Nursing 102 exam 4

A client who has had abdominal surgery complains of feeling as though "something gave way" in the incisional site. The nurse removes the dressing and notes the presence of a loop of bowel protruding through the incision. Which nursing interventions should the nurse take? Select all that apply 1. Contact the surgeon 2. Instruct the client to remain quiet 3. Prepare the client for wound closure 4. Document the findings and actions taken 5. Place a sterile saline dressing and icepacks over the wound 6. Place the client in a prone position without a pillow under the head.

1, 2, 3 ,4 Wound dehiscence is the separation of the wound edges. Wound evisceration is protrusion of the internal organs through an incision. If wound dehiscence or evisceration occurs, the nurse should call for help, stay with the client, and ask another nurse to contact the surgeon and obtain needed supplies to care for the client. The nurse places the client in a low fowlers position and the client is kept quite and instructed not to cough. Protruding organs are covered with a sterile saline dressing. Ice is not applied because of its vasoconstrictive effect. The treatment for evisceration is usually immediate wound closure under local or general anesthesia. The nurse also documents the findings and actions taken.

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? 1. Pneumonia 2. Hypoxemia 3. Fluid imbalance 4. Pulmonary embolism

1. Postoperative respiratory problems are atelectasis, pneumonia and pulmonary emboli. Pneumonia is the inflammation of lung tissue that causes productive cough, dyspnea, and lung crackles and can be caused by the retention of pulmonary secretions.

The nurse receives a telephone call from the postanesthesia care unit stating that a client is being transferred to the surgical unit. The nurse plans to take which action first on arrival of the client? 1. Assess the patency of the airway 2. Check tubes or drains for patency 3. Check the dressing to assess for bleeding 4. Assess the vital signs to compare with preoperative measurements

1. The first action of the nurse is to assess the patency of the airway snd respiratory function. If the airway is not patent, the nurse must take immediate measures for the survival of the client. The nurse then takes vital signs followed by checking of the dressing and tubes or drains.

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? 1. Urine output of 20ml/hour 2. Temperature of 99.7 F 3. Blood pressure of 114/70 4. Serous drainage on the surgical dressing

1. Urine output should be maintained at a minimum of 30mL/hour for an adult. An output of less than that for each of 2 consecutive hours should be reported to the health care provider.

A client is being discharged to home after application of a plaster leg cast. Which statement indicates that the client understands proper care of the cast? 1. "I need to avoid getting the cast wet." 2. I need to cover the casted leg with warm blankets 3. "I need to use my fingertips to lift and move my leg. 4. "I need to use something like a padded coat hanger end to scratch under the cast if it itches."

1. "I need to avoid getting the cast wet."

The nurse assess a client's surgical incision for signs of infection. Which finding by the nurse would be interpreted as a normal finding at the surgical site? 1. Red, hard skin 2. Serous drainage 3. Purulent drainage 4. Warm tender skin

2 Serous drainage is an expected finding at a surgical site. The other options indicate signs of wound infection. Wound infection usually appears 3 to 6 days after surgery.

A client in traction slides down in the bed so that the feet touch the foot of the bed. What should the nurse to do ensure that the pull of traction remains uninterrupted? A. Release weights, pull client up in bed, and then reapply weights B. Ask physician for a change in the amount of weight ordered C. Move client up in bed without releasing pull of traction on the extremity D. Elevate clients feet on a pillow

C. Move client up in bed without releasing pull of traction on the extremity

A client who has undergone preadmission testing has had blood drawn for serum laboratory studies, including a complete blood count, coagulation studies, and electrolytes and creatinine levels. Which laboratory result should be reported to the surgeon's office by the nurse, knowing that it could cause surgery to be postponed? 1. Sodium, 141 mEq/L 2. Hemoglobin, 8.0 g/dL 3. Platelets, 210,000/mm3 4. Serum creatinine, 0.8 mg/dL

2. Rationale-Routine screening tests include a complete blood count, serum electrolyte analysis, coagulation studies, and a serum creatinine test. The complete blood count includes the hemoglobin analysis. All these values are within normal range except for hemoglobin. If a client has a low hemoglobin level the surgery likely could be postponed by the surgeon.

