Nursing.com Test 4 Questions

You are the preoperative nurse and you are getting your client ready for their procedure and realize the client does not understand that they are receiving local anesthesia when they say which of the following? "You will talk to me during the procedure, right?" "I am so happy I will be asleep during this procedure" "Will the surgeon talk to me during the procedure?" "I'm glad I won't feel anything"

"I am so happy I will be asleep during this procedure" The client will not be "asleep" during the procedure.

The client who is about to have surgery is complaining to the nurse that the hospital is "starving me to death". Which of the following is the nurse's best response to the client? "I am so sorry you feel this way, would you like to speak with the Director of Surgery?" "I am so sorry you feel hungry. We ask clients not to eat or drink before surgery for safety" "I am so sorry you are so hungry, can I at least get you some crackers to hold you over?" "I am sorry that you feel this way, you'll be able to eat soon"

"I am so sorry you feel hungry. We ask clients not to eat or drink before surgery for safety" Being NPO before surgery is important to prevent aspiration.

A nurse is teaching a client with newly diagnosed diverticulitis about dietary changes. Which statement by the client indicates that teaching has been effective? A) "I should limit my water intake to 24 ounces per day." B) "It's ok if I have a small bowl of popcorn at night." C) "I should avoid eating raspberries for a month." D) "I can have squash or potatoes for dinner."

"I can have squash or potatoes for dinner." "I should limit my water intake to 24 ounces per day." Clients with newly diagnosed diverticulitis should consume low fiber early on then can change to high fiber foods if tolerated, low fat and plenty of fluids. "It's ok if I have a small bowl of popcorn at night." Clients with newly diagnosed diverticulitis should consume low fiber early on then change to high fiber, low fat and plenty of fluids. Popcorn should be avoided so corn kernels do not lodge in the diverticulum. "I can have squash or potatoes for dinner." Clients with newly diagnosed diverticulitis can consume squash or potatotes, which are fiber rich, if tolerated. "I should avoid eating raspberries for a month." Raspberries are a high-fiber fruit and do not have to be avoided for a month. Client can adjust foods and liquids based on symptoms.

A client asks the nurse her role as a nurse first assist. Which of the following is the best explanation of a nurse first assist? "I am the first nurse to see the client before surgery and I review their medications with them" "I make sure the client is positioned properly in surgery and that sterile technique is being used" "I have had additional training and I work closely with the surgeon in the operating room." "I take care of clients after the surgery is over to make sure their vital signs and breathing are ok"

"I have had additional training and I work closely with the surgeon in the operating room." "I take care of clients after the surgery is over to make sure their vital signs and breathing are ok" This describes the role of the PACU RN. "I am the first nurse to see the client before surgery and I review their medications with them" This describes the role of the Pre-op RN. "I have had additional training and I work closely with the surgeon in the operating room." This describes the RN First Assist. "I make sure the client is positioned properly in surgery and that sterile technique is being used" This describes roles of the Circulator RN.

A recovery room nurse is educating a new nurse about continuous bladder irrigation. Which of the following statements made by the new nurse indicates additional teaching is needed? "I need to check intake and output with this system." "The catheter must be drained and color noted at the frequency ordered." "The irrigation system typically produces clear, pale, yellow urine." "The bladder irrigation prevents clots from forming after surgery."

"The irrigation system typically produces clear, pale, yellow urine." Following bladder surgery there is blood present in the urine so it will appear from dark red to light pink.

A nurse is performing a continuous bladder irrigation on a client. A 650 mL bag of fluid irrigation was started at the prescribed rate of 30 mL/hour six hours ago. What is the total amount of fluid instilled for irrigation? 30 mLs 180 mLs 90 mLs 650 mLs

180

A nurse is performing continuous bladder irrigation on a client. The bag from the pharmacy contained 400 mLs of fluid. The order is for 20 mLs every hour. The nurse notes that 4 hours ago, the bag had 200 mLs in it. What is the total amount of fluid that has been irrigated? 200 mLs 280 mLs 80 mLs 120 mLs

280

When the perioperative nurse assesses the client for surgery, the BMI is assessed as low. The nurse knows that which of the following could be a concern? Select all that apply. A) Delayed wound healing B) Issues with intubation C) Issues with body temperature regulation D) Risk of pressure ulcers E) An increase in surgical complications

A, C, D, E Issues with intubation This is not a concern of low BMI. A client that is a high BMI would be at risk to have issues with intubation.

