NUR 112 unit 1 exam<3

A client has a potassium level of 6.4. (average is 3.6-5.2) Which would the nurse assess for first in the client? A. cardiac dysrhythmias B. tingling C. hyponatremia D. hypertension

A

A client recovering from a laparoscopic appendectomy is receiving 0.9% NS at 180ml/hr. Which condition would the client be monitored for? A. fluid overload B. hyperkalemia C. fluid deficit D. hyponatremia

A

A diabetic client well-controlled with insulin injection has been NPO since midnight before a scheduled mastectomy. While prepping the client for surgery in the clients room, which would the nurse anticipate needing? A. obtain a blood glucose measurement B. withhold any insulin does C. notify the unit supervisor D. call the surgeon.

A

A nurse is preparing a pre-operative client for the transfer to the OR. Which action would the nurse take in the care of this client at this time? A. ensure the client has voided B. administer all the daily meds C. practice preoperative breathing exercises D. verify the client has not eaten for 24 hr.

A

The nurse notes the oxygen saturation is 78% in an unconscious client who was transferred to the post-anesthesia care unit 10 min previously. Which action would the nurse take first? A. assess and open the airway B. administer epinephrine C. obtain a STAT ABG D. call the anesthesiologist

A

Which electrolyte imbalance would the nurse closely monitor in a client who has a nasogastric tube connected to suction? A. hypokalemia B. hyponatremia C. hypercalcemia D> hypomagnesemia

A

Which is a risk factor for hyper magnesia? A. DKA (diabetic ketoacidosis) B. hemo-concentration C. thiazide diuretics D. decreased calcium excretion

A

Which is an early sign of a possible UTI in an elderly client? A. lethargy, confusion, weakness B. dysuria, hematuria, hypertension C. short-term memory loss and dysuria D. paranoia, hematuria, anxiety

A

Which is included in the rights of administering meds? A. right patient B. right medication C. right time D. right route E. right dose

A B C D E (ALL)F

Which is an example of quality improvement used to prevent a sentinel event (A sentinel event is a patient safety event that results in death, permanent harm, or severe temporary harm.) in a peri-op client? A. a mandatory continuing education competency on "time-outs." B. an incident report detailing medication error C. a fall that occurs at night but is not reported D. a nurse assists a client to smoke in the smoking area

A.

A client is scheduled for blood to be drawn from the RADIAL ARTERY for an ABG determination. Before the blood is drawn, an ALLEN'S TEST is preformed. Which circulation does the ALLEN'S TEST determine adequacy?

A. ULNER CIRCULATION

A nurse discontinues a clients Foley catheter in the outpatient surgery area. Which is a priority goal for this client? A. report the first voiding to the physician. B. voiding prior to discharge C. storing the foley at home for use if unable to void. D. cleaning the foley for reuse if needed

B

A nurse is monitoring the status of a postoperative client, which sign would indicate an evolving complication for the nurse to monitor? A. absence of a Homan's sign. B. increasing restlessness C. hypoactive bowel sounds in all 4 quadrants. D. BP 110/70, pulse 86.

B

The male client asks to urinate 8 minutes after a prescribed opioid was administered IV. Which would be the best nursing action to promote safety? A. lower the bed to the lowest point and raise 2 side rails B. offer a urinal and position the client in bed to promote voiding C. have the client wait since a catheter will be inserted in the operating room. D. allow the client up to the bathroom since it has only been 8 minuets.

B

The nurse is working with a client who is one day post-op abdominal surgery. Which instruction would the nurse provide to the client to help prevent post-op blood clot formation? A. deep breathing B. improved mobility C. pain management D. strict bed rest

B

Which clinical manifestation would the nurse monitor for in the client admitted with hyper magnesia? A. elevated BP B. bradycardia C. increased deep tendon reflexes D. hyperventilation

B

Which post-anesthesia care unit (PACU) discharge criteria is specific to the client who has received spinal anesthesia? A. oxygen saturation reaches the pre-surgical baseline B. motor and sensory function returns C. nausea and vomiting are minimal D. headache is considered tolerable

B

Which surgical attire must be worn at the clients bedside during the intra-operative phase? Select all that apply. A. lab jacket B. mask C. eye protection D. sterile gown E. sterile gloves

B C D E

A client is admitted to the clinical facility with acute abdominal pain. The health care provider determines the client has appendicitis. An appendectomy is scheduled to take place in 3 hours. While waiting for the surgery, the client reports the pain has subsided. What initial action by the nurse would be indicated? A. notify the nursing supervisor the client is ready for surgery. B. contact the surgery department to get the surgical suit prepared. C. contact the healthcare provider due to the possibility of a rupture of the appendix D. determine when the client can be medicated for pain.