The nurse has conducted teaching with a client in an arm cast about the signs and symptoms of compartment syndrome. The nurse determines that the client understands the information if the client states that he or she should report which early symptom of compartment syndrome? 1. Cold, bluish-colored fingers 2. Numbness and tingling in the fingers 3. Pain that increases when the arm is dependent 4. Pain that is out of proportion to the severity of the fracture

2. Numbness and tingling in the fingers

The nurse is evaluating the pin sites of a client in skeletal traction. The nurse would be least concerned with which finding? 1. Inflammation 2. Serous drainage 3. Pain at a pin site 4. Purulent drainage

2. Serous drainage

When caring for a patient who has received a general anesthetic, the circulating nurse notes red, raised wheals on the patient's arms. Which action should the nurse take immediately? A .Apply lotion to the affected areas. B. Cover the arms with sterile drapes. C. Recheck the patient's arms in 30 minutes. D.Notify the anesthesia care practitioner (ACP) immediately.

ANS: D The presence of wheals indicates a possible allergic or anaphylactic reaction, which may have been caused by latex or by medications administered as part of general anesthesia. Because general anesthesia may mask anaphylaxis, the nurse should report this to the ACP. The other actions are not appropriate at this time.

A preoperative client expresses anxiety to the nurse about upcoming surgery. Which response by the nurse is most likely to stimulate further discussion between the client and the nurse? 1. "If it's any help, everyone is nervous before surgery." 2. "I will be happy to explain the entire surgical procedure with you." 3. "Can you share with me what you've been told about your surgery?" 4. "Let me tell you about the care you'll receive after surgery and the amount of pain you can anticipate".

3. Explanations should begin with the information that the client knows. By providing the client with individualized explanations of care and procedures, the nurse can assist the client in handling anxiety and fear for a smooth preoperative experience. Clients who are calm and emotionally prepared for surgery withstand anesthesia better and experience fewer postoperative complications.

the nurse has conducted preoperative teaching for a client scheduled for surgery in 1 week. The client has a history of arthritis and has been taking acetylsalicylic acid (Aspirin). the nurse determines that the client needs additional teaching if the client makes which statement? 1. "Aspirin can cause bleeding after surgery" 2. "Aspirin can cause my ability to clot blood to be abnormal" 3. "I need to continue to take the aspirin until the day of surgery" 4. "I need to check with my health care provider about the need to stop the aspirin before the scheduled surgery.'

3. Rationale-Anticoagulants alter normal clotting factors and increase the risk of bleeding after surgery. Aspirin has properties that can alter the clotting mechanism and should be discontinued at least 48 hours before surgery. However, the client should always check with his or her health care provider regarding when to stop taking the aspirin when a surgical procedure is scheduled. Options 1, 2, and 4 are accurate client statements.

The nurse is developing a plan of care for a client scheduled for surgery. The nurse should include which activity in the nursing care plan for the client on the day of surgery? 1. Avoid oral hygiene and rinsing with mouthwash 2. Verify that the client has not eaten for the last 24 hours 3. Have the client void immediately before going into surgery 4. Report immediately any slight increase in BP or pulse

3. The nurse would assist the client to void immediately before surgery so that the bladder will be empty. Oral hygiene is allowed, but the client should not swallow any water. The client usually has a restriction of food and fluids for 6 to 8 hours before surgery instead of 24 hours. A slight increase in BP and pulse is common during the preoperative period due to anxiety.

An adult received atropine sulfate (Atropine) as a pre-op medication 30 minutes ago and is now complaining of dry mouth and her pulse rate is higher than before the medication was administered. What is the nurse's best interpretation of these findings? 1. The client is having an allergic reaction to the drug 2. The client needs a higher dose of this drug 3. This is a normal side effect of Atropine 4. The client is anxious about the upcoming surgery

3. This is a normal side effect of Atropine

The nurse is conducting preoperative teaching with a client about the use of an incentive spirometer. The nurse should include which piece of information in discussions with the client? 1. Inhale as rapidly as possible 2. Keep a loose seal between the lips and the mouthpiece 3. After maximum inspiration, hold the breath for 15 seconds and exhale. 4. The best results are achieved when sitting up or with the head of the bed elevated 45 to 90 degrees

4 For optimal lung expansion with the incentive spirometer, the client should assume the semi-Fowlers or high fowlers position. The mouthpiece should be covered completely and tightly while the client inhales slowly, with a constant flow through the unit. The breath should be held for 5 seconds before exhaling slowly.

A client with a perforated gastric ulcer is scheduled for surgery. The client cannot sign the operative consent form because of sedation from opioid analgesics that have been administered. The nurse should take which most appropriate action in the care of this client? 1. Obtain a court order for the surgery. 2. Have the charge nurse sign the informed consent immediately 3. Send the client to surgery without the consent form being signed 4. Obtain a telephone consent from a family member, following agency policy

4. Every effort should be made to obtain permission from a responsible family member to perform surgery if the client is unable to sign the consent form. A telephone consent must be witnessed by two persons who hear the family member's oral consent. The two witnesses then sign the consent with the name of the family member, noting that an oral consent was obtained. Consent is not informed if it is obtained from a client who is confused, unconscious, mentally incompetent, or under the influence of sedatives. In an emergency the client may not be able to sign and family members may not be available. In this situation, a health care provider is permitted legally to perform surgery without consent, but tin this case it is not an emergency. Agency policies regarding informed consent should always be followed.

