NU 310 Exam 1
The PACU nurse is caring for a 45-year-old male patient who had a left lobectomy. The nurse is assessing the patient frequently for airway patency and cardiovascular status. The nurse should know that the most common cardiovascular complications seen in the PACU include what? Select all that apply. A. Hypotension B. Hypervolemia C. Heart murmurs D. Dysrhythmias E. Hypertension
A, D, E
You are discharging your patient who just received chemotherapy for AML. What findings does your patient need to report immediately? A. Nausea and vomiting B. Muscle twitching and cramping ( indicates hyperkalemia, pt may go into renal failure) C. Fatigue D. Vertigo with position changes
B
A nurse is assessing an older client who has received radiation therapy to treat lung cancer. Based on an understanding of the effects of radiation therapy, the nurse should focus the assessment on: A. Reviewing test results for low hemoglobin B. Observing for signs of infection C. Checking for and reporting fatigue to the provider D. Examining the skin for generalized urticarial
B
A client with lung cancer presents with calcium 14.2 mg/dl. What related clinical manifestations should the nurse expect? Select all that apply. A. Abdominal pain and discomfort B. Muscle and bone pain C. Confusion and lethargy D. Tachycardia E. Hyperactivity
A, B, C, D
A nurse is caring for a patient who has been hospitalized with an acute asthma exacerbation. What drugs should the nurse expect to be ordered for this patient to gain underlying control of persistent asthma? A. Rescue inhalers B. Anti-inflammatory drugs C. Antibiotics D. Antitussives
B
While monitoring a postoperative patient, the nurse knows that the most common cause of postoperative hypoxemia is ___________ A. Bronchospasm B. Atelectasis C. Pulmonary embolism D. Aspiration of gastric contents
B
The surgical nurse is preparing to send a patient from the pre-surgical area to the OR and is reviewing the patient's informed consent form. What are the criteria for legally valid informed consent? Select all that apply. A. Consent must be freely given. B. Consent must be notarized. C. Consent must be signed on the day of surgery. D. Consent must be obtained by a physician. E. Signature must be witnessed by a professional staff member.
A, D, E
A client is admitted to the emergency room with a respiratory rate of seven per min. Arterial blood gases (ABG) reveal the following values. pH 7.18 PaCO2 68 mm Hg Base excess -2 PaO2 78 mm HG Saturation 70% Bicarbonate 28 mEq/L Which of the following is an appropriate analysis of the ABGs? A. Respiratory acidosis B. Metabolic acidosis C. Metabolic alkalosis D. Respiratory alkalosis
A
A client newly diagnosed with cancer says he does not understand how cancer cells are identified. What information should the nurse give regarding cancer cells? A. "Cancer cells are immature and vary in size and shape by mutation." B. "Cancer cells multiply at a much slower rate than normal cells." C. "Cancer cells are very well organized and are like the tissue of origin." D. "Cancer cells are oval in shape and are missing the nucleus."
A
A client sustained a crush injury to the lower extremities while trying to do a car improvement project. The client was brought to the emergency room with blood pressure 70/50 mm Hg, pulse 123/min, and respirations 8/min. The nurse anticipates the results of which diagnostic test to best evaluate the client's oxygenation and ventilation status? A. Arterial blood gases B. Hematocrit and hemoglobin levels C. Serum lactate level D. Chest x-ray
A
A client was brought to the emergency room after sustaining a crushed injury. What electrolyte is most at risk to be abnormal as a result of the crush injury? A. Potassium B. Calcium C. Sodium D. Phosphorus
A
A nurse administers oxygen at 6 L/min via face mask to a client with COPD. Which clinical indicators should the nurse closely observe in the client? A. Mental confusion B. Cyanosis C. Hypertension D. Increased respirations
A
A nurse in an emergency department is preparing to care for a client who is being brought in with multiple system trauma following a motor vehicle crash. Which of the following is the priority focus of care? A. Airway protection B. Decreasing intracranial pressure C. Stabilizing cardiac arrhythmias D. Preventing musculoskeletal disability
A
A nurse is caring for a client who is post-operative day 2 after a large abdominal surgery. While assessing the client at the beginning of the shift, the nurse noted decreased breath sounds, crackles, and a mild cough. Most likely, what is the client experiencing? A. Atelectasis B. Acute Bronchitis C. Hypoxemia D. Pneumonia
A
A nurse is teaching a client about skin cancer. Which of the following client statements indicates a need for further teaching? A. Eating a high fiber diet will reduce my risk for developing skin cancer B. I should check my skin monthly for any changes C. I should avoid the use of tanning booths D. I should use sunscreen even on cloudy days
