medsurg final exam q's

the surgical nurse is preparing to send a pt from the presurgical area to the or and is reviewing the patients informed consent form what are the critreia for legally valid informed consent?

- consent must be freely given - consent must be obtained by a physician - signature must be witnessed by a professional staff member

falls which are a major health problem in the elderly population occur from multifactorial causes. when implementing a comprehensive plan to reduce the incidence of falls on a geriatric unit, what risk factors should nurses identify? select all that apply

- medication effects - poor lighting - sensory impairment

maintaining an aseptic environment in the or is essential to patient safety and infection control. when moving around surgical areas what distance must the nurse maintain from the sterile field

1 foot

the nurse is caring for a 65 year old pt who has previously been diagnosed with hypertension which of the following bp readings represents the threshhold bw high normal blood pressure and hypertension ?

140/90 mmHg

the nurse is planning the care of a pt who has been diagnosed with hypertension but who otherwise enjoys good health. when assessing the response to an antihypertensive drug reegimen what blood pressure would be the goal of treatment

140/90 mmhg or lower

the nurse has assessed a pts family history for generations. this is efficient in which resp disease

ASTHMA

the ed nurse is assessing the resp function of a teenage girl who presented with acute shortness of breath. auscultation reveals continuous wheezes during inspiration and expiration. this finding is must suggestive of

ASTHMA wheezing

a nurse is working with a child who is undergoing a diagnostic workup for suspected asthma. what are the signs and symptoms that are consistent wiith a diagnosis of asthma

chest tightness wheezing cough tightneess wheezing cough

a nurse is admitting a 45 year old man to the medical unit who has a history of pad. while providing his health history the pt reveals that he smokes about 2 packs of cigs a day. has a history of alch abuse. and does not exercise. what would be the priority health education for this patient

cigarettes contain nicotine which is a powerful vasoconstrictor and may cause or aggravate pad

a gerontologic nurse is teaching studnets about the high incidence and prevalence of dehydration in older adults what factors contribute to this phenomenon?

decreased kidney mass decreased renal blood flow decreased excretion of potassium all decreased

84 year old pt has returned from the post anesthetic care unit pacu followinig hip arthroplasty. the pt is oriented to name only. the pts family is very upset bc before having surgery the pt had no cognitive deficits. the pt is subsequently diagnosed with postoperative delirium. what shouuld the nusre explain to the pts family

delirium of this type is treatable and her cognition will return to previous levels

During your initial shift assessment, the patient complains of cramps in her legs and a tingling sensation in her feet. Your assessment indicates decreased deep tendon reflexes (DTRs) and you suspect the patient has hypokalemia. What other sign or symptom would you expect this patient to exhibit?

dilute urine

the nurse is preparing an elderly pt for a scheduled removal of orthopedic hardware, a procedure to be performed under general anesthetic. for which adverse effect should the nurse most closely monitor the pt

hypothermia

you are working on a burns unit and one of ur acutely ill pts is exhibiting symptoms of third spacing. based on this change in status, you should expect the pt to exhibit signsand symptoms of which imbalance?

hypovolemia

the nurse admits a pt to the pacu with a blood pressure of 132/90 mm hg and a pulse of 68 beats per minute. ater 30 minutes the pts blood pressure is 94/47 and the pulse is 110. the nurse documents that the pts skin is cold moist and pale of what is the pt showing signs

hypovolemic shock

hypertensive urgency goal

normalizing bp within 24-48 hours

hypertension diet

reduced fat and sodium

A nurse has written a plan of care for a man diagnosed with peripheral arterial insufficiency. One of the nursing diagnoses in the care plan is altered peripheral tissue perfusion related to compromised circulation. What is the most appropriate intervention for this diagnosis?

Encourage the patient to engage in a moderate amount of exercise.

The nurse is caring for a patient who is experiencing pain and anxiety following his prostatectomy. Which intervention will likely best assist in decreasing the patients pain and anxiety?

Use of guided imagery along with pain medication

One of the things a nurse has taught to a patient during preoperative teaching is to have nothing by mouth for the specified time before surgery. The patient asks the nurse why this is important. What is the most appropriate response for the patient?