The nurse is preparing a list of cast care instructions for a client who just had a plaster cast applied to his right forearm. Which instructions should the nurse include on the list? (select all that apply) A. keep the cast and extremity elevated B. the cast needs to be kept clean and dry C. allow the wet cast 24 to 72 hours to dry D. expect tingling and numbness in the extremity E. use a hair dryer set on a warm to hot setting to dry the cast F. use a soft padded object that will fit under the cast to scratch the skin under the cast

A. keep the cast and extremity elevated B. the cast needs to be kept clean and dry C. allow the wet cast 24 to 72 hours to dry

The nurse assesses a patient who had a total abdominal hysterectomy 2 days ago. Which information about the patient is most important to communicate to the health care provider? A. The right calf is swollen, warm, and painful. B. The patient's temperature is 100.3° F (37.9° C). C. The 24-hour oral intake is 600 mL greater than the total output. D. The patient complains of abdominal pain at level 6 (0 to 10 scale) when ambulating.

ANS: A The calf pain, swelling, and warmth suggest that the patient has a deep vein thrombosis, which will require the health care provider to order diagnostic tests and/or anticoagulants. Because the stress response causes fluid retention for the first 2 to 5 days postoperatively, the difference between intake and output is expected. A temperature elevation to 100.3° F on the second postoperative day suggests atelectasis, and the nurse should have the patient deep breathe and cough. Pain with ambulation is normal, and the nurse should administer the ordered analgesic before patient activities.

A patient receives 3% NaCl solution for correction of hyponatremia. Which assessment is most important for the nurse to monitor for while the patient is receiving this infusion? A. Lung sounds B. Urinary output C. Peripheral pulses D. Peripheral edema

ANS: A Lung Sounds Hypertonic solutions cause water retention, so the patient should be monitored for symptoms of fluid excess. Crackles in the lungs may indicate the onset of pulmonary edema and are a serious manifestation of fluid excess. Bounding peripheral pulses, peripheral edema, or changes in urine output are also important to monitor when administering hypertonic solutions, but they do not indicate acute respiratory or cardiac decompensation.

The nurse is preparing to witness the patient signing the operative consent form when the patient says, "I do not really understand what the doctor said." Which action is best for the nurse to take? A. Provide an explanation of the planned surgical procedure. B. Notify the surgeon that the informed consent process is not complete. C. Administer the prescribed preoperative antibiotics and withhold any ordered sedative medications. D. Notify the operating room staff that the surgeon needs to give a more complete explanation of the procedure.

ANS: B The surgeon is responsible for explaining the surgery to the patient, and the nurse should wait until the surgeon has clarified the surgery before having the patient sign the consent form. The nurse should communicate directly with the surgeon about the consent form rather than asking other staff to pass on the message. It is not within the nurse's legal scope of practice to explain the surgical procedure. No preoperative medications should be administered until the patient understands the surgical procedure and signs the consent form.

An older patient who had knee replacement surgery 2 days ago can only tolerate being out of bed with physical therapy twice a day. Which collaborative problem should the nurse identify as a priority for this patient? A. Potential complication: hypovolemic shock B. Potential complication: venous thromboembolism C. Potential complication: fluid and electrolyte imbalance D. Potential complication: impaired surgical wound healing

ANS: B The patient is older and relatively immobile, which are two risk factors for development of deep vein thrombosis. The other potential complications are possible postoperative problems, but they are not supported by the data about this patient

An inpatient nurse brings an informed consent form to a client for an operation scheduled for tomorrow. The client asks about possible complications from the operation. What response by the nurse is best? A. Answer the questions and document that teaching was done. B. Do not have the client sign the consent and call the surgeon. C. Have the client sign the consent, then call the surgeon. D. Remind the client of what teaching the surgeon has done.

ANS: B Do not have the client sign the consent and call the surgeon. In order to give informed consent, the client needs sufficient information. Questions about potential complications should be answered by the surgeon. The nurse should notify the surgeon to come back and answer the client's questions before the client signs the consent form. The other actions are not appropriate.