A
A nurse must assign a client who has active tuberculosis (TB) to a bed on a medical-surgical unit. Which of the following accommodations is appropriate for this client? A. A room with air exhaust directly to the outdoor environment B. A two-bed room with another nonsurgical client C. A bed in the intensive care unit D. A room with a minimum of four air exchanges per hour
A
A patient comes in after a severe motor vehicle accident his heart rate is 150, BP is 90/50, and respiratory rate is 18 what would you want to do first? A. Take blood for electrolytes B. Give potassium stat C. Administer opioids D. Document vital signs stat
A
A patient with emphysema receives discharge instructions regarding home oxygen use via nasal cannula. ÿWhich of the following statements should the nurse include? A. Do not smoke or be around others who do smoke B. Adjust the flow rate to comfort during meals C. Replace nasal cannula weekly D. Inhale through the mouth, exhale through the nose
A
A postoperative client asks the nurse why it is so important to deep-breathe and cough after surgery. When formulating a response, the nurse incorporates the understanding that retained pulmonary secretions in a postoperative client can lead to which condition? A. Pneumonia B. Hypoxemia C. Fluid Imbalance D. Pulmonary embolism
A
The nurse has just reassessed the condition of a postoperative client who was admitted 1 hour ago to the surgical unit. The nurse plans to monitor which parameter most carefully during the next hour? A. Urinary output of 20 mL/hour B. Temperature of 37.6 degrees Celsius (99.6° F) C. Blood pressure of 100/70 mm Hg D. Serous drainage on the dressing
A
The nurse is caring for a client who has a newly inserted chest tube connected to suction and a water seal drainage system. Which of the following indicates the chest tube is functioning properly? A. Fluctuation of the fluid level within the water seal chamber B. Secretions in the tubing connected to the drainage system C. Bubbling within the water seal chamber D. Equal amounts of secretions in each collection chamber
A
The nurse is caring for a client who is postoperative following a GI surgery and the health care provider changes the client's diet from NPO status to clear liquids. The nurse should check which priority item before administering the diet? A. Bowel sounds B. Ability to ambulate C. Appetite & typical diet D. Urine specific gravity
A
The nurse is teaching clients about decreasing the risks of COPD. What behaviors should the nurse emphasize? A. Abstain from cigarette smoking B. Maintain a high-protein diet C. Avoid exposure to respiratory infections D. Participate regularly in aerobic exercises
A
The nurse should teach the patient who is being radiated about protecting their skin and oral mucosa. An important teaching point would be to tell the patient to: A. Cleanse the skin with a mild soap, using fingertips, not a rough cloth B. Use approved emollient 2 hours before radiation to give skin time to absorb the medication and provide a shield for damage C. Apply a small ice compress to treat area afterward to decease localized redness, post radiation D. Use an ointment, after treatment, to decrease the feeling of burning, which may last for several hours
A
The nurse would be alerted to the occurrence of malignant hyperthermia when the patient demonstrates... A. Muscle rigidity B. Hypocapnia C. Decreased body temperature. D. Confusion upon arousal from anesthesia.
A
You are assessing a patient who is post-opt from a chest tube insertion. On assessment, you note there is 50 cc of serosanguinous fluid in the drainage chamber, fluctuation of water in the water seal chamber when the patient breathes in and out, and bubbling in the suction control chamber. Which of the following is the most appropriate nursing intervention? A. Document as normal finding B. Assess for an air leak due to bubbling noted in the suction chamber. C. Notify the physician about the drainage. D. Milk the tubing to ensure patency of the tubes.
A
You are checking your patients labs and notice they have a potassium level of 6, would be expected findings. A. Heart palpitations B. Muscle spasms C. Dark amber urine D. Drowsiness
A
You are providing care to a patient with a chest tube. On assessment of the drainage system, you note continuous bubbling in the water seal chamber and oscillation. Which of the following is the CORRECT nursing intervention for this type of finding? A. Check the drainage system for an air leak. B. Increase the suction to the drainage system until the bubbling stops. C. Continue to monitor the drainage system. D. Reposition the patient because the tubing is kinked.
