MedSurg - Perioperative, Shock, Fluid & Electrolytes

The nurse is caring for a patient newly diagnosed with sepsis. The patient has a serum lactate level of 6 mmol/L and fluid resuscitation has been initiated. Which of the following indicates that the fluid resuscitation received by the patient is adequate? a) Central venous pressure (CVP) of 6 mm Hg b) Urine output of 0.2 mL/kg/hr c) Mean arterial pressure (MAP) of 70 mm Hg d) ScvO 2 of 60%

c) Mean arterial pressure (MAP) of 70 mm Hg The nurse administers fluids to achieve a target CVP of 8 to 12 mm Hg, MAP > 65 mm Hg, urine output > 0.5 mL/kg/hr, and an ScvO2 > 70%.

In the treatment of shock, which of the following vasoactive drugs results in reduced preload and afterload, reducing the oxygen demand of the heart? a) Methoxamine (Vasoxyl) b) Epinephrine (Adrenaline) c) Nitroprusside (Nipride) d) Dopamine (Intropin)

c) Nitroprusside (Nipride) A disadvantage of nitroprusside is that it causes hypotension. Dopamine improves contractility, increases stroke volume, and increases cardiac output. Epinephrine improves contractility, increases stroke volume, and increases cardiac output. Methoxamine increases BP by vasoconstriction.

Vasoactive drugs, which cause the arteries and veins to dilate thereby shunting much of the intravascular volume to the periphery and causing a reduction in preload and afterload, include agents such as which of the following? a) Dopamine (Intropin) b) Furosemide (Lasix) c) Sodium nitroprusside (Nipride) d) Norepinephrine (Levophed)

c) Sodium nitroprusside (Nipride) Sodium nitroprusside is used in the treatment of cardiogenic shock. Norepinephrine (Levophed) is a vasopressor that is used to promote perfusion to the heart and brain. Dopamine (Intropin) tends to increase the workload of the heart by increasing oxygen demand; thus, it is not administered early in the treatment of cardiogenic shock. Furosemide (Lasix) is a loop diuretic that reduces intravascular fluid volume.

A patient receiving moderate sedation for a minor surgical procedure begins to vomit. What should the nurse do first? a) Administer an antiemetic medication. b) Provide a basin. c) Roll the patient on his or her side. d) Suction the mouth.

c) Roll the patient on his or her side. The patient must be rolled to the side to prevent aspiration. All the other interventions are correct for a vomiting sedated patient, but the highest priority is in preventing aspiration.

The nurse anticipates that a patient who is immunosuppressed is at the greatest risk for developing which of the following types of shock? a) Cardiogenic b) Neurogenic c) Septic d) Anaphylactic

c) Septic Septic shock is associated with immunosuppression, extremes of age, malnourishment, chronic illness, and invasive procedures. Neurogenic shock is associated with spinal cord injury and anesthesia. Cardiogenic shock is associated with disease of the heart. Anaphylactic shock is associated with hypersensitivity reactions.

The physician, concerned about aspiration during a surgical procedure, orders a medication to increase gastric pH. Which of the following medications would the nurse document as given? a) Midazolam (Versed) b) Vecuronium (Norcuron) c) Sodium citrate (Bicitria) d) Famotadine (Pepcid)

c) Sodium citrate (Bicitria) Sodium citrate increases the gastric pH therefore reducing the damage to the respiratory tract if aspiration should occur. Vecuronium is a muscle relaxant, famotidine decreases gastric acid production, and midazolam is an anesthetic agent.

The nurse is educating a patient scheduled for elective surgery. The patient currently takes aspirin daily. What education should the nurse provide in regard to the medication? a) Continue to take the aspirin as ordered. b) Aspirin should be increased until 3 days before surgery, and then it should be discontinued until 3 days after surgery. c) Stop taking the aspirin 7 days before the surgery, unless otherwise directed by your physician. d) Take half doses of the aspirin until 1 week after surgery.

c) Stop taking the aspirin 7 days before the surgery, unless otherwise directed by your physician. Aspirin should be stopped at least 7 to 10 days before surgery. The other directions provided are incorrect.

Which of the following colloid solutions is used to treat tissue hypoperfusion due to hemorrhage? a) Lactated Ringer's b) Hypertonic saline c) Dextran d) Albumin

d) Albumin Typically, if colloids are used to treat tissue hypoperfusion, albumin is the agent prescribed. Albumin is a plasma protein; an albumin solution is prepared from human plasma and is heated during production to reduce its potential to transmit disease. The disadvantage of albumin is its high cost compared with crystalloid solutions. Dextran interferes with platelet aggregation and is not recommended for hemorrhagic shock. Lactated Ringer's and hypertonic saline are crystalloids, not colloids.

The nurse recognizes that there are many risk factors for the development of hypovolemic shock. Which of the following are considered "internal" risk factors? Select all that apply. a) Dehydration b) Diarrhea c) Vomiting d) Burns e) Trauma

d) Burns a) Dehydration The internal (fluid shift) causes of hypovolemic shock include hemorrhage, burns, ascites, peritonitis, and dehydration. The external (fluid losses) causes of hypovolemic shock include trauma, surgery, vomiting, diarrhea, diuresis, and diabetes insipidus.

The anesthesiologist administered a transsacral conduction block. Which of the following documentation by the nurse is consistent with the anesthesia being administered? a) Denies sensation to perineum and lower abdomen b) Yelling and pulling at equipment c) Unresponsive to verbal or tactile stimuli d) No movement in right lower leg

a) Denies sensation to perineum and lower abdomen A transsacral block produces anesthesia of the perineum, and occasionally, the lower abdomen. Yelling and pulling at equipment can be related to the excitement phase of general anesthesia. Unresponsive to verbal or tactile stimuli and no movement in the right lower leg are not consistent with a transsacral conduction block.

The nurse is caring for a patient with a serum potassium level of 6.0 mEq/L. The patient is ordered to receive oral sodium polystyrene sulfonate (Kayexelate) and furosemide (Lasix). What other orders should the nurse anticipate giving? a) Discontinue the IV lactated Ringer's solution. b) Change the lactated Ringer's solution to 3% saline. c) Change the lactated Ringer's solution to 2.5% dextrose. d) Increase the rate of the IV lactated Ringer's solution.

a) Discontinue the IV lactated Ringer's solution. The lactated Ringer's IV fluid is contributing to both the fluid volume excess and the hyperkalemia. In addition to the volume of IV fluids contributing to the fluid volume excess, lactated Ringer's contains more sodium than daily requirements and excess sodium worsens fluid volume excess. Lactated Ringer's also contains potassium, which would worsen the hyperkalemia.

A medical student, scheduled to observe surgery, enters the unrestricted surgical zone wearing jeans, a t-shirt, and tennis shoes. What is the best action by the nurse? a) Educate the medical student on required attire for each surgical zone. b) Immediately escort the medical student out of the area. c) Provide the medical student a cap and mask. d) No action is needed.

a) Educate the medical student on required attire for each surgical zone. It would be best to educate the medical student on the required attire for each surgical zone. Since the student will be observing a surgery, the student will need to dress appropriately in each zone to decrease the risk of introducing pathogens. The unrestricted zone allows for street clothes; therefore, the student does not need to be removed. If no action is taken by the nurse, the student could enter the semirestricted or restricted zone without appropriate attire. Providing a cap and mask does not address the need to change out of the street clothes to observe the surgery.

The nurse is assessing a patient for local complication of IV therapy. Local complications include which of the following? Select all that apply. a) Extravasation b) Hematoma c) Infection d) Phlebitis e) Air embolism

a) Extravasation b) Hematoma d) Phlebitis Local complications of IV therapy include infiltration and extravasation, phlebitis, thrombophlebitis, hematoma, and clotting of the needle. Systemic complications occur less frequently but are usually more serious than local complications and include circulatory overload, air embolism, febrile reaction, and infection.

The circulating nurse is documenting all medications administered during a surgical procedure. The anesthesiologist administers an opioid analgesic. What medication would the nurse check as having being administered? a) Fentanyl (Sublimaze) b) Metocurine (Metubine) c) Etomidate (Amidate) d) Mivacurium (Mivacron)

a) Fentanyl (Sublimaze) Fentanyl is an opioid analgesic. Mivacurium and metocurine are muscle relaxants. Etomidate is an anesthetic agent.