Which topic is most important for the nurse to discuss preoperatively with a patient who is scheduled for abdominal surgery for an open cholecystectomy? A. Care for the surgical incision B. Medications used during surgery C. Deep breathing and coughing techniques D. Oral antibiotic therapy after discharge home

ANS: C Preoperative teaching, demonstration, and redemonstration of deep breathing and coughing are needed on patients having abdominal surgery to prevent postoperative atelectasis. Incisional care and the importance of completing antibiotics are better discussed after surgery, when the patient will be more likely to retain this information. The patient does not usually need information about medications that are used intraoperatively.

Which actions will the nurse include in the surgical time-out procedure before surgery (select all that apply)? A. Check for placement of IV lines. B. Have the surgeon identify the patient. C. Have the patient state name and date of birth. D. Verify the patient identification band number. E. Ask the patient to state the surgical procedure. F. Confirm the hospital chart identification number.

ANS: C, D, E, F These actions are included in surgical time out. IV line placement and identification of the patient by the surgeon are not included in the surgical time-out procedure.

Who is responsible for accompanying the surgical client to the postanesthesia recovery area after surgery and for giving a report of the client's intraoperative experience to the PACU nurse? A. The surgeon and scrub nurse B. The surgeon and circulating nurse C. The anesthesiologist and scrub nurse D. The anesthesiologist and circulating nurse

ANS: D The anesthesiologist (or certified registered nurse anesthetist) and the circulating nurse are responsible for accompanying the client to the postoperative recovery area and giving a report of the client's intraoperative experience.

The nurse is planning care for a pt with fluid volume overload & hyponatremia. Which of the following should be included in this pt's plan of care? 1. Restrict fluids. 2. Administer intravenous fluids. 3. Provide Kayexalate. 4. Administer intravenous normal saline with furosemide.

Answer: 1 Rationale 1: The nursing care for a pt with hyponatremia is dependent on the cause. Restriction of fluids to 1,000 mL/day is usually implemented to assist sodium increase & to prevent the sodium level from dropping further due to dilution. Rationale 2: The administration of intravenous fluids would be indicated in fluid volume deficit & hypernatremia. Rationale 3: Kayexalate is used in pts with hyperkalemia. Rationale 4: The administration of normal saline with furosemide is used to increase calcium secretion.

A pt is receiving intravenous fluids postoperatively following cardiac surgery. Nursing assessments should focus on which postoperative complication? 1. fluid volume excess 2. fluid volume deficit 3. seizure activity 4. liver failure

Answer: 1 Rationale 1: Antidiuretic hormone & aldosterone levels are commonly increased following the stress response before, during, & immediately after surgery. This increase leads to sodium & water retention. Adding more fluids intravenously can cause a fluid volume excess & stress upon the heart & circulatory system. Rationale 2: Adding more fluids intravenously can cause a fluid volume excess, not fluid volume deficit, & stress upon the heart & circulatory system. Rationale 3: Seizure activity would more commonly be associated with electrolyte imbalances. Rationale 4: Liver failure is not anticipated related to postoperative intravenous fluid administration.

An elderly pt comes into the clinic with the complaint of watery diarrhea for several days with abdominal & muscle cramping. The nurse realizes that this pt is demonstrating which of the following? 1. hypernatremia 2. hyponatremia 3. fluid volume excess 4. hyperkalemia

Answer: 2 Rationale 1: Hypernatremia is associated with fluid retention & overload. FVE is associated with hypernatremia. Rationale 2: This elderly pt has watery diarrhea, which contributes to the loss of sodium. The abdominal & muscle cramps are manifestations of a low serum sodium level. Rationale 3: This pt is more likely to develop clinical manifestations associated with fluid volume deficit. Rationale 4: Hyperkalemia is associated with cardiac dysrhythmias.

A pt with fluid retention related to renal problems is admitted to the hospital. The nurse realizes that this pt could possibly have which of the following electrolyte imbalances? 1. hypokalemia 2. hypernatremia 3. carbon dioxide 4. magnesium

Answer: 2 Rationale 1: The kidneys are the principal organs involved in the elimination of potassium. Renal failure is often associated with elevations potassium levels. Rationale 2: The kidney is the primary regulator of sodium in the body. Fluid retention is associated with hypernatremia. Rationale 3: Carbon dioxide abnormalities are not normally seen in this type of pt. Rationale 4: Magnesium abnormalities are not normally seen in this type of pt.