A
A nurse is caring for a client who has emphysema. Which of the following findings should the nurse expect to assess in this client? Select all that apply A. Dyspnea B. Bradycardia C. Barrel chest D. Clubbing of the fingers E. Shallow respirations
A, C, D, E
A nurse is reinforcing teaching to a client who has cancer. Which of the following should the nurse include as clinical manifestations of cancer? Select all that apply A. A non-healing ulcer B. Bloating C. Change in bowel pattern D. Change in moles E. Nagging cough
A, C, D, E
A nurse is planning the care for a client who has acute leukemia and received aggressive chemotherapy treatment 10 days ago. Which of the following hematologic laboratory abnormalities should the nurse expect to see? Select all that apply A. Decreased platelet count B. Increased hemoglobin count C. Decreased WBC count D. Increased platelet count E. Decreased RBC count
A, C, E
Your patient is post-op day one what would we do to prevent complications? (Select all that apply) A. Having them use IS B. Giving them pain meds when their pain is 8/10 C. Ambulating every hour D. Giving them sub-q enoxaparin
A, D
A client is experiencing hyperkalemia due to Addison's Disease. What clinical manifestations should the nurse expect? Select all that apply. A. Irregular heartbeat B. Shortness of breath C. Muscle weakness D. Increased appetite
A, B, C
The nurse is discharging a patient home from an outpatient surgery center. The nurse has reviewed all of the discharge instructions with the patient and her caregiver. What else should the nurse do before discharging the patient from the facility? Select all that apply. A. Provide all discharge instructions in writing. B. Provide the nurse's or surgeon's contact information. C. Give prescriptions to the patient. D. Irrigate the patient's incision and perform a sterile dressing change. E. Administer a bolus dose of an opioid analgesic.
A, B, C
Who should you evaluate first? A. A patient who is post op day one complaining of 7/10 pain B. A patient with a DVT who is complaining of shortness of breath C. A patient who has intermittent bubbling in the chest tube D. A patient who has positive blood cultures for pneumonia
B
A 45 y/o male is 3 days post-op for an appendectomy. This patient is 5'8 and weighs 310 pounds. The patient complains of feeling like "something gave out" as he was coughing. What would the nurse expect? A. Evisceration B. Dehiscence C. Abdominal distension D. Rupture of abdominal aortic aneurysm
B
A 76 years old client presented with difficulty breathing. The nurse assesses the client and findings show that the client has a temperature of 102.2 F (39 C), blood pressure 98/66 mm Hg, pulse 115/min, and respirations 30/min. Assessment also reveals crackles in the right lower lobe, dusky nail beds, and dry mucus membranes. The client is suspected to have pneumonia. What should the nurse do first? A. Blood cultures x2 for temperature > 102F (38.9C) B. Oxygen per nasal cannula 4L/min C. Normal saline (NS) solution at 125 mL/hr. D. Teaching incentive spirometer use
B
A home health nurse visits a client who has COPD and receives oxygen at 2 L/min via nasal cannula. The client tells the nurse she has been having difficulty breathing. Which of the following nursing actions is the priority at this time? A. Increase the oxygen flow to 3 L/min B. Evaluate the client's respiratory status C. Call emergency services for the client D. Have the client cough and expectorate secretions
B
A nurse is caring for a patient who is 12 hr postoperative and has a chest tube to a disposable water-seal drainage system with suction. Which of the following observations should alert the nurse to a problem that requires intervention? A. Constant bubbling in the suction-control chamber B. Continuous bubbling in the water-seal chamber C. Bloody drainage in the collection chamber D. Fluid-level fluctuations in the water-seal chamber
B
A nurse is providing preoperative teaching to a patient who will soon undergo a cardiac bypass. The nurse's teaching plan includes exercises of the extremities. What is the purpose of teaching a patient leg exercises prior to surgery? A. Leg exercises increase the patient's muscle mass postoperatively. B. Leg exercises improve circulation and prevent venous thrombosis. C. Leg exercises help to prevent pressure sores to the sacrum and heels. D. Leg exercise help increase the patient's level of consciousness after surgery
B
A patient is receiving thrombolytic therapy for the treatment of pulmonary emboli. What is the best way for the nurse to assess the patient's oxygenation status at the bedside? A. Obtain serial ABG samples. B. Monitor pulse oximetry readings. C. Test pulmonary function. D. Monitor incentive spirometry volumes.