The nurse is reviewing orders for a client with peptic ulcer disease (PUD). Which of the following would the nurse question? 500 mg calcium carbonate PO QID 20 mg famotidine PO BID 40 mg pantoprazole PO daily 325 mg aspirin PO daily

325 mg aspirin PO daily 325 mg aspirin PO daily Aspirin and NSAIDS are avoided with PUD because they exacerbate symptoms. 20 mg famotidine PO BID This is an H2 receptor blocker, which is an appropriate medication for a client with PUD. 40 mg pantoprazole PO daily This is a proton pump inhibitor appropriate for clients with PUD. 500 mg calcium carbonate PO QID This medication is appropriate to relieve symptoms of peptic ulcer disease.

Based on the nurse's understanding of local anesthesia which of the following clients would give concern for the procedure? Select all that apply. 34-year-old client with an allergy to lidocaine 88-year-old client with an allergy to bupivacaine 45-year-old client with an allergy to penicillin 76-year-old client with an allergy to cephalexin 10-year-old client with an allergy to amoxicillin

34-year-old client with an allergy to lidocaine A common local medication is lidocaine and this is the same drug class. 88-year-old client with an allergy to bupivacaine A common local medication is lidocaine and this is the same drug class.

The nurse is working with a client with acute pyelonephritis. Which of the following is a complication of this condition? Septic shock Dysuria Acute cystitis Renal stones

Septic shock Acute pyelonephritis can be a serious infection of the kidney, with a high incidence of sepsis and septic shock if not treated properly.

A client has been diagnosed with stress incontinence and has frequent episodes of leaking urine. Which of the following nursing interventions are most appropriate in this situation? Select all that apply. A) Collect a urine sample to test for infection B) Teach the client how to perform intermittent catheterization C) Help the client to use an anti-incontinence device D) Examine the client for signs of pelvic muscle weakness E) Teach the client to perform Kegel exercises

A, C, D, E

The nurse received report on 4 clients and has decided that the client who needs methotrexate should be seen first. Which of the following clients needs methotrexate? A client with rheumatoid arthritis A client with a bowel obstruction A client with seizures A client with asthma

A client with rheumatoid arthritis Methotrexate is an anti-rheumatic used to treat psoriasis or rheumatoid arthritis.

Which of the following is a sign of an open skull fracture? Unconsciousness A laceration over the site of the fracture Battle's sign A depression at the site of the fracture

A laceration over the site of the fracture A sign of an open skull fracture is a laceration over the site of the fracture. Also known as a compound skull fracture, an open skull fracture includes a break in the skin and splintering of the bone.

A nurse is caring for a client who is being treated for acute pyelonephritis. The nurse explains to the client that the risk factors for acute pyelonephritis include which of the following? Select all that apply. A) Urinary stones B) Suppressed immunity C) Catheter use D) Increased fluid intake E) Septic shock

A, B, C

A client with peptic ulcer disease is being assessed for an upper GI bleed. Which signs would the nurse expect to see with this diagnosis? Select all that apply. A) Hematochezia B) Epigastric pain C) Melena D) Lower leg edema E) Abdominal bloating

A, B, C Hematochezia is the presence of visible or clinically detectable blood in feces. It may be produced by anorectal disorders, such as hemorrhoids or by bleeding from diverticuli, cancers, some forms of dysentery, or angiodysplasia of the bowel (among other causes). It sometimes results from massive bleeding from the upper gastrointestinal tract. Abdominal bloating is not a sign of an upper GI bleed. An upper GI bleed occurs in the upper portion of the gastrointestinal tract, including the area within the esophagus. Signs or symptoms associated with bleeding from this area include dark blood in the stool, also called melena.

