most important for the nurse to discuss preoperatively with a patient who is scheduled for abdominal surgery for an open cholecystectomy?
Deep breathing and coughing techniques.
Which nonpharmalogical intervention appears to be effective decreasing neonatal procedural pain?
Oral sucrose and nonnutritive sucking
A child is upset because, when the cast is removed from her leg, the skin surface is caked with desquamated skin and sebaceous secretions. What should the nurse suggest to remove this material?
Soak in a bathtub
A patient who has an infected abdominal wound develops a temperature of 104 F (40 C). All the following interventions are included in the patient's plan of care. In which order should the nurse perform the following actions?
- Administer IV antibiotics - Administer acetaminophen (Tylenol) - Sponge patient with cool water - Perform wet to dry dressing change
Which activities can the nurse working in the outpatient clinic delegate to a licensed practical/vocational nurse (LPN/LVN)?
- Administer patch testing to a patient with allergic dermatitis - Apply a sterile dressing after the health care provider excises a mole
A nurse is teaching a patient with contact dermatitis of the arms and legs about ways to decrease pruritus. Which information should the nurse include in the teaching plan?
- Cool, wet cloths or dressing can be used to reduce itching - Take cool or tepid baths several times daily to decrease itching - Use of an over the counter (OTC) antihistamine can reduce scratching
When taking the health history of an older adult, the nurse discovers that the patient has worked in the landscaping business for 40 years. The nurse will plan to teach the patient about how to self-asses for which clinical manifestations?
- Erythema - Actinic keratosis
While ambulating in the room, a patient complains of feeling dizzy. In what order will the nurse accomplish the following activities?
- Have the patient sit down in a chair - Take the patient's blood pressure (BP) - Give the patient something to drink - Notify the patient's health care provider
A toddler is being sent to the operating room for surgery at 9 AM. As the nurse prepares the child, what is the priority intervention?
Verifying that the child and procedure are correct
A patient with rheumatoid arthritis has been taking corticosteroids for 11 months. Which nursing action is most likely to detect early signs of infection in this patient?
Ask about fatigue or feelings of malaise.
The nurse is caring for a patient diagnosed with furunculosis. Which nursing action could the nurse delegate to unlicensed assistive personnel (UAP)?
Cleaning the skin with antimicrobial soap
The nurse is teaching a staff development program about levels of sedation in the pediatric population. Which statement by one of the participants should indicate a correct understanding of the teaching?
During moderate sedation, the patient responds to verbal commands but may not respond to light tactile stimulation
A patient from a long-term care facility is admitted to the hospital with a sacral pressure ulcer. The base of the wound is yellow and involves subcutaneous tissue. How should the nurse classify this pressure ulcer?
Stage III
Monitored anesthesia care (MAC) is going to be used for a closed, manual reduction of a dislocated shoulder. Which action does the nurse anticipate?
Starting a 20-gauge IV in the patients unaffected arm
As the nurse prepares a patient the morning of surgery, the patient refuses to remove a wedding ring, saying, "I have never taken it off since the day I was married." Which response by the nurse is best?
Suggest that the patient give the ring to a family member to keep.
During assessment of the patient's skin, the nurse observes a similar pattern of small, raised lesions on the left and right upper back areas. Which term should the nurse use to document these lesions?
Symmetric
The nurse is caring for a patient the first postoperative day following a laparotomy for a small bowel obstruction. The nurse notices new bright-red drainage about 5 cm in diameter on the dressing. Which action should the nurse take first?
Take patient's vital signs.
The nurse is caring for an immobilized preschool child. What intervention is helpful during this period of immobilization?
Take the child for a walk by wagon outside the room
A 7-year-old is identified as being at risk for skin breakdown. What intervention should the nursing care plan include?
Ensuring that nutritional intake meets requirements
When caring for a preoperative patient on the day of surgery, which actions included in the plan of care can the nurse delegate to unlicensed assistive personnel (UAP)?
- Obtain and document baseline vital signs - Remove nail polish, apply spirometer polish
A patient's blood pressure in the post anesthesia care unit (PACU) has dropped from an admission blood pressure of 140/86 to 102/60 with a pulse change of 70 to 96. SpO2 is 92% on 3 L of oxygen. In which order should the nurse take these actions?