B
A patient scheduled for a cholecystectomy is undergoing routine pre-admission testing. Which lab values would warrant concern from the nurse? A. Calcium 10.5 mg/dL B. WBC 14,000 C. PTT 35 seconds D. HCT 35%
B
A perioperative nurse is caring for a postoperative patient. The patient has a shallow respiratory pattern and is reluctant to cough or to begin mobilizing. The nurse should address the patient's increased risk for what complication? A. Acute respiratory distress syndrome (ARDS) B. Atelectasis C. Aspiration D. Pulmonary embolism
B
An admitting nurse is assessing a patient with COPD. The nurse auscultates diminished breath sounds, which signify changes in the airway. These changes indicate to the nurse to monitor the patient for what? A. Kyphosis and clubbing of the fingers B. Dyspnea and hypoxemia C. Sepsis and pneumothorax D. Bradypnea and pursed lip breathing
B
In preparation for ambulation, the nurse is planning to assist a postoperative client to progress from a lying position to a sitting position. Which nursing action is most appropriate to maintain the safety of the client? A. Allow the client to rise from the bed to a standing position unassisted. B. Assess the client for dizziness and hypotension C. Elevate the head of the bed quickly to assist the client to a sitting position. D. Assist the client to move quickly from the lying position to the sitting position.
B
In preparation for ambulation, the nurse is planning to assist a postoperative client to progress from a lying position to a sitting position. Which nursing action is most appropriate to maintain the safety of the client? A. Allow the client to rise from the bed to a standing position unassisted. B. Assess the client for dizziness and hypotension C. Elevate the head of the bed quickly to assist the client to a sitting position. D. Assist the client to move quickly from the lying position to the sitting position.
B
The nurse assesses Client's surgical incision for signs of infection. Which finding by the nurse would be interpreted as normal findings at the surgical site? A. Red, hard skin B. Serous drainage C. Purulent drainage D. Warm, tender skin
B
The nurse caring for a patient post colon resection is assessing the patient on the second postoperative day. The nasogastric tube (NG) remains patent and continues at low intermittent wall suction. The IV is patent and infusing at 125 mL/hr. The patient reports pain at the incision site rated at a 3 on a 0-to-10 rating scale. 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? A. Diarrhea B. Dilute urine C. Increased muscle tone D. Joint pain
B
The nurse is caring for a client who is postoperative day-5 after undergoing partial gastrectomy. The client's diet was changed from NPO status to clear liquids. The nurse should check which priority item before administering the diet? A. Ability to ambulate B. Bowel sounds C. Appetite and typical diet D. Urine specific gravity
B
The nurse is preparing a patient for surgery. The patient states that she is very nervous and really does not understand what the surgical procedure is for or how it will be performed. What is the most appropriate nursing action for the nurse to take? A. Have the patient sign the informed consent and place it in the chart. B. Call the physician to review the procedure with the patient. C. Explain the procedure clearly to the patient and her family. D. Provide the patient with a pamphlet explaining the procedure.
B
The nurse would be alerted to malignant hyperthermia when the patient demonstrates which of the following? A. Hypocapnia B. Muscle rigidity C. Decrease body temperature D. Confusion upon arrival from anesthesia
B
The patient is admitted to your floor 3 days postoperatively after having a laparoscopic appendectomy. After performing your initial assessments, you note the absence of bowel sounds, and the patient states, "I feel like I have a brick in my stomach." Which postoperative complication should you be concerned about? A. Abdominal distension B. Paralytic ileus C. Constipation D. Dumping syndrome
B
What is the primary consideration of a PACU nurse caring for a post op patient? A. Checking vitals q 15 mins B. Maintaining a patent airway C. Administering prescribed meds D. Removing the dressing and checking the surgical site
B
What would delay your patients discharge from the hospital? A. Pain of 4/10 with ambulation B. Inability to void since surgery C. Hemoglobin of 8 D. Heart rate of 100
B
What would your patient be most at risk for that develops SIADH after chemo treatment? A. Muscle cramps and twitching B. Seizure like activity C. Chest palpitations D. Anorexia and pallor
B
Which nursing assessment data support that the client has experienced a pulmonary embolism? A. Calf pain with dorsiflexion of the foot. B. Sudden onset of chest pain and dyspnea C. Left-sided chest pain and diaphoresis D. Bilateral crackles and low-grade fever.