A patient is being cared for in the Neurological Intensive Care Unit following a spinal cord injury. Which of the following assessment findings indicate the patient may be experiencing neurogenic shock? a) HR: 48 bpm; BP: 90/60 mm Hg b) HR: 120 bpm; BP 88/58 mm Hg c) Cool, moist skin d) Shortness of breath

a) HR: 48 bpm; BP: 90/60 mm Hg The clinical characteristics of neurogenic shock are signs of parasympathetic stimulation. It is characterized by dry, warm skin rather than the cool, moist skin seen in hypovolemic shock. Another characteristic is hypotension with bradycardia, rather than the tachycardia that characterizes other forms of shock. The other signs and symptoms are associated with hypovolemic shock.

A patient is being treated with loop diuretics; gastric suctioning has been initiated. The nurse understands the patient is at risk for developing which of the following electrolyte imbalances? a) Hypokalemia b) Hypomagnesium c) Hyponatremia d) Hypocalcemia

a) Hypokalemia Potassium-losing diuretics, such as the thiazides and loop diuretics, can induce hypokalemia. Gastrointestinal (GI) loss of potassium is another common cause of potassium depletion. Vomiting and gastric suction frequently lead to hypokalemia.

A surgical patient has been transferred to the holding area. What nursing intervention(s) promote safe and effective nursing care? Select all that apply. a) Identify the patient using two identifiers. b) Review the medical records. c) Maintain an aseptic environment. d) Apply grounding devices to the patient. e) Verify the surgical site and mark it appropriately. f) Provide oral fluids to the patient.

a) Identify the patient using two identifiers. e) Verify the surgical site and mark it appropriately. b) Review the medical records. Identifying the patient, verifying and marking the surgical site, and reviewing the medical records all promote safe and effective care while the patient is in the holding area. Maintaining an aseptic environment and applying grounding devices are part of the intraoperative phase. Oral fluids should not be provided while the patient is in the holding area.

A patient continuously states, "I know all will go well." What cognitive coping strategy should the nurse document? a) Music therapy b) Optimistic self-recitation c) Imagery d) Distraction

b) Optimistic self-recitation When that patient verbalizes this statement, it is an optimistic response. Imagery occurs when the patient concentrates on a pleasant experience or restful scene. Distraction occurs when the patient thinks of an enjoyable story or recites a favorite poem or song. Music therapy would be an incorrect answer.

A list of commonly used medications for a particular surgical procedure is provided to the nurse. The anesthesiologist announces the administration of a nondepolarizing muscle relaxant. Which of the following medications should the nurse document as having been administered? a) Succinylcholine (Anectine) b) Pancuronium (Pavulon) c) Morphine sulfate d) Fentanyl (Sublimaze)

b) Pancuronium (Pavulon) Pavulon is a nondepolarizing muscle relaxant. Succinylcholine is a polarizing muscle relaxant. Fentanyl and morphine sulfate are opioid analgesic agents.

The nurse has administered the preanesthetic medication. What action should the nurse take next? a) Educate the patient on discharge instructions. b) Place the patient on bed rest with the side rails up. c) Obtain the patient's signature on the consent form. d) Review the patient's list of home medications.

b) Place the patient on bed rest with the side rails up. The preanesthetic medication can make the patient lightheaded and dizzy. Safety is a priority. The consent form should be signed before the patient is medicated. Consents signed after the patient is medicated are not legal. Reviewing the home medications and educating the patient should take place before the patient is medicated.

A patient is scheduled for elective surgery. To prevent the complication of hypotension and cardiovascular collapse, the nurse should report the use of what medication? a) Erythromycin (Ery-Tab) b) Prednisone (Deltasone) c) Hydrochlorothiazide (HydroDIURIL) d) Warfarin (Coumadin)

b) Prednisone (Deltasone) Patients who have received corticosteroids are at risk of adrenal insufficiency. Insufficiency related to corticosteroids can cause circulatory collapse and hypotension. Hydrochlorothiazide and erythromycin can cause respiratory complications. Warfarin will increase the risk of bleeding.

A patient is administered succinylcholine and propofol (Diprivan) for induction of anesthesia. One hour after administration, the patient is demonstrating muscle rigidity with a heart rate of 180. What should the nurse do first? a) Obtain cooling blankets. b) Administer dantrolene sodium (Dantrium). c) Document the assessment findings. d) Notify the surgical team.

d) Notify the surgical team. Tachycardia and muscle rigidity is often the earliest sign of malignant hyperthermia. Early recognition of malignant hyperthermia increases survival. The nurse would document the findings, administer dantrolene sodium (Dantrium), obtain cooling blankets as part of the treatment for malignant hyperthermia, but the nurse would need to ensure the surgical team is aware of the findings first.

A patient is undergoing a perineal surgical procedure. Which of the following actions by the nurse is appropriate? a) Place the patient in a dorsal recumbent position. b) Place the patient in Sims' position. c) Place the patient in the Trendelenburg position. d) Place the patient in lithotomy position.

d) Place the patient in lithotomy position. The lithotomy position is used for nearly all perineal, rectal, and vaginal surgeries. The Trendelenburg position is usually used for surgery on the lower abdomen and pelvis. Sims' or lateral position is used for renal surgery. The dorsal recumbent position is the usual position for surgical procedures.

The nurse is participating in the care of a patient who had a peripherally inserted central catheter (PICC) inserted in the right arm. Following catheter placement, the nurse should complete which of the following actions? a) Obtain written consent for the procedure. b) Assess the patient's blood pressure (BP) on the right arm. c) Administer the prescribed IV fluids. d) Send the patient for a chest x-ray.

d) Send the patient for a chest x-ray. A chest x-ray is needed to confirm the placement of catheter tip prior to initiation of ordered infusion. Consent should be obtained prior to the procedure, not after the procedure. No BPs should be taken on the extremity where the catheter is placed.

Organ failure associated with multiple organ dysfunction syndrome (MODS) usually begins in which of the following organs? a) The kidneys b) The liver c) The brain d) The lungs

d) The lungs During MODS, the organ failure usually begins in the lungs and is followed by failure of the liver, GI system, and kidneys.

The nurse is caring for a client diagnosed with bulimia. The client is being treated for a serum potassium level of 2.9 mEq/L. Which of the following statements made by the patient indicates the need for further teaching? a) "I can use laxatives and enemas but only once a week." b) "I will be sure to buy frozen vegetables when I grocery shop." c) "A good breakfast for me will include milk and a couple of bananas." d) "I will take a potassium supplement daily as prescribed."

a) "I can use laxatives and enemas but only once a week." The patient is experiencing hypokalemia most likely due to the diagnosis of bulimia. Hypokalemia is defined as a serum K+ level below 3.5 mEq/L [3.5 mmol/L], and usually indicates a deficit in total potassium stores. Patients diagnosed with bulimia frequently suffer increased potassium loss through self-induced vomiting, misuse of laxatives, diuretics, and enemas; thus, the patient should avoid laxatives and enemas. Prevention measures may involve encouraging the patient at risk to eat foods rich in potassium (when the diet allows) including fruit juices and bananas, melon, citrus fruits, fresh and frozen vegetables, lean meats, milk, and whole grains. If the hypokalemia is caused by abuse of laxatives or diuretics, patient education may help alleviate the problem.

The nurse is instructing a patient with recurrent hyperkalemia about following a potassium-restricted diet. Which of the following patient statements indicates the need for additional instruction? a) "I will not salt my food, instead I'll use salt substitute." b) "Bananas have a lot of potassium in them, I'll stop buying them." c) "I need to check if my cola beverage has potassium in it." d) "I'll drink cranberry juice with my breakfast...

a) "I will not salt my food, instead I'll use salt substitute." The patient should avoid salt substitutes. The nurse must caution patients to use salt substitutes sparingly if they are taking other supplementary forms of potassium or potassium-conserving diuretics. Potassium-rich foods to be avoided include many fruits and vegetables, legumes, whole-grain breads, lean meat, milk, eggs, coffee, tea, and cocoa. Conversely, foods with minimal potassium content include butter, margarine, cranberry juice or sauce, ginger ale, gumdrops or jellybeans, hard candy, root beer, sugar, and honey. Labels of cola beverages must be checked carefully because some are high in potassium and some are not.