You will need to have food and fluid restricted before surgery so you are not at risk for choking.

a circulating nurse provides care in a surgical department that has multiple surgeries scheduled for the day. the nurse should know how to monitor which patient most closley during the intraoperative period becuase of the increase risk for hypothermia?

a 74 year old woman with a low body mass index

a surgical pt has just been admitted to the unit from pacu with pt controlled analgesia pca. the nurse should know that the requirements for safe and effective use of pca include what

a clear understanding of the need to self dose

you are the nurse planning an educational event for the nurses on a subacute meical unit on the topic of normal, age-related physiological changes. what phenomenon would you include in your teaching plan

a decrease in muscle mass and bone densitiy

decrease erythropoeitin production leads to

a decreased hemoglobin and hematocrit

a gerontologic nurse is aware of demographic changes that are occuring in the us and this affets the way that the nurse plans and provides care. which of the following phenomena is currently undergoing the most rapid and profound change?

a growing number of ppl live to a very old age

an older adult pt has been treated for a venous ulcer and a plan is in place to prevent the occurence of future ulcers what should the nurse includde in this plan

a high protein diet that is rich in vitamins

the nurse at a long term care facility is assessing each of the residents. which resident most likely faces the greatest risk for aspiration

a resident who suffered a severe stroke several weeks ago

a 56 year old male blood pressure 146/98. my pressure has never been this high! reduce it?

a single elevated blood pressure does not confirm hypertension. you will need to have your blood pressure reassesssed several times before a diagnosis can be made

an intraoperative nurse is applying interventions that will address surgical patients risks for preoperative positioning injury. which of the following factors contribute to this increased risk for injury in the intraoperative phase of the surgical experience?

absence of reflexes diminished ability to communicate loss of pain sensation

the nurse is creating the plan of care for a pt who is status postsurgery for reduction of a femur fracture. what is the most important short term goal for this patient

adequate respiratory function

a school nurse is caring for a 10 year old girl who is having an asthma attack. what is the preferred intervention to alleviate this clients airflow obstruction

administer an inhaled beta adernergic agonist

The nurse is caring for a 78-year-old female patient who is scheduled for surgery to remove her brain tumor. The patient is very apprehensive and keeps asking when she will get her preoperative medicine. The medicine is ordered to be given on call to OR. When would be the best time to give this medication?

after being notified by the OR and before other preoperative preparations

the nurse is performing a preoperative asssssment on a pt going to surgery. the pt informs the nurse that he drinks approximately 2 bottles of wine each day and has for the last few years. what postoperative difficulties can the nurse anticipate for this pt

alcohol withdrawal syndrome 2 to 4 days after his last alcohol drink

most likely to have anemia is

an 81 year old woman who has chronic heart failure

the nurse is caring for a pt admitted with an acute exacerbation of chronic obstructive pulmonary disease. during assessment the nurse finds that the pt is experiencing increased dyspnea. what is the most accurate measurement of the concentration of oxygen in the pts blood

an arterial blood gas study (ABG)

a nurse will conduct an influenza vaccination campaign at an extended care facility. the nurse will be administering intramuscular doses of the vaccine. of what age related change should the nurse be aware when planning the appropriate administration of this drug

an older pt has less subcutaneous tissue and less msucle mass than a younger patient

the pts surgery is nearly finished and the surgeon has opted to use tissue adhesives to close the surgical wound. this requires the nurse to prioritize assessments related to what complication

anaphylaxis

the or nurse is providing care for a 25 year old major trauma pt who has been involved in a motorcycle accident. the nurse should know that the pt is at increased risk for what complication of surgery

anesthesia awareness due to major trauma in the past he has at riks for anesthetic awareness

a nurse is caring for a pt who has been hospitalized with an acute ashtma exacerbation what drugs should the nurse expect to be ordered for this pt to gain underlying control of persistent asthma

anti inflammatory drugs

the nurse is planning pt teaching for a pt who is scheduled for an open hemicolectomy, the nurse intends to address the topics of incision splinting and leg exercises durin this teachig session. when is the best time for the nurse to provide teaching?

as soon as possible before the surgical procedure.

the nurse is performing the shift assessment of a postsurgical pt. the nurse finds his mental status level of conciousness speech and oriientation are intact and at baseline but the pt tells you he is very anxious. what should the nurse do next

assess the pts oxygen levels

the nurse is caring for a pt who is receiving oxygen therapy for pneumonia how should the nurse best assess whether the patient is hypoxemic

assess the pts oxygen saturation level

the periooperative nurse is providing care for a pt who is recovering on the postsurgical unit following a transurethral prostate resection (TUPR) the pt is reluctant to ambulate citing the need to recover in bed. for what complication is the pt most at risk

atelectasis

nurse is providing care for a pt with hypertension. nurse should also assess the pt for signs and symptoms of which other problem

atherosclerosis

a nurse is creating an education plan for a pt with venous insufficiency. what measure should the nurse include in the plan

avoiding tight fitting socks

type 1 diabetes and smokes cigs. the nurse should provide what instruction about long term care to the client

be sure to practice meticulous foot care

a nurse is completing a focused resp assessment of a child with asthma. what assessment finding is most closely associated with the characterisc signs and symptoms of asthma

bilateral wheezes

a community health nurse teaching a group of adults about preventing and treating hypertension. the nurse should encourage these participates to collaborate iwth their primary care providers and regularly monitor which of hte folowing

blood lipid levels

a nurse is teaching a pt how to perform flow type incentive spirometry prior to his scheduled thoracic surgery, what instruction should the nurse provide to the pt