- Increase the iV infusion rate - Increase the oxygen flow rate - Assess the patient's dressing - Check the patient's temperature
Which data identified during the perioperative assessment alert the nurse that special protection techniques should be implemented during surgery?
History of spinal and hip arthritis
A patient with an open leg wound has a white blood cell (WBC) count of 13,500/L and a band count of 11%. Which action should the nurse take first?
Obtain wound cultures.
A patient has an open surgical wound on the abdomen that contains deep pink granulation tissue. How would the nurse document this wound?
Red wound
Which actions will the nurse include in the surgical time-out procedure before surgery?
- Have the patient state name and date of birth - Verify the patient identification band number - Ask the patient to state the surgical procedure - Confirm the hospital chart identification number
The nurse assesses a patient on the second postoperative day after abdominal surgery to repair a perforated duodenal ulcer. Which finding is most important for the nurse to report to the surgeon ?
200 mL sanguineous fluid in the wound drain
There is one opening in the schedule at the dermatology clinic, and 4 patients are seeking appointments today. Which patient will the nurse schedule for the available opening?
38-year-old with a 7-mm nevus on the face that has recently become darker
A patient scheduled to undergo total knee replacement surgery under general anesthesia asks the nurse, "Will the doctor put me to sleep with a mask over my face?" Which response by the nurse is most appropriate?
A drug may be given to you through your IV line first. I will check with the anesthesia care provider.
A patient who has never had any prior surgeries tells the nurse doing the preoperative assessment about an allergy to bananas and avocados. Which action is most important for the nurse to take?
Alert the surgery center about a possible latex allergy.
A 4-year-old girl is admitted to outpatient surgery for removal of a cyst on her back. Her mother puts the hospital gown on her, but the child is crying because she wants to leave on her underpants. What is the most appropriate nursing action at this time?
Allow her to wear her underpants
Which action most effectively demonstrates that a new staff member understand the role of the scrub nurse?
Keeps both hands above the operating table level
The nurse notes darker skin pigmentation in the skin folds of a middle-aged patient who has a body mass index of 40 kg/m. What is the nurses best action?
Ask the patient about type 2 diabetes or if there is a family history of it.
A patient who has severe refractory psoriasis on the face, neck, and extremities is socially withdrawn because of the appearance of the lesions. Which action should the nurse take first?
Ask the patient to describe the impact of psoriasis on quality of life.
A patient who has begun to awaken after 30 minutes in the postanesthesia care unit (PACU) is restless and shouting at the nurse. The patient's oxygen saturation is 96%, and recent laboratory results are all normal. Which action by the nurse is most appropriate?
Assess for bladder distention.
When performing a skin assessment, the nurse notes several angiomas on the chest of an older patient. Which action should the nurse take next?
Assess the patient for evidence of liver disease.
The nasogastric (NG) tube is removed on the second postoperative day, and the patient is placed on a clear liquid diet. Four hours later, the patient complains of sharp, cramping gas pains. What action by the nurse is most appropriate?
Assist the patient to ambulate.
Which is a complication that can occur after abdominal surgery if pain is not managed?
Atelectasis
Which is the most consistent and commonly used data for assessment of pain in infants?
Behavioral
Which action best describes how the scrub nurse maintains aseptic technique during surgery?
Changes gloves after touching the upper arm of the surgeons gown
A dark-skinned patient has been admitted to the hospital with chronic heart failure. How would the nurse best assess this patient for cyansosis?
Check the lips and oral mucous membranes
A patient who is just waking up after having hip replacement surgery is agitated and confused. Which action should the nurse take first?
Check the oxygen (o2) saturation.
A young adult patient who is receiving antibiotics for an infected leg wound has a temperature of 101.8 F (38.7 C). Which action by the nurse is most appropriate?
Check the patient's oral temperature again in 4 hours.
The health care provider diagnoses impetigo in a patent who has crusty vesicopustular lesions on the lower face. Which instructions should the nurse include in the teaching plan?
Clean the infected areas with soap and water
When assessing a new patient at the outpatient clinic, the nurse notes dry, scale skin; thin hair; and thick, brittle nails. What is the nurses best action?
Consult with the health care provider about the need for further diagnostic testing
The nurse prepares to obtain a culture from a patient who has a possible fungal infection on the foot. Which items should the nurse gather for this procedure?