A patient has been transported to the operating room for emergent surgery. Which statement by the nurse best supports the need for emergent surgery? a) "The patient was unresponsive, had a distended abdomen, and unstable vital signs following a motor vehicle accident." b) "The patient had epigastric abdominal pain, an elevated white blood count, and vomiting for 1 day." c) "The patient was tachycardic, had progressive weight loss, and bouts of insomnia as a result of hyperthyroidism." d) "The patient had severe pain and a laceration to the face with minimal bleeding after being attacked by a dog 1 hour ago."

a) "The patient was unresponsive, had a distended abdomen, and unstable vital signs following a motor vehicle accident." Emergency surgery means that the patient requires immediate attention and the disorder may be life threatening. The patient with unstable vital signs and a distended abdomen following a motor vehicle accident requires immediate attention. The patient with left sided abdominal pain may not need surgery. Epigastric pain with vomiting for 1 day is usually not an indication for emergent surgery. Lacerations to the face require sutures, not emergent surgery. A thyroidectomy to treat hyperthyroidism is a required surgery, not an emergent one.

The nurse is caring for a patient in cardiogenic shock. A dobutamine (Dobutrex) drip at 1 μg/kg/min is ordered for the patient. The patient weighs 90 kg. The dobutamine is supplied in a concentration of 500 mg in 250 mL D5W. IV infusion should be started at how many mL/hr? a) 2.7 mL/hr b) 11 mL/hr. c) 8.0 mL/hr d) 5.5 mL/hr

a) 2.7 mL/hr The nurse should administer 2.7 mL/hr. 1 mcg × 90 kg × 60 minutes / 2,000 (concentration)

A patient presents to the Emergency Department experiencing a severe anxiety attack and is hyperventilating. The nurse would expect the patient's pH value to be which of the following? a) 7.50 b) 7.35 c) 7.45 d) 7.30

a) 7.50 The patient is experiencing respiratory alkalosis. Respiratory alkalosis is a clinical condition in which the arterial pH is greater than 7.45 and the PaCO2 is less than 38 mm Hg. Respiratory alkalosis is always caused by hyperventilation, which causes excessive "blowing off" of CO2 and, hence, a decrease in the plasma carbonic acid concentration. Causes include extreme anxiety, hypoxemia, early phase of salicylate intoxication, Gram-negative bacteremia, and inappropriate ventilator settings.

For which of the following patients in shock would a nurse observe an elevated leukocyte count and a fever accompanied by warm, flushed skin during the assessment? a) A patient with an overwhelming bacterial infection b) A patient who has lost blood during childbirth c) A patient who has had severe allergic reaction to a bee sting d) A patient who has had an overdose of opioids

a) A patient with an overwhelming bacterial infection Unlike other forms of shock, patients with septic shock have an elevated leukocyte count and initially manifest fever accompanied by warm, flushed skin and a rapid, bounding pulse. Therefore, the patient with an overwhelming bacterial infection is most likely to exhibit these symptoms. Extreme loss of blood causes hypovolemic shock; an overdose of opioids causes neurogenic shock; and a severe allergic reaction causes anaphylactic shock.

A patient refuses to remove her wedding band when preparing for surgery. What is the best action for the nurse to take? a) Allow the ring to stay on the patient and cover it with tape. b) Remove the ring once the patient is sedated. c) Notify the surgeon to cancel surgery. d) Discuss the risk for infection caused by wearing the ring.

a) Allow the ring to stay on the patient and cover it with tape. Most facilities will allow a wedding band to remain on the patient during the surgical procedure. The nurse must secure the ring with tape. Although it is appropriate to discuss the risk for infection, the patient has already refused removal of the ring. The surgery should not be canceled and the ring should not be removed without permission.

A patient undergoing coronary artery bypass surgery is subjected to intentional hypothermia. The patient is ready for rewarming procedures. Which of the following actions by the nurse is appropriate? a) Apply a warm air blanket, gradually increasing body temperature. b) Place warm damp drapes on the patient, replacing them every 5 minutes. c) Temporarily set the OR temperature to 30°C. d) Administer IV fluids warmed to room temperature.

a) Apply a warm air blanket, gradually increasing body temperature. A warm air blanket can be used to treat hypothermia. The body temperature should gradually be increased. Sudden increase in body temperature could cause complications. The OR temperature should not exceed 26.6°C to prevent pathogen growth. Only dry materials should be placed on the patient because wet materials promote heat loss. IV fluids should be warmed to body temperature, not room temperature.

A 78-year-old woman is undergoing right hip surgery to repair a hip fracture. What nursing action is appropriate during the intraoperative phase? a) Appropriately position the patient using adequate padding and support. b) Discuss the need for higher doses of anesthetic agents with the anesthesiologist. c) Maintain an operating room temperature of 18°C to prevent hypothermia. d) Withhold pain medication due to decreased renal functioning.

a) Appropriately position the patient using adequate padding and support. Adequate padding and support should be used to prevent positioning injuries. The older adult is has lower bone mass, which increases the risk of intraoperative positioning injuries. Pain medication can still be used, just in smaller doses, due to decreased liver and kidney functioning. For the same reason as pain medication, lower doses of anesthetic agents are used with the older adult. The operating room is usually maintained from 20°C to 24°C; 18°C is lower than the recommended temperature and can promote hypothermia in the older adult who already has impaired thermoregulation and is prone to hypothermia.

When caring for a patient who has risk factors for fluid and electrolyte imbalances, which of the following assessment findings is the highest priority for the nurse to follow up? a) Irregular heart rate b) Blood pressure 96/53 mm Hg c) Weight loss of 4 lb d) Mild confusion

a) Irregular heart rate Irregular heart rate may indicate a potentially life-threatening cardiac dysrhythmia. Potassium, magnesium, and calcium imbalances may cause dysrhythmias. Weight loss is a good indicator of the amount of fluid lost, but following up on potential cardiac dysrhythmias is a higher priority. Confusion may occur with dehydration and hyponatremia, but following up on potential cardiac dysrhythmias is a higher priority. The blood pressure is slightly lower than normal but is not life threatening. Following up on potential cardiac dysrhythmias is a higher priority.

Which positioning strategy should be used for the patient diagnosed with hypovolemic shock? a) Modified Trendelenburg b) Supine c) Prone d) Semi-Fowler's

a) Modified Trendelenburg A modified Trendelenburg position is recommended in hypovolemic shock. Elevation of the legs promotes the return of venous blood.

During the preoperative assessment, the patient states he is allergic to avocados, bananas, and hydrocodone (Vicodin). What is the priority action by the nurse? a) Notify the surgical team to remove all latex-based items. b) Notify the nurse manager to follow up on the procedure. c) Notify the physician regarding postoperative pain medications. d) Notify the dietary department.

a) Notify the surgical team to remove all latex-based items. Allergies to avocados and bananas may indicate an allergy to latex. Although it is necessary to notify the dietary department and physician, it is not an immediate threat, as the patient is NPO (nothing by mouth) and pain medication will be ordered postoperatively. The nurse manager does not need to be notified of the patient's allergies.

What is the priority action by the scrub nurse when the surgeon is starting to close the surgical wound? a) Obtain a sponge count. b) Label the tissue specimen. c) Handing needed equipment to the surgeon. d) Prepare the needed sutures.

a) Obtain a sponge count. Standards call for the scrub nurse and the circulating nurse to obtain a sponge count at the beginning of the surgery when the surgical wound is being sutured and when the skin is being sutured. Tissue specimens should be labeled when obtained. The sutures should be ready prior to the surgeon needing them. While the scrub nurse hands equipment to the surgeon, the sponge count is a higher priority action.

Which following types of shock is caused by an infection? a) Septic b) Anaphylactic c) Cardiogenic d) Hypovolemic

a) Septic Septic shock is caused by an infection. Cardiogenic shock occurs when the heart has an impaired pumping ability. Hypovolemic shock occurs when intravascular volume is decreased. Anaphylactic shock is caused by a hypersensitivity reaction.

The nurse is educating a community group regarding types of surgery. A member of the group asks the nurse to describe a type of surgery that is curative. What response by the nurse is true? a) The excision of a tumor b) A biopsy c) A face-lift d) The placement of gastrostomy tube

a) The excision of a tumor An example of a curative surgical procedure is the excision of a tumor. A biopsy, a face-lift, and the placement of a gastrostomy tube are not examples of curative surgical procedures.