A postoperative pt is diagnosed with fluid volume overload. Which of the following should the nurse assess in this pt? 1. poor skin turgor 2. decreased urine output 3. distended neck veins 4. concentrated hemoglobin & hematocrit levels

Answer: 3 Rationale 1: Poor skin turgor is associated with fluid volume deficit. Rationale 2: Decreased urine output is associated with fluid volume deficit. Rationale 3: Circulatory overload causes manifestations such as a full, bounding pulse; distended neck & peripheral veins; increased central venous pressure; cough; dyspnea; orthopnea; rales in the lungs; pulmonary edema; polyuria; ascites; peripheral edema, or if severe, anasarca, in which dilution of plasma by excess fluid causes a decreased hematocrit & blood urea nitrogen (BUN); & possible cerebral edema. Rationale 4: Increased hemoglobin & hematocrit values are associated with fluid volume deficit.

A pt prescribed spironolactone is demonstrating ECG changes & complaining of muscle weakness. The nurse realizes this pt is exhibiting signs of which of the following? A. hyperkalemia B. hypokalemia C. hypercalcemia D. hypocalcemia

Answer: A Rationale A: Hyperkalemia is serum potassium level greater than 5.0 mEq/L. Decreased potassium excretion is seen in potassium-sparing diuretics such as spironolactone. Common manifestations of hyperkalemia are muscle weakness & ECG changes. Rationale B: Hypokalemia is seen in non-potassium diuretics such as furosemide. Rationale C: Hypercalcemia has been associated with thiazide diuretics. Rationale D: Hypocalcemia is seen in pts who have received many units of citrated blood & is not associated with diuretic use.

A nurse is assisting a physician in an emergency surgery for a client with intestinal perforation. Which of the following descriptions is most suitable to the type of surgery performed? A. Surgery required immediately for survival B. Surgery required within one or two days C. Surgery performed at the client's request D. Surgery planned as per client's convenience

Answer: A. Surgery required immediately for survival Rationale: An emergency surgery is a surgery required immediately for survival. Elective surgery is planned at the client's convenience; whereas, an optional surgery is performed at the client's request. When urgent surgery is required, it is necessary and done within one or two days.

A surgeon phones the nursing unit and asks the nurse to send the patient to surgery and sign the informed consent. Which of the following is most appropriate? A. Review surgical complications and procedure with the patient and RN signs consent as a witness. B. Explain procedure and risks/benefits and ask the patient to sign. C. Ask the patient to sign consent if they are comfortable, the RN signs as a witness. D. Include unsigned consent in the chart and send the patient to the pre-operative induction area.

C. Ask the patient to sign consent if they are comfortable, the RN signs as a witness.

The nurse is caring for a client with heart failure who is receiving high doses of a diuretic. On assessment, the nurse notes that the client has flat neck veins, generalized muscle weakness, and diminished deep tendon reflexes. The nurse suspects hyponatremia. What additional signs would the nurse expect to note in a client with hyponatremia? A. Muscle twitches B. Decreased Urinary output C. Hyperactive bowel sounds D. Increased specific gravity of the urine

Answer: C Rationale: Hyponatremia is evidenced by a serum sodium level lower than 135 mEq/L. Hyperactive bowel sounds indicate hyponatremia. The remaining options are signs of hypernatremia. In hyponatremia, muscle weakness, increased urinary output, and decreased specific gravity of the urine would be noted.

The nurse is caring for a client with heart failure. On assessment, the nurse notes that the client is dyspneic and crackles are audible on auscultation. What additional signs would the nurse expect to note in this client if excess fluid volume is present? A. Weight Loss B. Flat neck and Hand veins C. An increase in blood pressure D. Decreased central venous pressure (CVP)

Answer: C Rationale: A fluid volume excess is also known as overhydration or fluid overload and occurs when fluid intake or fluid retention exceeds the fluid needs of the body. Assessment findings associated with fluid volume excess include cough, dyspnea, crackles, tachypnea, tachycardia, elevated blood pressure, bounding pulse, elevated CVP, weight gain, edema, neck and hand vein distention, altered level of consciousness, and decreased hematocrit. The remaining options identify signs noted in fluid volume deficit.

Which patient should NOT be prescribed alendronate (Fosamax) for osteoporosis? A. A female patient being treated for high blood pressure with an ACE inhibitor. B. A patient who is allergic to iodine/shellfish. C. A patient on a calorie-restricted diet. D. A patient on bed rest who must maintain a supine position

Answer: D Rationale: Alendronate can cause significant gastrointestinal side effects, such as esophageal irritation, so it should not be taken if a patient must stay in a supine position. A&B: ACE inhibitors are not contraindicated with alendronate and there is no iodine allergy relationship. C: The patient should not eat or drink for 30 minutes after administration and should not lie down.