The nurse is caring for a client scheduled for plasmapheresis. Which of the following information is true regarding this procedure? Select all that apply. A) Plasmapheresis is also called therapeutic plasma exchange (TPE). B) Plasmapheresis removes plasma from the cellular component of blood. C) During plasmapheresis, anticoagulants help prevent blood from clotting. D) Plasmapheresis is used for autoimmune diseases to remove certain antibodies. E) Plasmapheresis uses an arteriovenous (AV) fistula access.

A, B, C, D Plasmapheresis removes plasma from the cellular component of blood. This is correct. Plasmapheresis describes a process that involves separating plasma from blood cells. The process is somewhat similar to hemodialysis and may be used to remove such elements as toxins, clotting factors, or triglycerides from a patient's circulation. It is also known as therapeutic plasma exchange (TPE). Plasmapheresis uses an arteriovenous (AV) fistula access. This is incorrect. Plasmapheresis uses standard intravenous catheter access. An AV fistula is for hemodialysis During plasmapheresis, anticoagulants help prevent blood from clotting. This is correct. Plasmapheresis describes a process that involves separating plasma from blood cells. The process is somewhat similar to hemodialysis and may be used to remove such elements as toxins, clotting factors, or triglycerides from a patient's circulation. It is also known as therapeutic plasma exchange (TPE). Plasmapheresis is also called therapeutic plasma exchange (TPE). This is correct. Plasmapheresis describes a process that involves separating plasma from blood cells. The process is somewhat similar to hemodialysis and may be used to remove such elements as toxins, clotting factors, or triglycerides from a patient's circulation. It is also known as therapeutic plasma exchange (TPE). Plasmapheresis is used for autoimmune diseases to remove certain antibodies. This is correct. Plasmapheresis describes a process that involves separating plasma from blood cells. The process is somewhat similar to hemodialysis and may be used to remove such elements as toxins, clotting factors, or triglycerides from a patient's circulation. It is also known as therapeutic plasma exchange (TPE).

The perioperative nurse is aware that surgical clients are at risk for complications associated with fluid volume and know the reasons why are which of the following? Select all that apply A) Preoperative NPO Status B) Blood loss C) Fluid shifts D) Preoperative antibiotics E) Stress response of surgery

A, B, C, E Preoperative NPO Status This is a reason surgical clients are at risk for fluid volume issues. They have not eaten or drank anything for several hours so they start off dehydrated. Fluid shifts This is a reason surgical clients are at risk for fluid volume issues. In surgery, the tissue is cut so fluid shifts out from the intravascular space. Stress response of surgery This is a reason surgical patients are at risk for fluid volume issues. The stress response can cause fluid to be retained which could cause complications. Blood loss This is a reason surgical patients are at risk for fluid volume issues. Clients lose blood in surgery which is part of their fluid volume.

An 88-year-old client from a local nursing home is having surgery for a bladder tumor. The nurse knows that which of the following are ways to assess the cognitive abilities of the client? Select all that apply A) Ask the client to point to where the healthcare provider be operating B) Ask the client if they can state what they are having done C) Confirm medical power of attorney paperwork is included in the client's chart D) Ask the client to state their name, birth date, procedure, and healthcare provider's name E) Confirm the client's vital signs are within normal limits

A, B, D Ask the client to point to where the healthcare provider be operating Verification of the surgical site and procedure are helpful in assessing the client's cognitive abilities. Ask the client if they can state what they are having done Verification of the surgical site and procedure are helpful in assessing the client's cognitive abilities. Confirm the client's vital signs are within normal limits Vital sign assessment is not useful in assessing the cognitive abilities of the client. Confirm medical power of attorney paperwork is included in the client's chart This is important, but the medical power of attorney does not assess the client's cognitive abilities. Ask the client to state their name, birth date, procedure, and healthcare provider's name Verification of name, birth date, procedure, and healthcare provider's name is helpful in assessing the client's cognitive abilities.