breathe in deeply through the spirometer, hold your breath brieefly, than exhale

a pt is schedule for surgery the next day and the diff phases of the pts surgical experience will require input from members of numerous health discipines. how should the pts care best be coordinated

by implementing an interdisciplinary approach to care

as an intraoperative nurse you are the advocate for each of the pts who receives care in the surgical settin. how can you best exemplify the principles of pt advocacy

by maintainting each of ur patients privacy

an 87 year old pt has been hospitalized with pneumonia. which nursing action would be priority in this pts plan of care

cautious hydration

the nurse just received a postoperative pt from the PACU to the medsurg unit. the pt is an 84 year old woman who had surgery for a left hip replacement which of the following concerns should the nurse prioritize for this pt in the first few hours on the unit

close monitoring of neurologic status

the home care nurse is planning to begin breathing retraining exrcises with a client newly admitted to the home health service. the home care nurse knows that breathing retraining is especially indicated it he pt has what diagnosis

copd

what potential therapuetic benefits of antihypertensives shoudl the nurse identify?

decreased peripheral resistence decreased blood volume decreased strength and rate of myocardial contractions

a nurse in a long eterm care is caring for an 83 year old woman who has history of hf and pad. at present the pt is unable to stand or ambulate. the nurse should implement meausre to prevent what compication

deep ven thrombosis

you are caring for a pt admitted with a diagnosis of acute kidney injury. when you review your pts most recent lab reports, you note that the pts magnesium levels are high. u should prioritizwe assessment for which of the following health problems

diminished deep tendon reflexes

the nurse is packing a pts abdominal wound with sterile half inch iodoform gauze. during the procedure the nurse drops some of the gauze onto the pts abdomen 2 inches away from the wound. what should the nurse do?

discard the gauze packing and repack the wound with new iodoform gauze

when creating plans of nursing care for pts who are undergoing surgery using general anesthetic, what nursing diagnoses should the nurse identify?

disturbed sensory perception related to anesthetic risk of latex allergy response related to surgical exposure anxiety related to surgical concerns

the home health nurse is caring for a pt who has a comorbidity of hypertension. what assessment question most directly addresses the possibility of worsening hypertension

do you ever see spots in front of your eyees?

when assessing venous disesase in pts lower extremeties the nurse knows that what test will most likely be ordered

duplex ultrasonography

the nurse is preparing to change a pts abdominal dressing the nurse recognizes the first step is to provide the pt with information regarding the procedure. which of the folliwng explanations should the nurse provide to the pt

during the dressing change i will provide privacy at a time of your choosing, it should not be painful, and you can look at the incision and help with the procedure if you want to

an admitting nurse is assessig a pt with copd the nurse auscultates diminished breath sounds which signify changes in the airway. these changes indicate to the nurse to monitor the pt for what

dyspnea and hypoxemia

. An asthma nurse educator is working with a group of adolescent asthma patients. What intervention is most likely to prevent asthma exacerbations among these patients?

educating patients about recognizing and avoiding asthma triggers

the nurse is doing a preoperative assessment of an 87 year old man who is slated to have a right lung lobe resection to treat lung cancer. what underlying principle should guide the nurses preoperative assessment of an elderly pt

elderly pts have less physiologic reserve than younger patients

how should the nurse best position a pt who has leg ulcers that are venous in origin

elevate the pts lower extremeties

the surgeons preoperative assessment of a pt has identified that the pt is at a high risk for venous thromboembolism. once the pt is admitted to the postsurgical unit, what intervention should the nurse prioitize to reduce the pts risk of developing this complication?

encourage early ambulation

a pt will be undergoing a total hip arthoplasty later in the day and it is anticipated that the pt may require blood transfusion during surgery. how can the nurse best ensure the pts safety if a blood transfusion is required

ensure that the pt has had a current cross match

a pt with advanced venous insufficiency is confined folllowing orthopedic surgery how can the nurse best prevent skin breakdown in the pts lower extremeties

ensure that the pts heels are protected and supported

a nurse in the preoperative holding area is admitted a woman prior to reduction mammoplasty. what should the nurse include in the care given to this patient? sata

establishing an iv line verifying the surgical site with the patient taking measures to ensure the pts comfort

prior to a pts scheduled surgery the nurse has described the way that members of diverse health disciplines will collaborate in the patients care. what is the main rationale for organizing perioroperative care in this collaborative manner

evidence based practiec

The nurse is caring for a patient who is admitted to the ER with the diagnosis of acute appendicitis. The nurse notes during the assessment that the patients ribs and xiphoid process are prominent. The patient states she exercises two to three times daily and her mother indicates that she is b

faciliate a detailed analysis of the pts electrolyte levels

a 47 year old pt who has come to the physicians office for his annual physical is being assessed by the office nurse. the nurse who is performing routine health screening for this pt should be aware that one of the first physical signs of aging is what

failing eyesight esp close vision

tthe nurse is assessing the respiratory status of a pt who is experiencing an exacerbation of her emphysema symptoms. when preparing to auscultate, what breath sounds should the nurse anticipate?