A patient with cancer is being treated on the oncology unit for bilateral breast cancer. The patient is undergoing chemotherapy. The nurse notes the patient's serum calcium level is 12.3 mg/ dL. Given this laboratory finding, the nurse should suspect which of the following statements? a) The patient's malignancy is causing the electrolyte imbalance. b) The patient has a history of alcohol abuse. c) The patient's diet is lacking in calcium-rich food products. d) The patient may be developing hyperaldosteronism.

a) The patient's malignancy is causing the electrolyte imbalance. The patient's laboratory findings indicate hypercalcemia. Hypercalcemia is defined as a calcium level greater than 10.2 mg/dL (2.6 mmol/L).The most common causes of hypercalcemia are malignancies and hyperparathyroidism. Malignant tumors can produce hypercalcemia by a variety of mechanisms. The patient's calcium level is elevated; there is no indication that the patient's diet is lacking in calcium-rich food products. Hyperaldosteronism is not associated with a calcium imbalance. Alcohol abuse is associated with hypocalcemia.

What action during a surgical procedure requires immediate intervention by the circulating nurse? a) The scrub nurse calling the blood bank to obtain blood products b) The surgeon reaching within the sterile field to obtain equipment c) The anesthesiologist monitoring blood gas levels d) The registered nurse's first assistant suturing the surgical wound

a) The scrub nurse calling the blood bank to obtain blood products The scrub nurse is "scrubbed" in and should only come in contact with sterile equipment. Using the phone to call the blood bank is the responsibility of the circulating nurse and it would break the sterility of the scrub nurse. The surgeon has "scrubbed" and should only touch within sterile fields. The anesthesiologist should monitor blood gas levels as needed, and it is appropriate for the registered nurse first assistant to suture the surgical wound.

The nurse would identify which of the following vitamin deficiencies to prevent the complication of hemorrhaging during surgery? a) Vitamin K b) Magnesium c) Zinc d) Vitamin A

a) Vitamin K Vitamin K is important for normal blood clotting. Vitamin A and zinc deficiencies would affect the immune system, whereas a magnesium deficiency would delay wound healing.

A patient is undergoing surgery with a brachial plexus block to the right wrist. The patient voices concerns about anesthesia awareness. What is the best response by the nurse? a) "The entire surgical team will monitor for anesthesia awareness and treat it appropriately." b) "Because of the type of anesthesia used, you may be aware of what is going on around you." c) "Anesthesia awareness is not a concern with type of surgery you are having." d) "Advances in medicines used decrease the chance of anesthesia awareness. What are your major concerns?"

b) "Because of the type of anesthesia used, you may be aware of what is going on around you." Anesthesia awareness is a complication of general anesthesia. The patient is undergoing surgery with a local conduction block, not general surgery. Honest discussion of awareness is needed so patients know what to expect while they are in the operating room. Although the entire surgical team should be monitoring for anesthesia awareness, it is not relevant to the surgical procedure being performed. Telling the patient that anesthesia awareness is not a concern is dismissive of the patient's feelings.

The nurse is completing a preoperative assessment. The nurse notices the patient is tearful and constantly wringing hands. The patient states, "I'm really nervous about this surgery. Do you think it will be ok?" What is the nurse's best response? a) "What family support do you have after the surgery?" b) "What are your concerns?" c) "You have nothing to worry about; you have the best surgical team." d) "No one has ever died from the procedures that you are having."

b) "What are your concerns?" Asking the patient about their concerns is an open-ended therapeutic technique. It allows the patient to guide the conversation and address their emotional state. Asking about family support is changing the subject and is nontherapeutic. Discussing the surgical team and the low death rate associated with a procedure is minimizing the patient's feelings and is nontherapeutic.

A patient is undergoing a lumbar puncture. The nurse educates the patient about surgical positioning. Which of the following statements by the nurse is appropriate? a) "You will be placed flat on the table, face down." b) "You will be lying on your side with your knees to your chest." c) "You will be on your back with the head of the bed at 30 degrees." d) "You will be flat on your back with the table slanted so your head is below your feet."

b) "You will be lying on your side with your knees to your chest." For the lumbar puncture procedure, the patient usually lies on the side in a knee-chest position. Flat on the table, face down does not open the vertebral spaces to allow access for the lumbar puncture. Having the patient lie on their back does not allow for access to the surgical site.

A patient is ordered to receive hypotonic IV solution to provide free water replacement. Which of the following solutions will the nurse anticipate administering? a) 0.9% NaCL b) 0.45% NaCl c) Lactated Ringer's Solution d) 5% NaCl

b) 0.45% NaCl Half-strength saline (0.45%) is hypotonic. Hypotonic solutions are used to replace cellular fluid because it is hypotonic compared with plasma. Another is to provide free water to excrete body wastes. At times, hypotonic sodium solutions are used to treat hypernatremia and other hyperosmolar conditions. Lactated Ringer's solution and normal saline (0.9% NaCl) are isotonic. A solution that is 5% NaCl is hypertonic.

The nurse is caring for a patient in the intensive care unit (ICU) following a saltwater near-drowning event. The client is restless, lethargic, and demonstrating tremors. Additional assessment findings include swollen dry tongue, flushed skin, and peripheral edema. The nurse anticipated that the patient's serum sodium value would be which of the following? a) 145 mEq/L b) 155 mEq/L c) 125 mEq/L d) 135 mEq/L

b) 155 mEq/L The patient is experiencing signs and symptoms (S/S) of hypernatremia. Hypernatremia is a serum sodium level higher than 145 mEq/L (145 mmol/L). A cause of hypernatremia is near drowning in seawater (which contains a sodium concentration of approximately 500 mEq/L). S/S of hypernatremia include thirst, elevated body temperature, swollen dry tongue and sticky mucous membranes, hallucinations, lethargy, restlessness, irritability, simple partial or tonic-clonic seizures, pulmonary edema, hyperreflexia, twitching, nausea, vomiting, anorexia, elevated pulse, and elevated blood pressure.

The nurse is caring for a patient with a metabolic acidosis (pH 7.25). Which of the following values is useful to the nurse in determining whether the cause of the acidosis is due to acid gain or to bicarbonate loss? a) Serum sodium level b) Anion gap c) PaCO 2 d) Bicarbonate level

b) Anion gap Metabolic acidosis is a common clinical disturbance characterized by a low pH (increased H+ concentration) and a low plasma bicarbonate concentration. It can be produced by a gain of hydrogen ion or a loss of bicarbonate. It can be divided clinically into two forms, according to the values of the serum anion gap: high anion gap acidosis and normal anion gap acidosis. A patient diagnosed with metabolic acidosis is determined to have normal anion gap metabolic acidosis if the anion gap is within this normal range. An anion gap greater than 16 mEq (16 mmol/L) (the normal value for an anion gap is 8-12 mEq/L (8-12 mmol/L) without potassium in the equation. If potassium is included in the equation, the normal value for the anion gap is 12-16 mEq/L (12-16 mmol/L) and suggests an excessive accumulation of unmeasured anions and would indicate high anion gap metabolic acidosis as the type. An anion gap occurs because not all electrolytes are measured. More anions are left unmeasured than cations. A low or negative anion gap may be attributed to hypoproteinemia. Disorders that cause a decreased or negative anion gap are less common compared to those related to an increased or high anion gap.

The nurse is caring for a patient who was admitted with fluid volume excess (FVE). Which of the following nursing assessments should the nurse include in the ongoing monitoring of the patient? Select all that apply. a) Nutritional status and diet b) Blood pressure, heart rate, and rhythm c) Intake and output, urine volume, and color d) Strength testing for muscle wasting e) Skin assessment for edema and turgor

b) Blood pressure, heart rate, and rhythm c) Intake and output, urine volume, and color e) Skin assessment for edema and turgor To assess for FVE the nurse measures: blood pressure, heart rate and rhythm, breath sounds, skin assessment for edema and turgor, inspection of neck veins, intake and output, daily weights, urine volume and color, dyspnea, and thirst are assessments that will assist the nurse in identifying improvement or worsening of the fluid volume excess. In addition, the nurse will be able to identify potential fluid volume deficit from overtreatment of the fluid volume excess.

Which of the following vasodilator medications is used in the treatment of shock? a) Norepinephrine (Levophed) b) Nitroglycerin (Tridil) c) Dopamine (Intropin) d) Dobutamine (Dobutrex)

b) Nitroglycerin (Tridil) Tridil is a vasodilator used to reduce preload and afterload and reduce oxygen demand of the heart. Intropin and Dobutrex are sympathomimetic and are used to improve contractility, increase stroke volume, and increase cardiac output. Levophed is a vasoconstrictor used to increase BP by vasoconstriction.