Cotton-tipped applicators
The nurse working in the postanesthesia care unit (PACU) notes that a patient who has just been transported from the operating room is shivering and has a temperature of 96.5° F (35.8° C). Which action should the nurse take?
Cover the patient with a warm blanket and put on socks
An older patient is being discharged from the ambulatory surgical unit following left eye surgery. The patient tells the nurse, "I do not know if I can take care of myself with this patch over my eye." Which action by the nurse is most appropriate?
Discuss the specific concerns regarding self-care.
The nurse is preparing a 9-year-old boy before obtaining a blood specimen by venipuncture. The child tells the nurse he does not want to lose his blood. What approach is best by the nurse?
Discuss with him how his body is always in the process of making blood.
The nurse assesses a patient's surgical wound on the first postoperative day and notes redness and warmth around the incision. Which action by the nurse is most appropriate?
Document the assessment.
A patient's T-tube is draining dark green fluid after gallbladder surgery. What action by the nurse is the most appropriate?
Document the color and amount of drainage.
A patient arrives in the emergency department with a swollen ankle after an injury incurred while playing soccer. Which action by the nurse is most appropriate?
Elevate the ankle above heart level.
In the post anesthesia care unit (PACU), a patient's vital signs are blood pressure 116/72, pulse 74, respirations 12, and SpO2 91%. The patient is sleepy but awakens easily. Which action should the nurse take first?
Encourage the patient to take deep breaths.
Which action should the perioperative nurse take to best protect the patient from burn injury during surgery?
Ensure correct placement of the grounding pad
A patient is undergoing psoralen plus ultraviolet A light (PUVA) therapy for treatment of psoriasis. What action should the nurse take to prevent adverse effects from this procedure?
Have the patient use protective eyewear while receiving PUVA
When caring for patient the second postoperative day after abdominal surgery for removal of a large pancreatic cyst, the nurse obtains an oral temperature of 100.8 F. Which action should the nurse take first?
Have the patient use the incentive spirometer.
Which action could the post anesthesia care unit (PACU) nurse delegate to unlicensed assistive personnel (UAP) who help with the transfer of a patient to the clinical unit?
Help with the transfer of the patient onto a stretcher.
A bone marrow biopsy will be performed on a 7-year-old girl. She wants her mother to hold her during the procedure. How should the nurse respond?
Holding may help your child relax
A patient's 43 cm leg wound has a 0.4 cm black area in the center of the wound surrounded by yellow-green semiliquid material. Which dressing should the nurse apply to the wound?
Hydrocolloid dressing (DuoDerm)
Which statement by a patient scheduled for surgery is most important to report to the health care provider?
I had a heart valve replacement last year.
Which statement, if made by a new circulating nurse, is appropriate?
I will assist in preparing the operating room for the patient.
A patient with atopic dermatitis has a new prescription for pimecrolimus (Elidel). After teaching the patient about the medication, which statement by the patient indicates that further teaching is needed?
If the medication burns when I apply it, I will wipe it off and call the doctor.
A patient in the dermatology clinic is scheduled for removal of a 15-mm multicolored and irregular mole from the upper back. The nurse should prepare the patient for which type of biopsy?
Incisional biopsy
A patient undergoing an emergency appendectomy has been using St. Johns wort to prevent depression. Which complication would the nurse expect in the post anesthesia care unit?
Longer time to recover from anesthesia
Which finding is most important for the nurse to communicate to the health care provider when caring for a patient who is receiving negative pressure wound therapy?
Low serum albumin level
A patient who has diabetes is admitted for an exploratory laparotomy for abdominal pain. When planning interventions to promote wound healing, what is the nurse's highest priority?
Maintaining the patient's blood glucose within a normal range
Which nursing action should the operating room (OR) nurse manager delegate to the registered nurse first assistant (RNFA) when caring for a surgical patient?
Make surgical incision and suture incisions as needed.
A 38-year-old female patient states that she is using topical fluorouracil to treat actinic keratoses on her face. Which additional assessment information will be most important for the nurse to obtain?
Method of birth control used by the patient
A nurse develops a teaching plan for a patient diagnosed with basal cell carcinoma (BCC). Which information should the nurse include in the teaching plan?
Minimizing sun exposure will reduce risk for future BCC
When caring for a patient who has received a general anesthetic, the circulating nurse notes red, raised wheals on the patient's arm. Which action should the nurse take immediately?