faint breath sounds with prolongedd expiration

the nurse in the medical icu is caring for a pt who is in respiratory acidosis due to inadequate ventilation. what diagnosis could hte pt have that could cause inadequate ventilation

guillain barr syndrome

the nurse is providing care for a pt with a new diagnosis of hypertension. how can the nurse best promote the pts adherence to the prescribed therapeutic regimen

have the pt participate in monitoring his or her own bp

a gerontological nurse practitioner provides primary care for a large number of older adults who are living with various forms of cardiovascular disease. thsi nurse is well aware that heart disease is the leading cause of death in the aged. what is an age related physiological change that contributes to this trend?

heart muscle and arteries lose their elasticity

one day after a pt is admitted to the medical unit you note that the pt is oliguric. you notify the acute care nurse practiioner who orders a fluid challenge of 200 mL of normal saline solution over 15 minutes. this intervention will achieve which of the following

help distinguish reduce renal blood flow from decreased renal function

an adult pt has just been admitted to the pacu following abdominal surgery. as the pt begins to awaken he is uncharacteristically restless. the nurse checks his skin and it is cold moist and pale. the nurse concerned the pt may be at risk for what

hemorrhage and shock

the educator should teach the pt that a peak flow meter measure what value

highest airflow during a forced expiration

the patient asks why its important to treat hypertension. best response

hypertension greatly increases your risk of stroke and heart disease

the pacu nurse is caring for a 45 year old mael pt who had a left lobectomy. the nurse is assessing the pt frequently for airway patency and cardiovascular status. the nurse should know that the most common cardiovascular complications seen in the pacu include what?

hypotension dysrhythmias hypertension hypotension, hypertension, dysrhythmias.

the intraoperative nurse is implementing a care plan that addresses the surgical patients risk for vomiting. interventions that address the potential for vomiting reduce the risk of what subsequent surgical complication

hypoxia

the nurse is teaching about tissue repair and wound healing to a pt who has a leg ulcer. which of the following statements by the pts indicates that teaching has been effective

ill eat plenty of fruits and vegetables

a patients severe asthma has necessitated the use of a long acitng beta agonist (LABA). which of the pts statements suggeest a need for further education

ill make sure to use this each time i feel an asthma attack coming on

the nurse caring for a patient with a leg ulcer has finished assessing the pt and is developing a problem list prior to writing a plan of care. what major nursing diagnosis might the care include

imblanced nutrition: less than body requirements due to them needing more nutrition automatically to heal for ulcer imbalanced nutrition

as an intraoperative nurse you know that the pts emotional state can influence the outcome of his or her surgical procedure. how would you best reinforce the pts ability to influence outcome

inccorporate cultural and religious considerations as appropriate

an elderly pt has come into the clinic for her twice yearly physical the pt tells the nurse that she is generally enjoying good health except occasional episodes of constipation over the past 6 months. what intervention should the nurse first suggest?

increase daily intake of water

a critical care nurse is caring for a pt diagnosed with pneumonia as a surgical complication the nuses assesment reveals that the pt has an increased work of breathing due to copious tracheobronchial secretions. what should the nurse encourage the pt to do

increase oral fluids unless contraindicated

a pts. medication regimen for hypertension includes hydrochlorothiazide. what efffect?

increased urine output

you are performing an admission assessment on an older adult pt newly admitted for end stage liver disease. what principle should guide your assessment of the pts skin turgor?

inelastic skin turgor is a normal part of aging

The clinic nurse is doing a preoperative assessment of a patient who will be undergoing outpatient cataract surgery with lens implantation in 1 week. While taking the patients medical history, the nurse notes that this patient had a kidney transplant 8 years ago and that the patient is taking immunosuppressive drugs. For what is this patient at increased risk when having surgery?

infection

the nurse is creating the care plan for a 70 year old obese pt who has bewn admitted to the postsurgical unit following a colon resection this pts age and increased body mass index means that she is at increased risk for what complication in the postoperative period?

infection

a 21 year old pt is positioned on the or bed prior to knee surgery to correct a sports related injury. the anesthesiologist administers the appropriate anesthetic. the or nurse should anticipate which of the following events as teams next step in the car of this patient?

intubating

a nurse is planning discharge teaching for an 80 year old pt with mild short term memory loss the discharge teaching will include how to perform basic wound care for the venous ulcer on his lower leg. when planning the necessary health education for this pt. what shiould the nurse plan to do

keep teaching periods short

what intervention should the nurse implement to prevent a spinal headache

keep the patient positioned supine

the nurse is preparing to send a pt to the or for a scheduled surgery. what should the nurse ensure is on the chart when it accompanies the pt to sugery?