The nurse is preparing a 40-year-old client for surgery when they explain they are concerned about blood clots. Based on the nurse's knowledge of postoperative complications which of the following statements is true? Select all that apply A) Facilities should follow DVT protocols to prevent this complication B) Shortness of breath and chest can be an indication of a pulmonary embolism C) Blood clots are only a concern with a family history D) Sequential compression devices are used to prevent deep vein thrombosis E) Deep vein thrombosis is typically painless in postoperative clients

A, B, D, Sequential compression devices are used to prevent deep vein thrombosis This is a true statement regarding blood clots. The sequential compression device will help keep the blood pumping and moving. Facilities should follow DVT protocols to prevent this complication This is a true statement regarding blood clots. DVT protocols help to ensure nurses are doing best practices to prevent a DVT and proper treatment if one is suspected. Shortness of breath and chest can be an indication of a pulmonary embolism This is a true statement regarding blood clots. When a blood clot is released into circulation and gets to the lung it is known as a pulmonary embolus. This will cause shortness of breath and chest pain.

A nurse is caring for a 78-year-old client with severe, debilitating rheumatoid arthritis who lives at home with the spouse. The nurse assesses the client's level of safety in the home. Which aspects should be included as part of this home safety assessment? Select all that apply. A) Whether there is space available for a caregiver to help with the client B) Whether there are stairs in the home C) Whether the home has ceiling fans D) Whether there are changes in floor levels E) there is sufficient lighting

A, B, D, E

Which of the following describes perioperative nursing? Select all that apply. A) Provide cultural care to the surgical client. B) Provide a head-to-assessment to ensure there is no risk for the client having surgery C) Provide at home care to clients after surgery D) Cares for a client before, during, and after surgery E) Incorporate client wishes into care as much as possible

A, B, D, E Provide a head-to-assessment to ensure there is no risk for the client having surgery As the pre-op nurse who is a peri-operative nurse will perform a thorough assessment to determine if there is an obvious risk to the client having surgery. Provide at home care to clients after surgery As this is not a true description of a peri-operative nurse. Provide cultural care to the surgical client. This is an important goal of the peri-operative nurse. Incorporate client wishes into care as much as possible As it is always important to provide client centered care. Cares for a client before, during, and after surgery This is a true description of a peri-operative nurse.

A 15-year-old client suffered a radial fracture and the provider applied a plaster cast to the arm. What information would the nurse give to this client and the family about cast care during this time? Select all that apply. A) Do not allow the cast to rest on a hard surface until it is completely dry B) Look and feel for areas where the plaster may be cutting into the skin C) Keep the newly applied cast covered for the first 24 hours D) Perform capillary refill on the distal fingertips and notify the provider if it is more than 3 seconds E) Perform isometric exercises to prevent muscle atrophy

A, B, D, E Perform capillary refill on the distal fingertips and notify the provider if it is more than 3 seconds A client with a plaster cast should learn how to assess capillary refill and know what to do if it is slow, because a slow capillary refill time means that their circulation may be compromised. Look and feel for areas where the plaster may be cutting into the skin A plaster cast may be used to stabilize a fracture while it heals. This cast will become extremely rigid when it dries, so the client should be taught to be aware of any areas of pain or discomfort. If pain or discomfort occurs, the client will need to return to the clinic to have it adjusted or replaced. Perform isometric exercises to prevent muscle atrophy The nurse should educate the client on some exercises to help reduce muscle atrophy. Some atrophy will occur, but by performing certain, limited exercises, the atrophy can be minimized. Do not allow the cast to rest on a hard surface until it is completely dry The client should also be taught how to protect the cast while it dries. It will dry to whatever shape it is, so it should remain intact to avoid becoming misshapen.

A client has a femur fracture. The nurse is concerned about a fat embolism and knows to monitor for which of the following signs and symptoms of fat embolism? Select all that apply. A) Tachycardia B) Hypotension C) Jaundice D) Tachypnea E) Fever

A, B, D, E Tachypnea A fat embolism can occur with long bone fractures such as the femur, pelvis, and tibia. Fat dislodges and travels through the bloodstream, eventually causing an obstruction somewhere in the blood vessels. This causes respiratory distress, and therefore tachypnea. Respiratory complications are a major symptom in fat embolism Tachycardia Tachycardia occurs with a fat embolism due to the increased work of breathing related to the fat embolism Hypotension Hypotension is not seen in the client with a fat embolism. (with the increased work of breathing, we would expect hypertension with fat embolism. Fever Fever is commonly seen when a fat embolism is present.