B
You are the surgical nurse caring for a 65-year-old female patient who is postoperative day 1 following a thyroidectomy. During your shift assessment, the patient complains of tingling in her lips and fingers. She tells you that she has an intermittent spasm in her wrist and hand and she exhibits increased muscle tone. What electrolyte imbalance should you first suspect? A. Hypophosphatemia B. Hypocalcemia C. Hypermagnesemia D. Hyperkalemia
B
You have a 80 year old male come in with pneumonia what would be the first symptoms he would present? A. Temperature elevation and chills B. Altered mental status C. A cough and SOB D. Increase sputum
B
You have a patient with uncontrolled asthma, you have just given him an albuterol nebulizer but he is still short of breath what would you do next? A. Do stat Pulmonary function tests B. Give IV Steroids C. Put him on continuous oxygen D. Given IV antibiotics
B
Your 24 year old patient comes in for knee surgery. He informs you that his dad spiked a fever of 104 when he had the same surgery. Why is this information relevant to you? A. He is at a risk for post op infection B. He is at a risk for malignant hyperthermia C. He is at a risk for DVT's D. This information is not relevant
B
Your patient comes in with a temperature of 101, heart rate of 100, respiratory rate of 30. He appears to be using accessory muscles to breath. Lungs sounds crackles at the bases. What would be your first thing to do? A. Obtain a sputum sample and blood cultures B. Give him oxygen so his O2 sat is >95% C. Give him a liter of normal saline D. Start him on IV antibiotics
B
Your patient has a calcium level of 16, what would be potential complications? A. Increase risk of falls B. Acute kidney injury C. Pneumonia D. Heart palpitations
B
The nurse is caring for a postoperative patient who needs daily dressing changes. The patient is 3 days postoperative and is scheduled for discharge the next day. Until now, the patient has refused to learn how to change her dressing. What would indicate to the nurse the patient's possible readiness to learn how to change her dressing? Select all that apply. A. The patient wants you to teach a family member to do dressing changes. B. The patient expresses interest in the dressing change. C. The patient is willing to look at the incision during a dressing change. D. The patient expresses dislike of the surgical wound. E. The patient assists in opening the packages of dressing material for the nurse.
B, C, E
Which assessment data indicate the postoperative client who had anesthesia is suffering a complication of the anesthesia? A. Loss of sensation of the lumbar (L5) dermatome B. Absence of the clients posterior tibial pulse C. The client has a respiratory rate of eight D. The blood pressure is within 20% of the client's baseline
C
Which comment by the client with lung cancer indicates a need for further teaching? A. "I will eat a diet with five servings of fruits and vegetables daily." B. "I will quit smoking and use the patch to help me." C. "The damage is done, why quit now?" D. "I will retire from my job at the dry cleaning company."
C
A 58-year-old male patient has been hospitalized for a wedge resection of the left lower lung lobe after a routine chest x-ray shows carcinoma. The patient is anxious and asks if he can smoke. Which statement by the nurse would be most therapeutic? A. "Smoking is the reason you are here." B. "The doctor left orders for you not to smoke." C. "You are anxious about the surgery. Do you see smoking as helping?" D. "Smoking is OK right now, but after your surgery it is contraindicated."
C
A college athlete comes to the emergency room after having an acute asthma attack during a game. The nurse conducts an assessment and finds the respiratory rate is 38 breaths /minute, bilateral wheezes heard on auscultation, and the athlete appears to be having difficulty breathing. Which of the actions should be done first by the nurse? A. Take a complete health history B. Provide emotional support to the patient C. Obtain an order for a bronchodilator to be given by nebulizer D. Apply a cardiac monitor to the patient
C
A nurse assesses her patient post-op and obtains vital signs. The patient's blood pressure is 90/50, heart rate is 120, the patient is in visible distress and his skin is clammy. What action should the nurse do immediately? A. Continue to monitor the patient and document vital signs B. Check the patient's blood sugar for hypoglycemia C. Notify the physician D. Ask the patient if he is in pain and administer pain medications
C
A nurse is caring for a client who is post-operative day 2 after a large abdominal surgery. While assessing the client at the beginning of the shift, the nurse noted decreased breath sounds, crackles, and a mild cough. Most likely, what is the client experiencing? A. Hypoxemia B. Acute Bronchitis C. Atelectasis D. Pneumonia
C
A nurse is preparing to discuss discharge planning with a 48-year-old man who smokes one pack of cigarettes per day and who has been admitted to the hospital after being involved in a motor vehicle accident. What information should the nurse include? A. Cancer risk is dramatically decreased if the smoker does not inhale. B. Smokeless tobacco is not associated with cancer risk. C. Tobacco use causes more cancer than all other causes combined. D. Light cigarettes can reduce an individual's cancer risk.