The nurse recognizes the value of leg exercises in the prevention of postoperative thrombophlebitis. When should the nurse teach the correct technique for leg exercises to a client? A. When early signs of venous stasis are evident B. In postanesthetic recovery C. Upon transfer from postanesthetic care unit to the postsurgical unit D. Prior to surgery

Answer: D. Prior to surgery Rationale: Though leg exercises are begun after surgery, such preventative measures should ideally be taught to the patient during the preoperative period.

The nurse has entered the room of a client who is postoperative day one and find the client grimacing and guarding her incision. The client refuses the nurse's offer of PRN analgesia, and on discussion, states that this refusal is motivated by his fear of becoming addicted to pain medications. How should the nurse respond to the client's concerns? A. "Research has shown that there is very little risk of clients becoming addicted to painkillers after they have surgery." B. "Actually, people who are not addicted to drugs before their surgery never develop a tolerance or addiction during their recovery." C. "The hospital has excellent resources dealing with any addition that might result from the medications you take to control your pain." D. "You should remind yourself that treating your pain is important now, and that dealing with any resulting dependency can come later."

Answer: a. "Research has shown that there is very little risk of clients becoming addicted to painkillers after they have surgery." Rationale: There is little danger of addiction to pain medications used in the postoperative management of pain.

A client is undergoing surgery for an appendectomy. This would be considered what type of surgery? A. Emergency surgery B. Palliative surgery C. Diagnostic surgery D. Elective surgery

Answer: a. Emergency surgery Rationale: An appendectomy is considered emergency or urgent surgery. Elective surgery can be scheduled in advance, and delay has no ill effects. Palliative surgery is done to relieve or reduce the intensity of an illness, and diagnostic surgery is done to make or confirm a diagnosis.

A female client age 54 years has been scheduled for a bunionectomy (removal of bone tissue from the base of the great toe) which will be conducted on an ambulatory basis. Which of the following characteristics applies to this type of surgery? A. The surgery is classified as urgent rather than elective. B. The client will be admitted the day of surgery and return home the same day. C. The surgery will be conducted using moderate sedation rather than general anesthesia. D. The client must be previously healthy with low surgical risks.

Answer: b. The client will be admitted the day of surgery and return home the same day. Rationale: Outpatient surgeries, also known as ambulatory surgeries, are conducted with admission and discharge on the same day. Such surgeries have become increasingly common in recent years, and some surgeries of increasing complexity and risk are conducted on an outpatient basis. General anesthesia is possible, and common. This approach is more common for elective surgeries than urgent surgeries.

A patient was admitted with nausea, vomiting, and abdominal pain. The patient is scheduled for an Endoscopic Retrograde Cholangiopancreatography (ERCP) procedure. What type of surgery would this describe? A. Explorative B. Diagnostic C. Curative. D. Palliative

B. diagnostic

A patient with comminuted fractures of the tibia and fibula is treated with open reduction and application of an external fixator. The next day, the patient complains of severe pain in the leg, which is unrelieved by ordered analgesics. The patient's toes are pink, but the patient complains of numbness and tingling. The most appropriate action by the nurse is to A. notify the patient's health care provider. B. check the patient's blood pressure. C assess the external fixator pins for redness or drainage. D elevate the extremity and apply ice over the wound site.

Correct Answer: A Rationale: The patient's clinical manifestations point to compartment syndrome and delay in diagnosis, and treatment may lead to severe functional impairment. There is no reason to suspect that patient's symptoms are caused by hypotension or hypertension or by infection at the pin sites. Elevation of or ice application to the leg will decrease arterial flow and further reduce perfusion.

A patient hospitalized with multiple fractures has a long-arm plaster cast applied for immobilization of a fractured left radius. Until the cast has completely dried, the nurse should A. keep the left arm in a dependent position. B. handle the cast with the palms of the hands. C. place gauze around the cast edge to pad any roughness. D. cover the cast with a small blanket to absorb the dampness.

Correct Answer: B Rationale: Until a plaster cast has dried, placing pressure on the cast should be avoided to prevent creating areas inside the cast that could place pressure on the arm. The left arm should be elevated to prevent swelling. The edges of the cast may be petaled once the cast is dry, but padding the edges before that may cause the cast to be misshapen. The cast should not be covered until it is dry because heat builds up during drying.

The nurse observes a patient doing all these activities after having a hip-replacement surgery. Which patient action requires that the nurse intervene immediately? A.The patient sits straight up on the edge of the bed. B.The patient leans over to pull shoes and socks on. C.The patient bends over the sink while brushing the teeth. D.The patient uses crutches with a swing-to gait.