laboratory reports nurses notes verification form

the anesthetist is coming to the surgical admissions unit to see a pt prior to surgery scheduled for tmrw morning. which of the following is the priority information that the nurse should provide to the anesthetist during the visit

latex allergy

a nurse is providing preoperative teaching to a pt who will soon undergo a cardiac bypass. the nurses teaching plan includes exercises of the extremeties. waht is the purpose of teaching a pt leg exercises prior to surgery

leg exercises improve circulation and prevent venous thrombosis

the nurse is caring for a pt who has been diagnosed with an elevated cholesterol level, the nurse is aware that plaque on the inner lumen of arteries is composed chiefly of what

lipids and fibrous tissue

the nurse has performed a thorough nursing assessment of the care of a pt with chronic leg ulcers. the nurses assessment should include which of the following components

location and type of pain bilateral comparison of peripheral pulses comparison of temp in pts legs identification of mobility limitations

u are providing care for an 82 yeeaer old man whose signs and symptoms of parkinsons disease have become more severe over the past seveal months. the man tells u that he can no longer do as many things for himself as he used to be able to do. what factor should you recognize as impacting your pts life most significantly

loss of independence

the nurse realizes that the desired goal for cholesterol levels is which of the following

low ldl values and high hdl values

the nurse is caring for a pt who has just been transferred to the pacu from the or. what is the highest nursing priority

maintaining a patent airway

an or nurse is teaching a nursing student about the principles of surgical asepsis as a requirement in the restricted zone of the operating suite. what personal protective equipment should the nurse wear at all times in the restricted zones of the or

mask covering the nose and mouth

the nurse who is a member of the palliative care team is assessing a pt. the pt indicates that he has been saving his prn anelgesics until hte pain is intense bc his pain control has been inadequate. what teaching should the nurse do with this patient

medication should be taken when pain levels are low so the pain is easier to reduce.

you are frequently assessing an 84 year old womans pain after she suffered a humeral fracutre in a fall,. when applying the nursing process in pain management for a pt of this age, what principle should you best apply

monitor for signs of drug toxicity due to a decrease in metabolism

a patient is receiving thrombolytic therapy for the treatment of pulmonary emboli, what is the best way for the nurse to assess the pts oxygenation status at the bedside

monitor pulse oximetry readings

an or nurse will be participating in the intraoperative phase of a patients kidney transplant. what action will the nurse prioritize in this aspect of nursing care

monitoring the pts physiologic status

hypertension most common nursing diagnosis

noncompliance with therapeutic regimen related to adverse effects of prescribed therapy

a patient is 2 hours postoperative w/ a foley catheter in situ. the last hourly urine output recorded for this pt was 10 ml. the tubing of the foley is patent. what should the nurse do

notify the physician and continue to monitor the hourly urine output closely

teaching adult female about risk factors for primary hypertension.

obestiy and high intake of sodium and saturated fat

durin the care of a preoperative pt the nurse has given the pt a preoperative benzodiazepine the pt is now requesting to void. what action should the nurse take

offer the pt a bedpan or urinal

an 83 year old woman who was diagnosed with alzheimers disease 2 years ago and the disease has progressed at an increasing pace in recent months. the pt has lost 16 pounds over the past 3 months leading to a nursing diagnosis of imbalanced nutrition: less than body requirements. what intervention should the nurse include in this pts plan of care?

offer the pt only one food item at a time to promote focused eating.

a gerontologic nurse is teaching a group of med nurses about the high incidence and mortality of pneumonia in older adults. what is a contributing factor to this that the nurse should describe

older adults often lack the classic signs and symptoms of pneumonia

a nurse working in a long term care facility is performing the admission assessment of a newly admitted 85 year old resident. during inspection of the residents feet, the nurse notes that she appears to have early evidence of gangrene on one of her great toes. the nurse knows that gangrene in the elderly is often the first sign of what

pad

the pacu nurse is caring for a male pt who had a hernia repair. the pts blood pressure is now 164/92 mmhg and has no history of hypertension prior to surgery and his preoperative blood pressure was 112/68 mmhg. the nurse should assess for what potential causes of hypertension following surgery?

pain, hypoxia, or bladder distention

a medical nurse is appraising the effectiveness of a pts current pain control regimen. the nurse is aware that if an intervention is deemed ineffective, goals need to be reassessed and other measure need to be considered. what is the role of the nurse in obtaining additional pain relief for the pt?