A nurse is caring for a client with Zollinger-Ellison syndrome. Which interventions should be included in the plan of care? Select all that apply. A) Assess for melena B) Pantoprazole daily C) High fat diet D) Vitamin D supplements E) Genetic counseling

A, B, E

The nurse is educating a client on managing gout. Which of the following statements by the client indicates more education is necessary? Select all that apply. A) "I try to limit my intake of water. I feel like that helps my symptoms" B) "I can't wait to get home. My wife and I have our weekly wine and cheese night with friends" C) "Man, these tophi are incredibly painful" D) I need to make sure I get a refill of my allopurinol for my gout" E) "When I have a flare-up, I try to increase my activity to get the blood flowing better and hopefully have it resolve faster"

A, B, E "I can't wait to get home. My wife and I have our weekly wine and cheese night with friends" This statement indicates that more education is necessary. Wine and cheese are high in purines, which worsen symptoms of gout. Foods high in purines should be avoided. "When I have a flare-up, I try to increase my activity to get the blood flowing better and hopefully have it resolve faster" This statement indicates that more education is necessary. While activity and blood flow can help decrease pain and prevent flare ups, rest is always recommended during an actual flare up. "I try to limit my intake of water. I feel like that helps my symptoms" This statement indicates that more education is necessary. Adequate hydration is necessary to help flush the excess crystals in the system. Limiting water intake is never recommended for a client with gout.

A nurse is caring for a client diagnosed with cystitis. What signs and symptoms are expected with this diagnosis? Select all that apply. A) Polyuria B) Flank pain C) Dysuria D) Leukocytosis E) Hyperthermia

A, C

The surgical nurse is taking care of a client who is undergoing colon resection. The perioperative team recognizes that the client has lost an excessive amount of blood during the procedure. The nurse is aware that this complication can lead to which of the following? Select all that apply A) Hypovolemia B) Impaired tissue integrity C) Electrolyte disturbances D) Perioperative hyperthermia E) Increased risk of infection

A, C Electrolyte disturbances Electrolyte disturbances can occur from fluid balance issues during surgery. Hypovolemia Hypovolemia can occur from fluid balance issues during surgery as blood is lost. Impaired tissue integrity This can be associated with the pooling of blood around the client and not necessarily the blood loss itself. Perioperative hyperthermia Perioperative hypothermia can occur from excessive blood loss. Increased risk of infection An increased risk of infection is not associated with excessive blood loss but more so perioperative hypothermia.

Which of the following describes the role of a circulator nurse in the peri-operative setting? Select all that apply. A) Non-sterile member of the operating room team B) Cleans all of the instruments C) Verifies completion of pre-operative orders, lab work, and consent forms by pre-operative nurse D) Provides follow-up instructions to the surgical patient. E) Assists the surgeon to close the surgical site

A, C Non-sterile member of the operating room team As the circulating nurse remains non-sterile in the operating room to support the sterile team members. Verifies completion of pre-operative orders, lab work, and consent forms by pre-operative nurse As this is the role of the circulator nurse before taking the client to surgery. Provides follow-up instructions to the surgical patient. his is the role of the post anesthesia care unit nurse. Assists the surgeon to close the surgical site This is the role of the nurse first assist. Cleans all of the instruments This is not the role of a circulator. The circulator nurse verifies preoperative work has been done and assists the sterile members in the operating room.

A nurse is performing a bladder irrigation using a syringe. The client has a catheter that is draining urine. Which of the following steps is performed next? Select all that apply. A) Allow irrigation solution to empty out of the catheter into a sterile basin B) Gather sterile irrigation kit which includes sterile gloves, bulb syringe, solution container, and sterile basin. C) Instill sterile irrigation solution into the catheter and then remove the syringe and allow the solution to flow out of the catheter into the sterile basin D) Instill irrigation solution into the bladder and clamp the catheter for 30 minutes E) Push approximately 1000 mL of irrigation solution through a syringe into the catheter in the client's bladder