A patient presents to the emergency department (ED) with her husband. The patient appears in respiratory distress. The husband states "I think she ate a dessert made with peanuts; she's allergic to peanuts." The nurse should administer which of the following agents first? a) Albuterol (Proventil) nebulizer b) Epinephrine (Adrenalin) intramuscularly (IM) c) Diphenhydramine (Benadryl) IV d) IV infusion of normal saline

b) Epinephrine (Adrenalin) intramuscularly (IM) All of the interventions are indicated in the treatment of anaphylactic shock. However, IM epinephrine is administered first because of its vasoconstrictive actions. Diphenhydramine (Benadryl) is administered IV to reverse the effects of histamine, thereby reducing capillary permeability. Nebulized medications, such as albuterol (Proventil), may be given to reverse histamine-induced bronchospasm. Fluid management is critical, as massive fluid shifts can occur within minutes due to increased vascular permeability.

A patient has been administered ketamine (Ketalar) for moderate sedation. What is the priority nursing intervention? a) Administering oxygen b) Frequent monitoring of vital signs c) Providing a quiet dark room d) Assessing for hallucinations

b) Frequent monitoring of vital signs Vital signs must be monitored frequently to assess for respiratory depression and intervene quickly. Oxygen may need to be administered if respiratory depression occurs; therefore, monitoring vital signs is a higher priority nursing intervention. Providing a dark quiet room is appropriate after the procedure is completed and the patient is recovering. Hallucinations may be experienced as a side effect of the medication.

An anxious preoperative surgical patient is encouraged to concentrate on a pleasant experience or restful scene. What cognitive coping strategy would the nurse document as being used? a) Progressive muscular relaxation b) Imagery c) Distraction d) Optimistic self-recitation

b) Imagery Imagery has proven effective for anxiety in surgical patients. Optimistic self-recitation is practiced when the patient is encouraged to recite optimistic thoughts such as, "I know all will go well." Distraction is employed when the patient is encouraged to think of an enjoyable story or recite a favorite poem. Progressive muscular relaxation requires contracting and relaxing muscle groups and is a physical coping strategy as opposed to a cognitive strategy.

A patient with fractured skull after falling from a ladder requires surgery. The nurse should anticipate transporting the patient to surgery during what time frame? a) In 1 week b) Immediately c) In 1 day d) In 48-72 hours

b) Immediately Emergent surgery occurs when the patient requires immediate attention. A fractured skull is an indication for emergent surgery. An urgent surgery occurs when the patient requires prompt attention, usually within 24-30 hours. Any surgery scheduled beyond 30 hours is classified as required or elective and a fractured skull does not meet the requirements for elective or required surgery.

Which stage of shock would encompass mechanical ventilation, altered level of consciousness, and profound acidosis? a) Compensatory b) Irreversible c) Precompensatory d) Progressive

b) Irreversible The irreversible stage encompasses use of mechanical ventilation, altered consciousness, and profound acidosis. The compensatory stage encompasses decreased urinary output, confusion, and respiratory alkalosis. The progressive stage involves metabolic acidosis, lethargy, and rapid, shallow respirations. There is not a stage of shock called the precompensatory stage.

The nurse is caring for a patient undergoing alcohol withdrawal. Which of the following serum laboratory values should the nurse monitor most closely? a) Calcium b) Magnesium c) Phosphorus d) Potassium

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

A student nurse is scheduled to observe a surgical procedure. The nurse provides the student nurse with education on the dress policy and provides all needed attire to enter a restricted surgical zone. Which observation by the nurse requires immediate intervention? a) Shoe covers are used. b) Mask is placed over nose and extends to bottom lip. c) Hair is pulled back and covered by a cap. d) Scrub top and drawstring are tucked into pants.

b) Mask is placed over nose and extends to bottom lip. The mask should be tight fitting covering the nose and mouth. The mask should be extended down past the chin. The mask may not effectively cover the mouth if only extended to the bottom lip. The hair, scrub top, drawstring, and shoe covering are all appropriate and do not require intervention.

An obese patient is scheduled for open abdominal surgery. What priority education should the nurse provide this patient? a) Prevention of wound dehiscence b) Prevention of respiratory complications c) Venous thromboembolism prevention d) Wound care and infection prevention

b) Prevention of respiratory complications All answers are correct but the obese patient has an increased susceptibility to respiratory complications, and maintaining a patent airway would be the priority.

Which stage of shock is best described as that stage when the mechanisms that regulate blood pressure fail to sustain a systolic pressure above 90 mm Hg? a) Irreversible b) Progressive c) Compensatory d) Refractory

b) Progressive In the progressive stage of shock, the mechanisms that regulate BP can no longer compensate, and the mean arterial pressure falls below normal limits. The refractory or irreversible stage of shock represents the point at which organ damage is so severe that the patient does not respond to treatment and cannot survive. In the compensatory state, the patient's BP remains within normal limits due to vasoconstriction, increased heart rate, and increased contractility of the heart.

The circulating nurse is unsure if proper technique was followed when placing an object in the sterile field during a surgical procedure. What is the best action by the nurse? a) Ask another nurse to review the technique used. b) Remove the entire sterile field from use. c) Mark the patient's chart for future review of infections. d) Remove the item from the sterile field.

b) Remove the entire sterile field from use. If there is any doubt about the maintenance of sterility, the field should be considered not sterile. Because the object in question was placed in the sterile field, the sterile field must be removed from use. Removing the individual item is not appropriate, as the field was potentially contaminated. Reviewing the patient's chart at a later date does not decrease the chance of infection. Although another nurse could observe the technique used to put objects in a sterile field, it does not solve the immediate concern.

A scrub nurse is diagnosed with a skin infection to the right forearm. What is the priority action by the nurse? a) Ensure the infection is covered with a dressing. b) Report the infection to an immediate supervisor. c) Return to work after being on antibiotics for 24 hours. d) Request role change to circulating nurse.

b) Report the infection to an immediate supervisor. The infection needs to be reported immediately because of the asepsis environment of the operating room. The usual barriers may not protect the patient when an infection is present. The employee will need to follow the policy of the operating room regarding infections. Covering the infections with a dressing may be necessary but the infection must first be reported. The scrub nurse may still be able to work depending on the policy; therefore, returning to work after 24 hours is not the priority action. Even if the nurse requests a role change to circulating nurse, the policy for infections in the operating room must be followed; therefore, it must first be reported.

A nurse is witnessing a patient sign the consent form for surgery. After the patient signs the consent form, the patient starts asking questions regarding the risks and benefits of a surgical procedure. What action by the nurse is most appropriate? a) Notify the nurse manager of the patient's questions. b) Request that the surgeon come and answer the questions. c) Answer the patient's questions. d) Place the consent form in the patient's medical record.

b) Request that the surgeon come and answer the questions. It is the physician's responsibility to provide information pertaining to risks and benefits of surgery. It is not the responsibility of the nurse or nurse manager to discuss risks and benefits. The consent form should not be placed in the medical record until all questions are answered fully for the patient.

A patient is undergoing thoracic surgery. What priority education should the nurse provide to assist in preventing respiratory complications? a) Pain medication should be taken before completing deep breathing and coughing exercises. b) Splint the incision site using a pillow during deep breathing and coughing exercises. c) Deep breathing and coughing exercises should be completed every 8 hours. d) Deep breathing and coughing exercises may be used as relaxation techniques.

b) Splint the incision site using a pillow during deep breathing and coughing exercises. Splinting the incision site will help decrease pain and support the incision. This will increase compliance with the deep breathing and coughing exercises that assist with the prevention of respiratory complications. Pain medication should be taken regularly and not only before deep breathing and coughing exercises. Deep breathing and coughing exercises should be done at least every 2 hours, more frequently if possible. While some patients will find the exercises relaxing, most patients find it painful to complete the exercises.

A patient is brought to the operating room for an elective surgery. What is the priority action by the circulating nurse? a) Obtain a sponge and syringe count. b) Verify consent. c) Acquire ordered blood products. d) Document start of surgery.

b) Verify consent. Without consent, surgery cannot be performed. Documentation of the start of surgery can only happen once the surgery has started. Blood products must be administered within an allotted time frame and therefore should not be acquired unless needed. The sponge and syringe count is a safety issue that should be completed before surgery and while the wound is being sutured, but the patient has not consented, the surgery should not take place.