patient advocate

ineffective health maintenance related to nonadhereence to tehreaptetic ergimen

patient takes medication as prescribed and reports any adverse effects

nurse is developing care plan for a pt who is being treated for hypertension. measureable pt outcome of hypertension patient

patient will reduce NA+ intake to no more than 2.4 g daily

the nursing instructor is discussing the difference between ambulatory surgical centers and hospital based surgical units. a student asks why some pts have surgery in the hospital and others are sent to ambulatory surgey centers .waht is the instrcutors best response

patients admitted to the hospital for surgery usually have multiple health needs

a pt is recovering in the hospital from cardiac surgery. the nurse has idenfitied the diagnosis of risk for ineffective airway clerance related to pulmonary secretions. what intervention best addressesthis risk

patients consistent performance of deep breathing and coughing exercises

nurse is caring for an older adult with hypertension treated with a diuretic and beta blocker. what to integrate into management of this clients hypertension

pay close attention to hydration status becuase of increased sensitivity to extracellular volume depletion

the or nurse acts in the circulating role during a pts scheduled cesarean section. for what tasks is this nurse solely responsible

performing documentation

a pediatric nurse practitioner is caring for a child who has just been diagnosed with asthma. the nurse has provided the parents iwth info that includes potential causative agents for an asthmatic reaction. what potential causative agent should the nurse describe

pets

the nurse is caring for an 82 yr old female pt in the pacu. the woman begins to awaken and responds to her name but is confused restless and agitated. what principle should guide the nurses subsequent assessment

postoperative confusion is common in the older adult patient but it could also indicate a significant blood loss

The nurse is caring for an 88-year-old patient who is recovering from an ileac-femoral bypass graft. The patient is day 2 postoperative and has been mentally intact, as per baseline. When the nurse assesses the patient, it is clear that he is confused and has been experiencing disturbed sleep patterns and impaired psychomotor skills. What should the nurse suspect is the problem with the patient?

postoperative delirium

the nurse ie performing wound care on a 68 year old postsurgical pt. which of the following practice violates the principles of surgical asepsis?

pouring solution onto a sterile field cloth

122/84 and 130/88 is

prehypertensive normal <120/<80 prehypertensive 129-39/80-89 stage 1 hypertensive: 140-59/90-99 stage 2 hypertensive: >160/>100

the nurse is caring for a pt with a large venous leg ulcer what intervention should the nurse implement to promote healing and prevent infection

provide a high calorie high protein diet

the nurse is discharging a pt home from an outpt surgery center. the nurse has reveiewed all of the discharge instructions with the pt and her caregiver. what else should the nurse do before discharging the pt from the facility?

provide all discharge instructions in writing provide the nurses or surgeons contact information give prescriptions to the patients

the nurse is caring for a 79 year old man who has returned to the postsurgical unit following abdominal surgery. the pt is unable to ambulate and is now refusing to wear an external pneumatic compression stocking. the nurse should explain that refusing to wear external pneumatic compression stockings increases his risk of what postsurgical complication?

pulmonary embolism

in addition to heart rate blood pressure resp rate and temp the nurse needs to assess a patients arterial oxygen saturation sao2. what procedure will best accomplish this

pulse oximetry

a postoperative pt rapidly presents with hypotension, rapid thready pulse oliguria and cold pale skin,. the nurse suspects that the pt is experiencing a hemorrhage. what should be the nurses first action

quickly attempt to determine the cause of hemmorahge

the nurse is caring for a pt on the medical surgical unit postoperatively day 5 during each pt assessmehnt the nurse evaluates the pt for infection. which of the following would be most indicating of infection

red warm tender incision

when uncontrolled hypertension is prolonged can risk for developing

renal failure

the surgical pt is 35 year old woman who has been administered general anesthesia. the nurse recognziezes that the pt is in stage 2 the excitement stage which intervention would be most appropriate for the nurse to implement during this stage

restrain the pt

primary hypertension gradual onset blurry vision decreased visual acuity indicative of

retinal blood vessel damage

nurse is aware that the difference between primary hypertension and secondary hypertension is

secondary hypertension has a sepcific cause

a nurse is planning the care of a pt with emphysema who will soon be discharged. what teaching should the nurse prioritize in the plan of care

setting realistic short term and long range goals

a patient with emphysema is experiencing shortness of breath. to relieve this patients symptoms, the nurse should assist her into what position

sitting upright leaning forward slightly

the nurse caring for pt recently diagnosed with lung disease encourages the pt not to smoke. what is the primary rationale

smoking damages the ciliary cleansing mechanism

hypertensive emergency. anticipate administration of what medication

sodium nitroprusside (Nitropress)

a surgical pt has been in the pacu for the past 3 hours. what are the determining factors for the pt to be discharged from the pacu

stable blood pressure sufficient oxygen saturation adeqaute respiratory function

an or nurse the nurse should know that a basic guide line for maintaining surgical asepsis is what?

sterile surfaces or articles may touch other sterile surfaces.

iron supplements

stool will darken in color

relationship between bp and age. best response by student?