A, C Push approximately 1000 mL of irrigation solution through a syringe into the catheter in the client's bladder 1000 mL is a much larger amount than should be in the bladder. The nurse will instill the amount of solution as per the provider's order. (typically 15-20 ccs per irrigataiton Instill irrigation solution into the bladder and clamp the catheter for 30 minutes The solution should be instilled, then drained, but does not need to be clamped. Gather sterile irrigation kit which includes sterile gloves, bulb syringe, solution container, and sterile basin. Gather sterile irrigation kit which includes sterile gloves, bulb syringe, solution container, and sterile basin. Instill sterile irrigation solution into the catheter and then remove the syringe and allow the solution to flow out of the catheter into the sterile basin Catheter irrigation involves inserting a catheter into the client's bladder and injecting a certain amount of sterile irrigation solution into the bladder. The solution could be sterile water or saline. Allow irrigation solution to empty out of the catheter into a sterile basin After the solution has entered the bladder, the nurse then lets the solution drain out of the end of the catheter tip (the catheter is not attached to a collection bag at this time), and into a receptacle. The process of bladder irrigation removes elements that have been in the bladder that need to be removed, such as mucous or blood clots.

A client has just finished surgery and is coming to the PACU for recovery. Postoperative hypothermia is a complication of the surgical client and the nurse knows that which of the following is true regarding this complication? Select all that apply. A) Anesthesia can cause postoperative hypothermia B) Shorter surgeries increase the risk of postoperative hypothermia C) Fluid shift during surgery can cause postoperative hypothermia D) Postoperative hypothermia can prolong recovery time E) Evisceration can cause postoperative hypothermia

A, C, D, Postoperative hypothermia can prolong recovery time This is true of postoperative hypothermia. If the client is hypothermic this will prolong the recovery as the client is rewarmed. Anesthesia can cause postoperative hypothermia This is true of postoperative hypothermia. Fluid shift during surgery can cause postoperative hypothermia This is true of postoperative hypothermia. As blood is lost from surgery this causes heat loss.

The surgeon working with the nurse has asked that the client be placed in the right lateral position. The nurse knows that which of the following positioning techniques can apply to this request? Select all that apply A) Client will be right side down B) Client will be right side up C) Pillows may be placed between knees D) Client will be side lying E) Axillary roll will be used for positioning

A, C, D, E

The nurse is interviewing a client going to the operating room for a total hip replacement. During the interview, the client is unable to state their name or birthdate. The client takes medication for dementia. The nurse would expect which of the following when obtaining the informed consent? Select all that apply. A) The client and their surrogate decision-maker signed their names to the consent form B) The client signed their name to the written consent form C) The client is not considered "competent" which is necessary with informed consent D) The client's legal surrogate has signed their name to the written consent form E) The client's legal surrogate decision-maker is aware of the information related to the procedure

A, C, E The client signed their name to the written consent form The client is not competent or able to make decisions for themselves, which is a requirement with informed consent. The client and their surrogate decision-maker signed their names to the consent form The client, in this case, will not be receiving the information or signing. The client is not considered "competent" which is necessary with informed consent hey are not oriented to the situation and are unable to make decisions for themselves. The client's legal surrogate decision-maker is aware of the information related to the procedure They are the clent's legal decision maker. The client's legal surrogate has signed their name to the written consent form They will be receiving the information necessary to accept the procedure on behalf of the client.

A surgeon is telling a client about an upcoming surgical procedure so that the client can provide informed consent. Which of the following describes the concept of a reasonable client standard when signing informed consent? Select all that apply. A) The information that is needed to know to be able to make a decision and sign consent is provided B) The information is general and applies to most surgical procedures C) The data is tailored precisely to the client's needs D) The information is what a typical client would need to know to sign consent E) The data is what any provider would say when explaining the procedure

A, D The information is what a typical client would need to know to sign consent When signing consent, a reasonable client standard describes the information that a typical and reasonable client would need to know to be able to make a decision and sign consent. The data is what any provider would say when explaining the procedure The "standard" in reasonable client standard refers to the standard of a typical client. This is not the same as information that just "any" provider would give. The information is general and applies to most surgical procedures The information included must be specific to the type of surgical procedure the client is agreeing to at that time. The data is tailored precisely to the client's needs Specifically tailoring to the client's needs is too detailed to be considered 'standard'. The information that is needed to know to be able to make a decision and sign consent is provided This describes a reasonable standard for a client in order to sign consent.