Notify the anesthesia care practitioner (ACP) immediately
The nurse is preparing to witness the patient signing the operative consent form when the patient says, "I do not really understand what the doctor said." Which action is best for the nurse to take?
Notify the surgeon that the informed consent process is not complete.
Five minutes after receiving the ordered preoperative midazolam (Versed) by IV injection, the patient asks to get up to go to the bathroom to urinate. Which action by the nurse is most appropriate?
Offer a urinal or bedpan and position the patient in bed to promote voiding.
A teenaged male patient who wrestles in high school is examined by the nurse in the clinic. Which assessment finding would prompt the nurse to teach the patient about the importance of not sharing headgear to prevent the spread of pediculosis?
Papular, wheal-like lesions with white deposits on the hair shaft
Which action included in the perioperative patient plan of care can the charge nurse delegate to a surgical technologist?
Pass sterile instruments and supplies to the surgeon.
A postoperative patient has a nursing diagnosis of ineffective airway clearance. The nurse determines that interventions for this nursing diagnosis have been successful if which is observed?
Patient's breath sounds are clear to auscultation
A postoperative patient has not voided for 8 hours after return to the clinical unit. Which action should the nurse take first?
Perform a bladder scan
Which abnormality on the skin of an older patient is the priorotiy to discuss immediately with the health care provider?
Petechiae present on the chest and abdomen
An older patient who had knee replacement surgery 2 days ago can only tolerate being out of bed with physical therapy twice a day. Which collaborative problem should the nurse identify as a priority for this patient?
Potential complication; venous thromboembolism
A patient in the dermatology clinic has a thin, scaly erythematous plaque on the right cheek. Which action should the nurse take?
Prepare the patient for a biopsy.
The nurse assesses a circular, flat, reddened lesion about 5 cm in diameter on a middle-aged patient's ankle. How sold the nurse determine if the lesion is related to intradermal bleeding?
Press firmly on the lesion.
Which action will the nurse take immediately after surgery for patient who received ketamine (Ketalar) as an anesthetic agent?
Provide a quiet environment in the postanethesia care unit.
The nurse plans to provide preoperative teaching to an alert older man who has hearing and vision deficits. His wife usually answers most questions that are directed to the patient. Which action should the nurse take when doing the teaching?
Provide additional time for the patient to understand preoperative instructions and carry out procedures.
A 5-year-old child returns from the pediatric intensive care unit after abdominal surgery. The orders state to monitor vital signs every 2 hours. On assessment, the nurse observes that the child's heart rate is 20 beats/min less than it was preoperatively. What should be the nurse's next action?
Recheck the pulse and blood pressure in 15 minutes
Which action best describes the role of the certified registered nurse anesthetist (CRNA) on the surgical care team?
Releases or discharges patients form the post anesthesia care unit.
Which integumentary assessment data from an older patient admitted with bacterial pneumonia is of most concern for the nurse?
Reports a history of allergic rashes
A patient with a systemic bacterial infection feels cold and has a shaking chill. Which assessment finding will the nurse expect next?
Rising body temperature.
The nurse is caring for a patient with diabetes who has abdominal surgery 3 days ago. Which finding is most important for the nurse to report to the health care provider?
Separation of the proximal wound edges by 1 cm
A patient who takes diuretic and a b-blocker to control blood pressure is scheduled for breast reconstruction surgery. Which patient information is most important to communicate to the health care provider before surgery?
Serum potassium 3.2 mEq/L
A patient with an enlarging, irregular mole that is 7 mm in diameter is scheduled for outpatient treatment. The nurse should plan to prepare the patient for which procedure?
Surgical excision
An older patient with a squamous cell carcinoma (SCC) on the lower arm has a Mohs procedure in the dermatology clinic. Which nursing action will be included in the postoperative plan of care?
Teach about the use of cold packs to reduce bruising and swelling
A patient scheduled for an elective hysterectomy tells the nurse, "I am afraid that I will die in surgery like my mother did!" Which response by the nurse is most appropriate?
Tell me more about what happened to your mother.
A patient has received atropine before surgery and complains of dry mouth. Which action by the nurse is best?
Tell the patient dry mouth is an expected side effect.