Correct Answer: B Rationale: Leaning over would flex the hip at greater than 90 degrees and predispose the patient to hip dislocation. The other patient actions are appropriate and do not require any immediate action by the nurse to protect the patient.

A patient is to be discharged from the hospital 4 days after undergoing a total hip arthroplasty. A statement by the patient that indicates a need for additional discharge instructions is A."I should not cross my legs while sitting." B."I can sleep in any position that is comfortable for me." C."I will use a toilet elevator on the toilet seat." D."I will have someone else put on my shoes and socks."

Correct Answer: B Rationale: The patient needs to sleep in a position that allows excessive internal rotation or flexion of the hip. The other patient statements indicate that the patient has understood the teaching.

A patient has a short-arm plaster cast applied at the outpatient center for a wrist fracture. An understanding of discharge teaching is apparent when the patient says, A."I can get the cast wet as long as I dry it right away with a hair dryer." B."I should avoid moving my fingers and elbow until the cast is removed." C."I will apply an ice pack to the cast over the fracture site for the next 24 hours." D."I can rub lotion on any itching areas under the cast with a cotton-tipped applicator."

Correct Answer: C Rationale: Ice application for the first 24 hours after a fracture will help to reduce swelling and can be placed over the cast. Plaster casts should not get wet. The patient should be encouraged to move the joints above and below the cast. Patients should not insert objects inside the cast.

The nurse provides discharge instructions to a patient with an above-the-knee amputation who will be fitted with a prosthesis when healing is complete and the residual limb is well molded. The nurse determines that teaching has been effective when the patient says, A."I should change the limb sock when it becomes soiled or stretched out." B."I should use lotion on the stump to prevent drying and cracking of the skin." D."I should elevate my residual limb on a pillow 2 or 3 times a day." E."I should lay on my abdomen for 30 minutes 3 or 4 times a day."

Correct Answer: E Rationale: The patient lies in the prone position several times daily to prevent flexion contractures of the hip. The limp sock should be changed daily. Lotion should not be used on the stump. The residual limb should not be elevated because this would encourage flexion contracture.

Ten hours after surgery, a postoperative client reports that the antiembolism stockings and sequential compression devices itch and are too hot. The client asks the nurse to remove them. What response by the nurse is best? A. "Let me call the surgeon to see if you really need them." B. "No, you have to use those for 24 hours after surgery." C. "OK, we can remove them since you are stable now." D. "To prevent blood clots you need them a few more hours."

D. "To prevent blood clots you need them a few more hours." According to the Surgical Care Improvement Project (SCIP), any prophylactic measures to prevent thromboembolic events during surgery are continued for 24 hours afterward. The nurse should explain this to the client. Calling the surgeon is not warranted. Simply telling the client he or she has to wear the hose and compression devices does not educate the client. The nurse should not remove the devices.

A post-operative shoulder repair patient (post-op day 3) reports left calf pain. The nurse finds redness and swelling on assessment. What complication best explains these findings? A. Positioning during surgery B. Wound infection C. Atelectasis D. Deep vein thrombosis

D. DVT

The nurse receives the client in the postanesthesia care unit (PACU) following a procedure requiring general anesthesia. The most important assessment made by the nurse relates to the client's: A. Level of consciousness. B. Pain. C. Vital signs. D. Respiratory status.

D. Respiratory status. Explanation: General anesthesia causes relaxation of all muscles, including respiratory muscles, requiring mechanical ventilation. The client's respiratory status must be monitored closely following general anesthesia.

The nurse interviews a patient scheduled to undergo general anesthesia for a hernia repair. Which information is most important to communicate to the surgeon and anesthesiologist before surgery? A. The patient drinks 3 or 4 cups of coffee every morning before going to work. B. The patient takes a baby aspirin daily but stopped taking aspirin 10 days ago. C. The patient drank 4 ounces of apple juice 3 hours before coming to the hospital. D. The patient's father died after receiving general anesthesia for abdominal surgery.

D. The patient's father died after receiving general anesthesia for abdominal surgery. The information about the patient's father suggests that there may be a family history of malignant hyperthermia and that precautions may need to be taken to prevent this complication. Current research indicates that having clear liquids 3 hours before surgery does not increase the risk for aspiration in most patients. Patients are instructed to discontinue aspirin 1 to 2 weeks before surgery. The patient should be offered caffeinated beverages postoperatively to prevent a caffeine-withdrawal headache, but this does not have preoperative implications.