Which of the following arterial blood gas (ABG) results would the nurse anticipate for a patient with a 3-day history of vomiting? a) pH: 7.45, PaCO2: 32 mm Hg, HCO3- : 21 b) pH: 7.55, PaCO2: 60 mm Hg, HCO3-: 28 c) pH: 7.28, PaCO2: 25 mm Hg, HCO3: 15 d) pH: 7.34, PaCO2: 60 mm Hg, HCO3: 34

b) pH: 7.55, PaCO2: 60 mm Hg, HCO3-: 28 The patient's ABG would likely demonstrate metabolic alkalosis. Metabolic alkalosis is a clinical disturbance characterized by a high pH (decreased H+ concentration) and a high plasma bicarbonate concentration. It can be produced by a gain of bicarbonate or a loss of H+. A common cause of metabolic alkalosis is vomiting or gastric suction with loss of hydrogen and chloride ions. The disorder also occurs in pyloric stenosis where only gastric fluid is lost. The other results do not represent metabolic alkalosis.

When a patient is in the compensatory stage of shock, which of the following symptoms occurs? a) Respiratory acidosis b) Tachycardia c) Urine output of 45 mL/hr d) Bradycardia

b) tachycardia The compensatory stage of shock encompasses a normal BP, tachycardia, decreased urinary output, confusion, and respiratory alkalosis.

A patient is scheduled for an invasive procedure. What is the priority documentation needed regarding the procedure? a) Prescriptions for postoperative medications b) A health history obtained by the primary physician c) A signed consent form from the patient d) The medication reconciliation form

c) A signed consent form from the patient A signed consent is required and is important for initiating invasive procedures. The nurse should therefore check for the patient's signed consent form. A health history, medication reconciliation, and postoperative prescriptions are good items to have, but are not required documentation before performing an invasive procedure.

A patient with a history of alcoholism and scheduled for an urgent surgery asks the nurse, "Why is everyone so concerned about how much I drink?" What is the best response by the nurse? a) "The amount of alcohol you drink will determine the amount of pain medication you will need postoperatively." b) "It is a required screening question for all patients having surgery." c) "It is important for us to know how much and how often you drink to help prevent surgical complications." d) "We can have counselors available after surgery; if it is determined you need help for your drinking."

c) "It is important for us to know how much and how often you drink to help prevent surgical complications." Alcohol use and alcoholism can contribute to serious postoperative complications. If the medical and nursing staff is aware of the use or abuse, measures can be implemented proactively to prevent complications. Although alcohol may interfere with a medication's effectiveness, it does not determine the amount of pain medications that are prescribed following surgery. Even though this is a required screening question and counselors can be made available for those who want help, those are not the best responses to answer the patient's question.

A new scrub technician is being orientated to the operating room. The scrub technician states to the nurse, "You can skip the fire safety information because I have worked in hospitals for the last 10 years." What is the best response by the nurse? a) "This is a requirement of your job, just tough through it." b) "OK, but you will be required to review the hospital's policy on fire safety on your own." c) "The operating room has some unique circumstances that increases the chances of fire." d) "I know this information is not exciting but I'm required to cover this information with you."

c) "The operating room has some unique circumstances that increases the chances of fire." The operating room environment has some unique characteristics that do increase the chance of fires, such as drapes that allow oxygen concentration. By engaging the new employee to understand the underlying reason for fire safety in the operating room, the new employee will develop a greater understanding and appreciation for fire safety. If fire safety is only presented as a requirement for the job then the employee may not understand the importance of fire safety. The hospital's policy for fire safety is broad; the employee would need to review the fire safety policies specifically for the operating room.

A parent of a 16-year-old patient asks the nurse, "How could the surgeon operate without my consent?" What is the best response given by the nurse? a) "We obtained consent from your child after your child requested the surgery." b) "The surgical procedure being performed does not require consent." c) "Your child had life-threatening injuries that required immediate surgery." d) "Two doctors decided your child needed the surgery, therefore we did not need to get consent."

c) "Your child had life-threatening injuries that required immediate surgery." In an emergency, it may be necessary for the surgeon to operate as a lifesaving measure without the patient's or parent's informed consent. Informed consent must be obtained before any invasive procedure. A minor cannot consent for a surgical procedure. Two doctors' opinions do not overrule the need to obtain informed consent.

A patient is admitted to the emergency department (ED) following a motorcycle accident. Upon assessment, the patient's vital signs reveal blood pressure (BP) of 80/60 mm Hg and heart rate (HR) of 145 beats per minute (bpm). The patient's skin is cool and clammy. Which of the following patient medical orders will the nurse complete first? a) Type and cross match b) Two large-bore IVs and begin crystalloid fluids c) 100% oxygen per nonrebreather mask d) C-spine x-rays

c) 100% oxygen per nonrebreather mask The management in all types and all phases of shock includes the following: support of the respiratory system with supplemental oxygen and/or mechanical ventilation to provide optimal oxygenation, fluid replacement to restore intravascular volume, vasoactive medications to restore vasomotor tone and improve cardiac function, and nutritional support to address the metabolic requirements that are often dramatically increased in shock. The first priority in the initial management of shock is maintenance of the airway and ventilation; thus, 100% oxygen should be applied per a nonrebreather mask. The other orders should be completed after the patient's airway is secured.

The nurse has been assigned to care for the following patients. Which patient is at the highest risk for a fluid and electrolyte imbalance? a) A 45-year-old man who had a laparoscopic appendectomy 24 hours ago being advanced to a regular diet. b) A 66-year-old woman who had an open cholecystectomy with a T-tube placed that is draining 125 mL of bile per shift. c) An 82-year-old woman who receives all nutrition via tube feedings. Her medications include carvedilol (Coreg) and torsemide (Demadex). d) A 79-year-old man admitted with a diagnosis of pneumonia.

c) 82-year-old woman who receives all nutrition via tube feedings. Her medications include carvedilol (Coreg) and torsemide (Demadex). The 82-year-old patient has three risk factors: advanced age, tube feedings, and diuretic usage (Demadex). This patient has the highest risk for fluid and electrolyte imbalances. The 45-year-old man has the risk factor of surgery but is not the patient at the highest risk. The 79-year-old patient has the risk factor of advanced age but is not the patient at the highest risk. The 66-year-old patient has the risk factors of age and the bile drain but is not the patient at the highest risk.

Which of the following blood pressure (BP) readings would result in a pulse pressure indicative of shock? a) 130/90 mm Hg b) 120/90 mm Hg c) 90/70 mm Hg d) 100/60 mm Hg

c) 90/70 mm Hg Pulse pressure is calculated by subtracting the diastolic measurement from the systolic measurement; the difference is the pulse pressure. Normally, the pulse pressure is 30 to 40 mm Hg. Narrowing or decreased pulse pressure is an earlier indicator of shock than a drop in systolic BP. A BP reading of 90/70 mm Hg indicates a narrowing pulse pressure.

The nurse is caring for a male patient in the early stages of sepsis. The patient is not responding well to fluid resuscitation measures and his hemodynamic status is worsening. Which of the following nursing interventions is most appropriate for the nurse to implement? a) Begin a continuous IV infusion of insulin per protocol. b) Initiate enteral feedings as prescribed. c) Administer norepinephrine as prescribed. d) Administer recombinant human activated protein C (rhaAPC) (Xigris) as prescribed.

c) Administer norepinephrine as prescribed. Vasopressor agents are used if fluid resuscitation does not restore an effective BP and cardiac output. Norepinephrine centrally administered is the initial vasopressor of choice. Ongoing research has found that Xigris does not positively impact the outcome of patients with severe sepsis and it is no longer available for patient use. IV insulin may be implemented to treat hyperglycemia but is not indicated to improve the patient's hemodynamic status. Enteral feedings are recommended but not to improve the patient's hemodynamic status.

Which type of shock occurs from an antigen-antibody response? a) Neurogenic b) Cardiogenic c) Anaphylactic d) Septic

c) Anaphylactic During anaphylactic shock, an antigen-antibody reaction provokes mast cells to release potent vasoactive substances, such as histamine or bradykinin, causing widespread vasodilation and capillary permeability. Septic shock is a circulatory state resulting from overwhelming infection causing relative hypovolemia. Neurogenic shock results from loss of sympathetic tone causing relative hypovolemia. Cardiogenic shock results from impairment or failure of the myocardium.