structural and functional changes in the cardiovascular system that occur with age contribute to increases in blood pressure

you are the nurse caring for a 77 year old male patient who has been involved in a motor vehicle accidnet you and your colleague note that the pts labs indicate minimally elevated serum creatinine levels which your colleague dismissess. what can this increase in creatinine indicate in older adults

substantially reduced renal function

the perioperative nurse is constantly assessing the surgical pt for signs and symptoms of complications of surgery. which syptoms should first signal to the nursethe possibility that he pt is developing malignant hyperthermia

tachycardia

a student nurse is developing a teaching plan for an adult pt with asthma. what teaching point should have the highest priority in the plan of care that the student is developing

take prescribed medications as scheduled

the nursing lab instructor is teaching how to take bp. ensure accurate measurement teach the students to avoid

taking the bp atleast 10 min after nicotine or coffee ingestion (should be 30 min after caffeine or nicotine(

the nurse is assessing a woman who is pregnant at 27 weeks gestation. the patient is concerned about the recent emergency of varicose veins on the backs of her calves. what is the nurses best response

teach the pt that circulatory changes during pregnancy frequently cause varicose veins.

the admitting nurse in a short stay surgical unit is responsible for numerous aspects of care. what must the nurse verify before the pt is taken to the preoperative holding area?

that preoperative teaching was performed

the nursing instructor is discussing postoperative care with a group of nursing students. a student nurse asks why does the pt go to the PACU instead of just going straight up to the postsurgical unit? what is the best response

the PACU allows the pt to recover from the effects of anesthesia, and the pt stays in the PACU until he or she is oriented, has stable vital signs, and is without complications.

you are the nurse caring for an elderly pt with cardiovascular disease. the pt comes to the clinic with a suspected respiratory infection and is diagnosed with pneumonia. as the nurse what do you know about the altered responses of older adults?

the altered responses of older adults reinforce the need for the nurse to monitor all body systems to identify possible systemic complications

you are caring for a pt with late-stage alzheimers disease. the pts wife tells you that the pt has now become completely dependent and that she feels guilty if she takes any time for herself. what outcome would be appropriate for the nurse to develop to assist the pts wife

the caregiver distinguishes essential obligations from those that can be controlled or limited

the nurse knows that elderly pts are at higher risk for complications and adverse outcomes during the nitraoperative period, what is the best rationale for this phenomenon

the elderly pt has reduced ability to adjust rapidly to emotional and physical stress

graduated compression stockings have been prescribed to treat a pts venous insufficiency. what education should the nurse prioritze when introducing this intervention to the patient

the importance of ensuring the stockings are applied evenly with no pressure points

the pt asks the nurse what he could have done to minimize the risk of contracing the disease. what would be the nurses best answer

the most important risk factor for copd is cigarette smoking

the nurse admitted a pt who is insulin dependent to the same day surgical suite for carpal tunnel surgery. how should this pts diagnosis of type 1 diabetes affect the care that the nurse plans

the nurse should assess the pts blood glucose levels vigilantly

the nurse is caring for postoperative pt who needs daily drssing changes. the pt is 3 days postoperative and is scheduled for discharge the next day. until now the pt has refused to learn how to change her dressing. what would indicate to the nurse the pt possible readiness to learn how to change her dressing?

the patient exprssess interest in the dressing change the pt is willing to loook at the incision during a dressing change the pt assists in opening the packages of dressing material for the nurse

the or nurse is taking the pt into the or when the pt informs the operating nurse that his grandmother spiked a 104 f temperature in the or and nearly died 15 years ago,, what relevance does this information have regarding the pt

the patient may be at risk for malignant hyperthermia

the pacu nurse is caring for a pt who has been deemed ready to go to the postsurgical floor after her surgery. what would the pacu nurse be responsibel for reporting to the nurse on the floor?

the patients preoperative level of consciousness the presence of family and or significant others the patients full name

the nurse is preparing a pt for sugery prior to her hysterectomy without oophorectomy the nurse is witnessing the pts signature on a consent form. which comment by the pt would best indicate informed consent

the physicial is going to remove my uterus and told me about the risk of bleeding

the nurse is caring for a pt after abdominal surgery in the pacu. the pts blood pressure has increased and the pt is restless. the pts oxygen saturation is 97%. what cause for this change in status should the nurse first suspect

the pt is in pain

the circulating nurse in an outpatient surgery center is assessing a pt who is scheduled to receive moderate sedation. what principle should guide the care of a pt receiving this form of anesthesia?

the pt must never be left unattended by the nurse

in anticipation of a pts scheduled surgery the nurse is teaching her to perform deep breathing and coughing to use postoperatively. what action should the nurse teach the pt?