After the home health nurse teaches a patient's family member about how to care for a sacral pressure ulcer, which finding indicates that additional teaching is needed?
The family member dries the wound using a hair dryer set on a low setting.
A new nurse performs a dressing change on a stage II left heel pressure ulcer. Which action by the new nurse indicates a need for further teaching about pressure ulcer care?
The new nurse cleans the ulcer with a sterile dressing soaked in half-strength peroxide.
An experienced nurse orients a new nurse to the post anesthesia care unit (PACU). Which action by the new nurse, if observed by the experienced nurse, indicates that the orientation was successful?
The new nurse turns an unconscious patient to the side upon arrival in the PACU.
The nurse instructs a patient about application of corticosteroid cream to an area of contact dermatitis on the right leg. Which patient action indicates that further teaching is needed?
The patient applies a thick layer of the cream to the affected skin
A patient arrives at the ambulatory surgery center for a scheduled laparoscopy procedure in outpatient surgery. Which information is of most concern to the nurse?
The patient is planning to drive home after surgery.
The nurse working in the dermatology clinic assess a young adult female patient who is taking isotretinoin (Accutane) to treat severe cystic acne. Which assessment finding is most indicative of need for further questioning of the patient?
The patient recently had an intrauterine device removed
Which information in the preoperative patient's medication history is most important to communicate to the health care provider?
The patient takes garlic capsules daily but did not take any on surgical day.
The nurse is interviewing a patient with contact dermatitis. Which finding indicates a need for patient teaching?
The patient uses Neosporin ointment on minor cuts or abrasions
A patient has the following risk factors for melanoma. Which risk factor should the nurse assign as the priority focus of patient teaching?
The patient uses a tanning booth throughout winter.
After receiving a change-of-shift report, which patient should the nurse assess first?
The patient who has been receiving chemotherapy and has a temperature of 102 F
The nurse should delegate care of which patient to a licensed practical/vocational nurse (LPN/LVN)?
The patient who requires a hydrocolloid dressing change for stage III sacral ulcer
A 38-year-old female is admitted for an elective surgical procedure. Which information obtained by the nurse during the preoperative assessment is most important to report to the anesthesiologist before surgery?
The patient's stamen that her last menstrual period was 8 weeks previously.
The nurse assesses a patient who had a total abdominal hysterectomy 2 days ago. Which information about the patient is most important to communicate to the health care provider?
The right calf is swollen, warm, and painful.
Which information should the nurse include when teaching a patient who has just received a prescription for ciprofloxacin (Cipro) to treat a urinary tract infection?
Use a sunscreen with a high SPF when exposed to the sun
The nurse assess a patient who has just arrived in the postanesthesia recovery area (PACU) after a blepharoplasty. Which assessment data should be reported to the surgeon immediately?
The skin around the incision is pale and cold when palpated.
The nurse educator facilitates student clinical experiences in the surgical site. Which action, if performed by a student, would require the nurse educator to intervene?
The student wears surgical scrubs in the semirestricted area.
A patient reports chronic itching of the ankles and continuously scratches the area. Which assessment finding will the nurse expect?
Thickening of the skin around the ankles
A patient with atopic dermatitis has been using a high-potency topical corticosteroid ointment for several weeks. The nurse should assess for which adverse effect?
Thinning of the affected skin
Which information should the nurse include when teaching patients about decreasing the risk for sun damage to the skin?
Try to stay out of the sun between the hours of 10 AM and 2 PM
A patient who is scheduled for a therapeutic abortion tells the nurse, "Having an abortion is not right." Which functional health pattern should the nurse further assess?
Value-belief
A patient is being prepared for a spinal fusion. While in the holding area, which action by a member of the surgical team requires rapid intervention by the charge nurse?
Walking into the hallway outside an operating room without the hair covered.
What is the best method to prevent the spread of infection when the nurse is changing the dressing over a wound infected with Staphylococcus aureus?
Wash hands and properly dispose of soiled dressings
A patient in surgery receives a neuromuscular blocking agent as an adjunct to general anesthesia. While in the post anesthesia care unit (PACU), what assessment finding is most important for the nurse to report?
Weak chest wall movement
The health care provider prescribes topical 5-FU for a patient with actinic keratosis on the left cheek. The nurse should include which statement in the patient's instructions?
Your cheek area will be painful and develop eroded areas that will take weeks to heal.