The nurse is caring for as 78-year-old patient with extensive cardiovascular disease. Which of the following types of shock states is the patient most likely to develop? a) Neurogenic b) Septic c) Cardiogenic d) Anaphylactic

c) Cardiogenic Older adults, particularly those with cardiac disease, are susceptible to cardiogenic shock. Older adults are not susceptible to developing neurogenic, septic, or anaphylactic shock.

A patient asks about the purpose of withholding food and fluid before surgery. Which response by the nurse is appropriate? a) It prevents overhydration and hypertension. b) It decreases urine output so that a catheter would not be needed. c) It prevents aspiration and respiratory complications. d) It decreases the risk of elevated blood sugars and slow wound healing.

c) It prevents aspiration and respiratory complications. The major purpose of withholding food and fluid before surgery is to prevent aspiration, which can lead to respiratory complications. Preventing overhydration, decreasing urine output, and decreasing blood sugar levels are not major purposes of withholding food and fluid before surgery.

The nurse is caring for a patient with a central venous line in place for the treatment of shock. Which of the following nursing interventions are essential for the nurse to complete to reduce the risk of infection? Select all that apply. a) Always perform hand hygiene before manipulating or accessing the line ports. b) Instruct the patient to wear a face mask and gloves while the central venous line is in place. c) Maintain sterile technique when changing the central venous line dressing. d) Wear clean gloves prior to accessing the line port. e) Perform a 10-second "hub scrub" using chlorhexidine and friction in a twisting motion on the access hub."

c) Maintain sterile technique when changing the central venous line dressing. a) Always perform hand hygiene before manipulating or accessing the line ports. d) Wear clean gloves prior to accessing the line port. The following nursing interventions are essential to reduce the risk of infection: maintain sterile technique when changing the central venous line dressing; always perform hand hygiene before manipulating or accessing the line ports; wear clean gloves prior to accessing the line port; and perform a 15- to 30-second "hub scrub" using chlorhexidine or alcohol and friction in a twisting motion on the access hub; this reduces biofilm on the hub that may contain pathogens.

The nurse is conducting a preoperative assessment on a patient scheduled for gallbladder surgery. The patient reports having a frequent cough producing green sputum for 3 days and denies fever. Upon auscultation, the nurse notes rhonchi throughout the right lung with an occasional expiratory wheeze. Respiratory rate is 20, temperature is 99.8 taken orally, heart rate is 87, and blood pressure is 124/70. What is the nurse's best action? a) Document the findings and continue the patient through the preoperative phase. b) Wait 1 hour and complete the assessment again. c) Notify the surgeon to possibly delay the surgery. d) Notify the primary physician about the assessment findings.

c) Notify the surgeon to possibly delay the surgery. A respiratory infection can delay a nonemergent surgical procedure because the infection can increase the risk for respiratory complications. Therefore, the nurse should notify the surgeon about delaying the surgery. The primary physician may be called to care for the assessment findings but that should be done only after the surgeon has been notified. Continuing through the preoperative phase without notifying the surgeon and waiting 1 hour is not appropriate.

What is the priority action when the circulating nurse is completing a second verification of the surgical procedure and surgical site? a) Ask the surgeon if the marked surgical site is correct. b) Review the complications and allergies with the anesthesiologist. c) Obtain the attention of all members of the surgical team. d) Discuss the surgical procedure and surgical site with the patient.

c) Obtain the attention of all members of the surgical team. The second verification of the surgical procedure and surgical site should include all members of the surgical team. This verification should be done at one time with all members of the team involved. The marked surgical site is confirmed with all members of the surgical team, not just the surgeon or patient. Complications, allergies, and anticipated problems are also discussed among the entire surgical team.

A patient is scheduled to have a cholecystectomy. Which of the nurse's finding is least likely to contribute to surgical complications? a) Diabetes b) Pregnancy c) Osteoporosis d) Urinary tract infection

c) Osteoporosis Osteoporosis is most likely not going to contribute to complications related to a cholecystectomy. Pregnancy decreases maternal reserves. Diabetes increases wound-healing problems and risks for infection. Urinary tract infection decreases the immune system, increasing the chance for infections.

Clinical characteristics of neurogenic shock are noted by which type of stimulation? a) Cerebral b) Sympathetic c) Parasympathetic d) Endocrine

c) Parasympathetic The clinical characteristics of neurogenic shock are signs of parasympathetic stimulation. Sympathetic stimulation causes vascular smooth muscle to constrict, and parasympathetic stimulation causes vascular smooth muscle to relax or dilate. The patient experiences a predominant parasympathetic stimulation that causes vasodilation lasting for an extended period, leading to a relative hypovolemic state. It is not characterized by sympathetic, endocrine, or cerebral stimulation.

A patient is being treated in the ICU 24 hours after having a radical neck dissection completed. The patient's serum calcium level is 7.6 mg/dL. Which of the following physical examination findings is consistent with this electrolyte imbalance? a) Muscle weakness b) Slurred speech c) Presence of Trousseau's sign d) Negative Chvostek's sign

c) Presence of Trousseau's sign A patient status post radical neck resection is prone to developing hypocalcemia. Hypocalcemia is defined as a serum values lower than 8.6 mg/dL [2.15 mmol/L]. Signs and symptoms of hypocalcemia include: Chvostek's sign, which consists of muscle twitching enervated by the facial nerve when the region that is about 2 cm anterior to the earlobe, just below the zygomatic arch, is tapped, and a positive Trousseau's sign can be elicited by inflating a blood pressure cuff on the upper arm to about 20 mm Hg above systolic pressure; within 2 to 5 minutes, carpal spasm (an adducted thumb, flexed wrist and metacarpophalangeal joints, and extended interphalangeal joints with fingers together) will occur as ischemia of the ulnar nerve develops. Slurred speech and muscle weakness are signs of hypercalcemia.

The nurse is caring for a client with a systolic BP less than 80 mm Hg, respirations are rapid and shallow, heart rate is over 150 beats per minute, and the client's urine output is 20 mL/hr. The nurse recognizes that the client is demonstrating which stage of shock? a) Compensatory b) Irreversible c) Progressive d) Refractory

c) Progressive The client's low systolic BP and abnormal respiratory pattern suggest that shock is worsening and that compensatory mechanisms are either absent or ineffective. In compensatory shock, the client's BP is normal, respirations are above 20, and heart rate is above 100, but below 150. In progressive shock, the client's skin appears mottled and mentation demonstrates lethargy. In refractory or irreversible shock, the client requires complete mechanical and pharmacologic support.

The nurse is analyzing the electrocardiographic (ECG) rhythm tracing of a patient experiencing hypercalcemia. Which of the following ECG changes is typically associated with this electrolyte imbalance? a) Prolonged QT intervals b) Elevated ST segments c) Prolonged PR intervals d) Peaked T waves

c) Prolonged PR intervals Cardiovascular changes associated with hypercalcemia may include a variety of dysrhythmias (e.g., heart blocks) and shortening of the QT interval and the ST segment. The PR interval is sometimes prolonged. The other changes are not associated with an elevated serum calcium level.

A nurse is caring for a patient with acute renal failure and hypernatremia. Which of the following actions can be delegated to the nursing assistant? a) Teach the patient about increased fluid intake. b) Monitor for signs and symptoms of dehydration. c) Provide oral care every 2-3 hours. d) Assess the patient's daily weights for trends.

c) Provide oral care every 2-3 hours. Providing oral care for the patient every 23 hours is within the scope of practice of a nursing assistant. The other actions should be completed by the registered nurse.

The nurse is educating patients requiring surgery for various ailments on the perioperative experience. What education provided by the nurse is most appropriate? a) Intraoperative techniques used to perform the surgery b) Expected pain levels and narcotic pain medication used to treat the pain c) Three phases of surgery and safety measures for each phase d) Risks and benefits of the surgical procedures

c) Three phases of surgery and safety measures for each phase The perioperative period includes the preoperative, intraoperative, and postoperative phases. Specific safety guidelines are followed for all surgical patients. The information provided should be general enough to be informative about surgery and should not focus on individual surgeries, as all the patients are having different surgeries. Intraoperative techniques, expected pain levels, and pain medication are specific to the patient and type of surgery. The risks and benefits of the surgical procedure should be discussed by the physician.

The nurse is triaging the surgical patients. Which patient would the nurse document as urgent for surgical care? a) A patient scheduled for cosmetic surgery b) A patient needing cataract surgery c) A patient with severe bleeding d) A patient with an acute gallbladder infection

d) A patient with an acute gallbladder infection An acute gallbladder infection is considered an urgent surgical procedure. Cosmetic surgery and cataract surgery are not considered urgent surgical procedures. Severe bleeding could be considered an emergent surgical procedure.