C
A nurse is teaching a client about the risks for cancer. Which of the following client statements indicates the need for further teaching? A. I will use sunscreen when laying out in the sun. B. I take Milk of Magnesia for occasional constipation C. I used to smoke but switched to chewing tobacco 3 years ago D. I see a dermatologist regularly for the mole on my thigh
C
The nurse has instructed a preoperative client using an incentive spirometer to sustain the inhaled breath for 3 seconds. When the client asks about the rationale for this action, the nurse explains that this action achieves which function? A. Dilates the major bronchi B. Increases surfactant production C. Maintains inflation of the alveoli D. Enhances ciliary action in the tracheobronchial tree
C
The nurse is assessing a patient's surgical dressing on the first postoperative day, the nurse notes new, bright-red drainage about 5 cm in diameter. What would be the nurse's first response to this finding? A. Assess in 1 hour for increased drainage. B. Notify the surgeon of a potential hemorrhage. C. Assess the patient's blood pressure and heart rate. D. Remove the dressing and assess the surgical incision.
C
The nurse is caring for a 78-year-old man who has had an outpatient cholecystectomy. The nurse is getting him up for his first walk postoperatively. To decrease the potential for orthostatic hypotension and consequent falls, what should the nurse have the patient do? A. Sit in a chair for 10 minutes prior to ambulating. B. Drink plenty of fluids to increase circulating blood volume. C. Stand upright for 2 to 3 minutes prior to ambulating. D. Perform range-of-motion exercises for each joint.
C
The nurse is caring for a patient on the medical-surgical unit postoperative day five. During each patient assessment, the nurse evaluates the patient for infection. Which of the following would be most indicative of infection? A. Presence of an indwelling urinary catheter B. Rectal temperature of 99.5ºF (37.5ºC) C. Red, warm, tender incision D. White blood cell (WBC) count of 8,000/mL
C
The nurse is preparing a 65 years old woman with body mass index (BMI) of 38.5 for knee surgery. The nurse knows that based on the patient's age and BMI that the patient is at a high risk for what complication post-op? A. Falls B. Hyperglycemia C. Infection D. Azotemia
C
When would be an incorrect time to clamp the chest tube? A. When changing out the system B. When assessing for potential air leaks C. When having the patient ambulate with PT D. When turning the patient and briefly placing the system above their body
C
You are assigned a patient 24 hours post op from a laparoscopic colon resection. The surgery was completed without complications and since being admitted to your floor from the PACU, the patient has been bed ridden. The most recent vital signs are as follows: 126/82, 76, respirations 19, oral temperature 101.3. The elevated temperature most likely indicates what condition? A. Small bowel obstruction B. Bacterial infection C. Atelectasis D. Allergic reaction to anesthesia
C
Your post-op patient appears to have an increased work of breathing. His SpO2 is 95%.When assessing his lungs you notice crackles in the bases. What would be an appropriate nursing intervention? A. Put in on a nasal cannula to help with breathing B. Give him normal saline at 125ml/hr C. Have him use incentive spirometer D. Provide antibiotics because this is possibly a pneumonia
C
The PACU nurse is caring for a patient who has been deemed ready to go to the post-surgical floor after her surgery. What would the PACU nurse be responsible for reporting to the nurse on the floor? Select all that apply. A. The names of the anesthetics that were used B. The identities of the staff in the OR C. The patient's preoperative level of consciousness D. The presence of family and/or significant others E. The patient's full name
C, D, E
A nurse is caring for a client diagnosed with breast cancer The client is scheduled for radiation therapy to the breast. Which of the following should the nurse teach the client to expected. Select all that apply A. Wash the area with soap and hot water B. Dry mouth and taste changes C. Reporting of fatigue and nausea D. Administer stool softeners and fluids E. Breast tenderness and swelling
C, E
A patient is admitted back to the floor following surgery. The student nurse working on the unit knows that which of the following interventions should be implemented to prevent atelectasis? Select all that apply. A. Administering an inhaled corticosteroid B. Around-the-clock spO2 monitoring C. Incentive Spirometry hourly D. Range of Motion (ROM) exercises in bed E. Ambulating the patient within 24 hours after surgery
C, E
A 92 years old client underwent a major cardiac surgery. On the first day post surgery, what is an important nursing intervention to prevent a postoperative complication? A. Maintain the legs in a dependent position. B. Massage the client's legs. C. Assist the client to sit up in bed after surgery. D. Remind the client to exercise the legs and feet.