Alendronate (Fosamax) is prescribed for a patient with osteoporosis. The nurse teaches the patient that a. the drug must be taken with food to prevent GI side effects. B. bisphosphonates prevent calcium from being taken from the bones. C. lying down after taking the drug prevents light-headedness and dizziness. D. taking the drug with milk enhances the absorption of calcium from the bowel.

The answer is: b

A scrub nurse is assisting a surgeon with a kidney transplant. What are the patient responsibilities of the scrub nurse? Select all that apply. A. Maintaining sterile technique B. Draping and handling instruments and supplies C. Identifying and assessing the patient on admission D. Integrating case management E. Preparing the skin at the surgical site F. Providing exposure of the operative area

a, b. The scrub nurse is a member of the sterile team who maintains sterile technique while draping and handling instruments and supplies. Two duties of the circulating nurse are to identify and assess the patient on admission to the operating room and prepare the skin at the surgical site. The RNFA actively assists the surgeon by providing exposure of the operative area. The APRN coordinates care activities, collaborates with physicians and nurses in all phases of perioperative and postanesthesia care, and integrates case management, critical paths, and research into care of the surgical patient.

A responsibility of the nurse is the administration of preoperative medications to patients. Which statements describe the action of these medications? Select all that apply. A. Diazepam is given to alleviate anxiety. B. Ranitidine is given to facilitate patient sedation. C. Atropine is given to decrease oral secretions. D. Morphine is given to depress respiratory function. E. Cimetidine is given to prevent laryngospasm. F. Fentanyl citrate-droperidol is given to facilitate a sense of calm.

a, c, f. Sedatives, such as diazepam (Valium), midazolam (Versed), or lorazepam (Ativan) are given to alleviate anxiety and decrease recall of events related to surgery. Anticholinergics, such as atropine and glycopyrrolate (Robinul) are given to decrease pulmonary and oral secretions and to prevent laryngospasm. Neuroleptanalgesic agents, such as fentanyl citrate-droperidol (Innovar) are given to cause a general state of calm and sleepiness. Histamine-2 receptor blockers, such as cimetidine (Tagamet) and ranitidine (Zantac) are given to decrease gastric acidity and volume. Narcotic analgesics, such as morphine, are given to facilitate patient sedation and relaxation and to decrease the amount of anesthetic agent needed.

How do you position a client with left hip fracture in Buck's traction? a) head of bed raised at 45 degree angle b) left calf on pillow from knee to ankle c) position the left on affected side with pillows between legs d) position the left in the center of the bed with the leg extended

b) left calf on pillow from knee to ankle - elevate the leg with pillow to relieve pressure from the heel of the foot and to improve the effectiveness of the countertraction.

A nurse is caring for an elderly female client with osteoporosis. When teaching the client, the nurse should include information about which major complication? A. Negative calcium balance B. Dowager's hump C. Bone fractured D. Loss of estrogen

c) Bone fracture Explanation:Bone fracture is a major complication of osteoporosis; it results when the loss of calcium and phosphate increases the fragility of bones. Estrogen deficiencies result from menopause — not osteoporosis. Calcium and vitamin D supplements may be used to support normal bone metabolism, but a negative calcium balance isn't a complication of osteoporosis. Dowager's hump results from bone fractures. It develops when repeated vertebral fractures increase spinal curvature.

A client has Buck's extension traction applied to the right leg. The nurse plans which of the following interventions to prevent complications from the device?a) provide pin care once a shift b) massage the skin of the right leg with lotion every 8 hours c) inspect the skin on the right leg at least once every 8 hours d) release the weights on the right leg for range of motion exercises daily

c) inspect the skin on the right leg at least once every 8 hours Buck's extension traction is a type of skin traction. The nurse inspects the skin of the limb in traction at least once every 8 hours for irritation or inflammation. Massaging the skin with lotion is not indicated. The nurse never releases the weights of traction unless specifically ordered by the physician. There are no pins to care for with skin traction.

The nurse is conducting the preoperative assessment. The client reports having a cup of black coffee before arriving for the scheduled surgery. What should the nurse do with this information? A. Instruct the client to refrain from further intake B. Administer the preoperative medication C. Notify the surgeon D. Document the fluid intake in the medical record

c. Notify the surgeon The nurse should notify the surgeon with the information if the client has had anything to eat or drink within 8 hours prior to​ surgery, because this increases the​ client's risk of aspiration. The surgical procedure will be​ cancelled, especially if the surgery is elective. The client should not be given the preoperative medication until the surgeon in notified of the fluid intake. The nurse needs to do more than document the information in the medical record. The client should have been instructed to refrain from food or fluids for 8 hours before the surgery prior to arriving to the hospital for the procedure.