The nurse is caring for a patient with a serum sodium level of 113 mEq/L. The nurse should monitor the patient for the development of which of the following? a) Headache b) Nausea c) Hallucinations d) Confusion

d) Confusion Normal serum concentration level ranges from 135 to 145 mEq/L. Hyponatremia exists when the serum level decreases below 135 mEq/L, there is. When the serum sodium level decreases to less than 115 mEq/L (115 mmol/L), signs of increasing intracranial pressure, such as lethargy, confusion, muscle twitching, focal weakness, hemiparesis, papilledema, seizures, and death, may occur. General manifestations of hyponatremia include poor skin turgor, dry mucosa, headache, decreased saliva production, orthostatic fall in blood pressure, nausea, vomiting, and abdominal cramping. Neurologic changes, including altered mental status, status epilepticus, and coma, are probably related to cellular swelling and cerebral edema associated with hyponatremia. Hallucinations are associated with increased serum sodium levels.

What action by the nurse best encompasses the preoperative phase? a) Shaving the patient using a straight razor b) Monitoring vital signs every 15 minutes c) Documenting the application of sequential compression devices (SCD) d) Educating the patients on signs and symptoms of infection

d) Educating the patients on signs and symptoms of infection Educating the patient on prevention or recognition of complications begins in the preoperative phase. Applying SCD and frequent vital sign monitoring happens after the preoperative phase. Only electric clippers should be used to remove hair.

A nurse on the surgical team has been assigned the role of scrub nurse. What action by the scrub nurse is appropriate? a) Keeping all records and adjusting lights b) Leading the surgical team in a debriefing session c) Coordinating activities of other personnel d) Handing instruments to the surgeon and assistants

d) Handing instruments to the surgeon and assistants The responsibilities of a scrub nurse are to assist the surgical team by handing instruments to the surgeon and assistants, preparing sutures, receiving specimens for laboratory examination, and counting sponges and needles. Responsibilities of a circulating nurse include leading the surgical team in a debriefing session, keeping records, adjusting lights, and coordinating activities of other personnel.

The nurse is assigned to care for a patient with a serum phosphorus level of 5.0 mg/dL. The nurse anticipates that the patient will also experience which of the following electrolyte imbalances? a) Hypermagnesemia b) Hyponatremia c) Hyperchloremia d) Hypocalcemia

d) Hypocalcemia The patient is experiencing an elevated serum phosphorus level. Hyperphosphatemia is defined as a serum phosphorus level that exceeds 4.5 mg/dL (1.45 mmol/L). Because of the reciprocal relationship between phosphorus and calcium, a high serum phosphorus level tends to cause a low serum calcium concentration.

A patient is undergoing general anesthesia. The nurse anesthetist starts to administer the anesthesia. The patient starts giggling and kicking her legs. What stage of anesthesia would the nurse document related to the findings? a) I b) IV c) III d) II

d) II Stage II is the excitement stage that is characterized by struggling, shouting, and laughing. Stage I is the beginning of anesthesia during which the patient breathes in the anesthetic mixture and feelings of warmth, dizziness, and detachment occur. Stage III is surgical anesthesia characterized by unconsciousness and quietness. Surgical anesthesia is reached by continued administration of anesthetic vapor and gas. Stage IV is medullary depression.

A patient with a magnesium level of 2.6 mEq/L is being treated on a medical-surgical unit. Which of the following treatments should the nurse anticipate will be used? a) Dialysis b) Oral magnesium oxide (MagOx) c) Fluid restriction d) IV furosemide (Lasix)

d) IV furosemide (Lasix) The nurse should anticipate the administration of Lasix for the treatment of hypermagnesemia. Administration of loop diuretics (e.g., furosemide) and sodium chloride or lactated Ringer's IV solution enhances magnesium excretion in patients with adequate renal function. Fluid restriction is contraindicated. The patient should be encouraged to increase fluids to promote the excretion magnesium by way of the urine. MagOx is contraindicated as it would further elevate the patient's serum magnesium level. In acute emergencies, when the magnesium level is severely elevated, hemodialysis with a magnesium-free dialysate can reduce the serum magnesium to a safe level within hours.

An obese patient is undergoing abdominal surgery. A surgical resident states, "The amount of fat we have to cut through is disgusting" during the procedure. What is the best response by the nurse? a) Report the resident to the attending surgeon. b) Ignore the comment. c) Discuss concerns regarding the comments with the charge nurse. d) Inform the resident that all communication needs to remain professional.

d) Inform the resident that all communication needs to remain professional. The nurse must advocate for the patient, especially when the patient cannot speak for themselves. By informing the resident that all communication needs to be professional, the nurse is addressing the comment at that moment in time, advocating for the patient. Ignoring the comment is not appropriate. The nurse may need to address the concerns of unprofessional communication with the attending surgeon or the charge nurse if the behavior continues. The best action is to address the behavior when it is happening.

The nurse is educating new employees regarding the wearing of masks in the operating room. What information should the nurse provide? Select all that apply. a) Masks can be worn outside the surgical department if the surgery is less than 5 minutes away. b) You must change masks between treating patients. c) Masks must be worn at all times in the semirestricted zone. d) Masks should cover the nose and mouth completely. e) Masks should be tight fitting. f) When not using the mask, you can wear it around your neck.

d) Masks should cover the nose and mouth completely. a) You must change masks between treating patients. e) Masks should be tight fitting. Masks are changed between patients. Regardless of time, the masks should not be worn outside the surgical department. Masks should fit tightly and cover the nose and the mouth completely. The mask must be either on or off; it must not be allowed to hang around the neck. Masks must be worn at all times in the restricted zone. The semirestricted zone requires scrubs and cap.

The nurse is caring for a patient with severe diarrhea. The nurse recognizes that the patient is at-risk for developing which of the following acid-base imbalances? a) Metabolic alkalosis b) Respiratory alkalosis c) Metabolic acidosis d) Respiratory acidosis

d) Metabolic acidosis The patient is at risk for developing metabolic acidosis. Metabolic acidosis is caused by diarrhea, lower intestinal fistulas, ureterostomies, and use of diuretics; early renal insufficiency; excessive administration of chloride; and the administration of parenteral nutrition without bicarbonate or bicarbonate-producing solutes (e.g., lactate).

The nurse is analyzing the arterial blood gas (AGB) results of a patient diagnosed with severe pneumonia. Which of the following ABG results indicates respiratory acidosis? a) pH: 7.32, PaCO 2 : 40 mm Hg, HCO 3 -: 18 mEq/L b) pH: 7.50, PaCO 2 : 30 mm Hg, HCO 3 -: 24 mEq/L c) pH: 7.42, PaCO 2 : 45 mm Hg, HCO 3 -: 22 mEq /L d) pH: 7.20, PaCO 2 : 65 mm Hg, HCO 3 -: 26 mEq/L

d) pH: 7.20, PaCO2: 65 mm Hg, HCO3-: 26 mEq/L Respiratory acidosis is a clinical disorder in which the pH is less than 7.35 and the PaCO2 is greater than 42 mm Hg and a compensatory increase in the plasma HCO3- occurs. It may be either acute or chronic. The ABG of pH: 7.32, PaCO2: 40 mm Hg, HCO3- : 18 mEq/L indicates metabolic acidosis. The ABGs of pH: 7.50, PaCO2: 30 mm Hg, and HCO3- : 24 mEq/L indicate respiratory alkalosis. The ABGs of pH 7.42, PaCO2: 45 mm Hg, and HCO3- : 22 mEq/L indicate a normal result/no imbalance.

The nurse is caring for a patient diagnosed with hyperchloremia. Signs and symptoms of hyperchloremia include which of the following? Select all that apply. a) Hypotension b) Lethargy c) Dehydration d) Weakness e) Tachypnea

e) Tachypnea d) Weakness b) Lethargy The signs and symptoms of hyperchloremia are the same as those of metabolic acidosis: hypervolemia and hypernatremia. Tachypnea; weakness; lethargy; deep, rapid respirations; diminished cognitive ability; and hypertension occur. If untreated, hyperchloremia can lead to a decrease in cardiac output, dysrhythmias, and coma. A high chloride level is accompanied by a high sodium level and fluid retention.