D
A nurse in an urgent care center is caring for a client who is having an acute asthma exacerbation. Which of the following actions is the nurse's highest priority? A. Initiating oxygen therapy B. Providing immediate rest for the client C. Positioning the client in high-Fowler's D. Administering a nebulized beta-adrenergic
D
A nurse is assessing a client who has a respiratory disorder. If the client has hypoxia, the nurse should expect which of the following findings? A. Bradycardia B. Bradypnea C. Pallor D. Cyanosis
D
A nurse is caring for a client who was admitted to receive chemotherapy for treatment of ovarian cancer. The client vomited after each previous dose of chemotherapy. Which of the following actions should the nurse take to prevent vomiting? A. Speak to the provider about decreasing the chemotherapy dose B. Withhold food and fluids prior to and during treatment C. Provide the client with an emesis basin during treatment D. Administer an antiemetic prior to chemotherapy
D
A nurse is observing the closed chest drainage system of a client who is 1 day post thoracotomy. The nurse notes continuous bubbling in the suction control chamber. The nurse should A. Observe all of the tubing connections for leaks B. Check the suction control outlet on the wall C. Notify the physician D. Continue to monitor the client's respiratory status
D
A patient has undergone a hysterectomy and is on a medical surgical floor for recovery. She is 12 hours post op and physical therapy comes to ambulate her. Which situation would the nurse continue to ambulate the patient? A. Patient's chart shows H&H low & stable vitals B. Blood pressure shows a significant decrease from laying to sitting C. Order states bed rest for 48 hours due to increased bleeding risk D. Patient is hesitant to start walking & has 3/10 pain in surgical area
D
An older adult client has been diagnosed with chronic obstructive pulmonary disease (COPD). What characteristic of the client's current health status would prevent the safe and effective use of a metered-dose inhaler (MDI)? A. The client has cataracts B. The client requires both corticosteroids and beta2-agonists C. The client has not yet quit smoking D. The client has severe arthritis in her hands
D
The nurse is orienting a new nurse to the oncology unit. When reviewing the safe administration of antineoplastic agents, what action should the nurse emphasize? A. Adjust the dose to the patient's present symptoms. B. Wash hands with an alcohol-based cleanser following administration. C. Use gloves and a lab coat when preparing the medication. D. Dispose of the antineoplastic wastes in the hazardous waste receptacle.
D
The nurse is planning patient teaching for a patient who is scheduled for an open hemicolectomy. The nurse intends to address the topics of incision splinting and leg exercises during this teaching session. When is the best time for the nurse to provide teaching? A. Upon the patient's admission to the post-anesthesia care unit (PACU) B. When the patient returns from the PACU C. During the intra-operative period D. As soon as possible before the surgical procedure
D
The nurse is preparing to administer chemotherapeutic agents to a client being treated for ovarian cancer. What is the most important action for the nurse to do? A. Instruct the client to remain in bed. B. Take the client's vital signs before administration. C. Hang the medication in a light-protective container. D. Use personal protective equipment.
D
The nurse recognizes the importance of "Time Out." What is the purpose of "Time Out" during surgery? A. So, the anesthesiologist can wake up the client and confirm that the correct procedure is being done on the correct person B. To allow the operating room (OR) team time to scrub and gown C. As a signal for the scrub nurse or certified scrub technician to perform and instrument and sponge count D. So, all members of the OR team participate in the positive identification of the client, identify the correct site, and identify the planned procedure
D
You are caring for a patient who has a diagnosis of syndrome of inappropriate antidiuretic hormone secretion (SIADH). Your patient's plan of care includes assessment of specific gravity every 4 hours. The results of this test will allow the nurse to assess what aspect of the patient's health? A. Nutritional status B. Potassium balance C. Calcium balance D. Fluid volume status
D