C

A client with a calcium imbalance is at risk for pathological fracture. Which would be included in the clients plan of care? A. place client on seizure precautions B. instruct the client to increase magnesium-containing foods C. move the client carefully and slowly D. administer magnesium sulfate IV or PO

C

A nurse is assessing a client for Chvostek's sign. Which technique would the nurse use to preform this test? A. apply a bp cuff to the clients arm B. place the stethoscope bell over the clients carotid artery C. tap lightly on the clients cheek D. ask the client to lower their chin to their chest

C

The health care provider changes the dose of the clients DILTIZEM HYDROCHLORIDE to 180 mg po every 12 hours. The nurse is preparing to administer the new order and finds several tablets labeled DILTIAZEM HYDROCHLORIDE ER 90 mg in the client's drawer. Which action by the nurse would be correct? A. call the physician to clarify the order B. administer 2 90 mg ER tablets to the client C. call the pharmacy to obtain the new dose D. administer one 90 mg ER tablet for the morning dose

C

What dietary order would you expect to facilitate in the client who is one day post-op? A. NPO B. BRAT diet C. progressive diet D. pureed diet

C

Which medication would the nurse administer as a part of a pharmacological treatment aimed to prevent pulmonary embolism? A. heparin sulfate B. vitamin K C. enoxaparin (Lovenox) D. Protamine sulfate

C

Which technique would you avoid to prevent pulmonary emboli in a post op client? A. application of elastic wraps to the lower extremities B. measuring calf circumference every shift C. calf muscle massage D. early ambulation

C

2 hours after an appendectomy, the nurse auscultates the clients abdomen. The nurse is unable to hear the bowel sounds. Which would the nurse do first? A. position the client on their right side with the bed flat B. check the dressing and apply an abdominal binder C. palpate the bladder and measure abdominal girth D. document the findings

D

A client with dementia takes Percodan for post op pain. The client is confused and is being cared for in the home by the client's spouse. a home health nurse is accessing the home environment. Which finding would the nurse recommend to modify? A. protective door handle covers on door opening to the outside. B. nonskid mat and shower chair in the shower stall. C. cleaning supplies and medicines stores in sperate lockable cabinets. D. throw rugs in front of doorways and sinks

D

The nurse records the clients vital signs before transferring him to the pre-anesthesia area for an exploratory laparotomy. The clients temperature is 102.2 degrees orally. Which would the nurse do next? A. notify the accepting nurse in the pre-anesthesia area after transfer of the client. B. administer 650 mg of acetaminophen and recheck the temperature in 30 min. C. apply a cooling blanket and recheck the temperature in 30 min. D. contact and inform the surgeon and the operating suite of the temperature.

D

What should you never apply to appendicitis?

HEAT!!!! Never apply heat to the abdomen of a client with appendicitis. Heat can cause rupture of the appendix, leading to peritonitis, a life-threatening condition.

The nurse is conducting pre-operative education and wants to use a variety of teaching methos. Which factor may limit the use of pre-written handouts?

First grade literacy in a 40 year old women

Your patient is to receive low-molecular-weight heparin, Lovenox. What would teach your patient regarding this medication?

Lovenox will help prevent clot formation in the legs.

The nurse is discussing preoperative teaching for a client scheduled for an abdominal hysterectomy. Which would the nurse make sure to include in the preoperative teaching?

Methods of effective coughing and deep breathing

NORMAL POST-OPERATIVE FINDINGS

Verify that the informed consent is accurately completed, signed, and witnessed.

The nurse is caring for a client who sustained a brain injury and is no longer competent to make healthcare decisions, which person would the nurse suggest to make decisions regarding care for the client

health care power of attorney

What is appendicitis?

inflammation of the appendix. When the appendix becomes inflamed or infected, rupture may occur within a matter of hours, leading to peritonitis and sepsis.

What is peritonitis?

inflammation of the peritoneum. If your appendix bursts, the lining of your abdomen (peritoneum) will become infected with bacteria.

The nurse is caring for a post-operative client who has been readmitted due to persistent diarrhea for the previous 3 days. Which would be the nurses priority concern.

metabolic acidosis

How will my patient with hypovolemia present?

tachycardia, rapid thready pulse, hypotension, orthostatic hypotension, diminished peripheral pulses