the pt should take a deep breath in through the mouth and exhale through the mouth, take a short breth, and cough from deep in the lungs

prompted the primary care provider to prescribe furosemide (lasix) the nurse should monitor for which of the following

the pts potassium level

u are the nurse caring for an unconcious trauma victim who needs emergency surgery. the pt is a 55 year old man with an adult son. he is legally divorced and is planning to be remarried in a few weeks. his parents are at the hospital w the other fam members. the physician hase xplained the need for surgery the procedure to be done and the risks to the children parents and finace. who should be asked to sign the surgery consent form

the son

ur caring for an 88 year old woman who is scheduled for a right mastectomy. elderly pts are frequently more anxious prior to surgery than younger pts. what would you increase wiith this pt to decrease her anxiety

therapeutic touch

you are creating a nursing care plan for a pt with a primary diagnosis of cellulitis and a secondary diagnosis of chronic pain. what common trait of pts who live with chronic pain should inform your care planning?

they can experience acute pain in addition to chronic pain

a nurse is explaining to a pt with asthma what her new prescription for prednisone is used for. what would be the most accurate explanation that the nurse could give

to gain prompt control of inadeqautely controlled persistent asthma

the nusre is providing preioperative teaching to a pt scheduled for surgery. the nurse is instructing the pt on the use of deep breathing, coughing, and the use of incentive spirometry when the patient states, i dont know why youre focusing on my breathing. my surgery is on my hip, not my chest. what rationale for these instructions should the nurse provide

to promote optimal lung expansion

hypertension. lifestyle changes . avoid tobacco use. primary rationale

tobacco use increases the pts concurrent risk of heart disease

the dressing surrounding a mastectomy pts jackson pratt drain has scant drainage on it, the nurse believes that the amt of drainainge on the dressing may be increasing. how can the nurse best confirm this suspicion

trace the outline of the drainage on the dressing for future comparison

uncontrolled hypertension health consequences

transcient ischcemic attacks cerebrovascular accident retinal hemorrhage trancient ischemic attack certobracascular accident retinol hemmorahge from hypertension complications

the pacu nurse is caring for a pt who has arrived from the or. during the intitial assessment the nurse observes that the pts skin has become blue and dusky. the nurse looks listens and feels for breathing and determines that the patient is not breathing, what is the priorty intervention

treat the possibible airwy obstruction by tilting the head back and pushing forward on the angle of the lower jaw

accurate bp reading

try to rest 5 minutes quietly befrore the reading is taken

a medical patient rings her call bell and expresses alarm to the nurse stating ive just coughed up this blood. that cant be good can it? how can the nurse best determine whether the source of blood was the pts lungs?

try to see if the blood is frothy or mixed with mucus

the nurse is providing care for a pt who has just been diagnosed with peripheral arterial occlusive disease. pad. what assessment finding is most consistent w/ this diagnosis

unequal peripheral pulses between extremeties

a nurse is providing discharge teaching for a client with copd when teaching about breathing exrcises waht should the nurse include in the teaching

use diaphragamatic breathing

a nurse is assessing a new pt who is diagnosed with pad. the nurse cannot feel the pulse in the pts left foot how should the nurse proceed with assessment?

use doppler ultrasound to identify the pulses

an older adult primary hypertension started beta blocker. nurses health education should include

use of strategies to prevent falls stemming from postural hypotension

The nurse is performing a preadmission assessment of a patient scheduled for a bilateral mastectomy. Of what purpose of the preadmission assessment should the nurse be aware?

verifies completion of preoperative diagnostic testing

pernicious anemia needs to administer

vitamin b12

an occupational health nurse is providing an education event and has been asked by an administrative worker about the risk of varicose veins. what should the nurse suggest as a proactive preventative measure for varicose veins

walk for several minutes every hour to promote circulation

the prevention of vte is an important part of the nursing care of high risk pts. when providing pt teaching for these high risk patients the nurse should advise lifestyle changes, including which of the following?

weight loss regular exercise smoking cessation

a clinic nurse is conductin a preoperative interview with an adult pt who will soon be scheduled to undergo cardiac surgery. what interview question most directly addresses the pts safety

what prescription and nonprescription medications do you currently take

a 77 year old mans coronary artery bypass graft has been successful and discharge planning is underway. when planning the pts subsequent care, the nurse should know that the postooerative phase of perioperative nursing ends at what time?

when a follow up evluation in the clinical or home setting is done

The nurse is caring for a trauma victim in the ED who will require emergency surgery due to injuries. Before the patient leaves the ED for the OR, the patient goes into cardiac arrest. The nurse assists in the successful resuscitation and proceeds to release the patient to the OR staff. When can the ED nurse perform the preoperative assessment?

when assisting with the resuscitation

coffee ground like emsesis. when can the pt most likely anticipate the surgery will be scheduled

without delay because the bleed is emergent

the nurse is caring for a pt in the postoperative period following an abdominal hysterectomy. the pt states, i dont want to use my pain meds bc theyll make me dependent and i wont get better as fast. which response is most important when explaining the use of pain medication

you will move more easily and heal more quickly with decreased pain. dependence only occurs when it is administered for an extended period of time