A nurse is caring for a client who is suffering from a gastric ulcer. Which of the following is an appropriate nursing intervention? Select all that apply. A) Take a proton pump inhibitor B) Drink caffeinated beverages C) Drink plenty of milk D) Eat small, frequent meals E) Take a histamine blocker

A, D, E

The post-anesthesia care unit (PACU) nurse knows that which of the following can be expected to learn about the client from the peri-operative nurse during hand-off report? Select all that apply A) Location of catheters B) ASA classification of patient C) Estimated blood loss D) Medications given by surgeon during procedure E) Surgical procedure performed

A, D, E Location of catheters This is typically communicated to the PACU RN by the perioperative RN during the hand-off report. ASA classification of patient This is not typically communicated by the perioperative RN but by the PACU RN. Medications given by surgeon during procedure This is typically communicated to the PACU RN by the perioperative RN during the hand-off report. Estimated blood loss This is not typically communicated by the perioperative RN but by the PACU RN. Surgical procedure performed This is typically communicated to the PACU RN by the perioperative RN during the hand-off report.

The nurse working in the PACU knows that which of the following can be expected to learn from the anesthesia provider during the hand-off report? Select all that apply A) Fluids administered B) Location of drains C) Dressing type D) Client special requests E) ASA classification of client

A, E ASA classification of client This is information that the anesthesia provider will communicate to the PACU RN during the hand-off report. Fluids administered This is information that the anesthesia provider will communicate to the PACU RN during the hand-off report.

A client who has suffered from severe rheumatoid arthritis for 10 years has decided not to have surgery after injuring a leg in a fall. Which of the following describes how the nurse would advocate for this client in this case? Select all that apply. A) Develop an alliance between the client and the provider B) Discuss the case with hospital administrators who can convince the client to change her mind C) Contact the client's family to suggest talking to the client D) Notify the anesthesiologist about the client's need for pain control E) Seek to educate the client about the procedure

A, E Develop an alliance between the client and the provider A nurse must act as a client advocate, even if the nurse does not agree with all of the client's decisions. In this case, the nurse should continue to provide client care by acting as a liaison between the provider and the client. Seek to educate the client about the procedure A nurse must act as a client advocate, even if the nurse does not agree with all of the client's decisions. In this case, the nurse should continue to provide client care by continuing to educate the client about treatment options and outcomes. Notify the anesthesiologist about the client's need for pain control This action undermines the client's autonomy to make a choice, so they do not demonstrate client advocacy.

The circulating nurse plays a huge role in protecting the client through intraoperative nursing priorities. Which of the following actions by the nurse decreases the risk of injury to the client? Select all that apply A) Verifying that prepping solutions have not pooled around the client B) Perform surgical counts at the beginning of the procedure only C) Perform a surgical "time out" at the end of the procedure D) Using cold solutions to keep the client cool E) Verifying that all items used on the sterile field are sterile

A, E Verifying that prepping solutions have not pooled around the client This decreases the risk of injury to the client. This decreases the risk of skin breakdown occurring. Verifying that all items used on the sterile field are sterile This decreases the risk of injury to the client. Sterile equipment decreases the risk of infection. Using cold solutions to keep the client cool Warm solutions should be used to decrease injury. Cold solutions can cause hypothermia. Perform surgical counts at the beginning of the procedure only Surgical counts are also performed during the procedure and before closure. Perform a surgical "time out" at the end of the procedure The "time out" should be performed before incision.

A client with chronic pain due to arthritis is diagnosed with a stomach ulcer. Which of the following medications is appropriate for the nurse to give the client for arthritis pain relief? Aspirin Ibuprofen Naprosyn Acetaminophen

Acetaminophen Acetaminophen is not an NSAID, and is safe to take long-term for relief of chronic pain. The other medications are NSAIDS and affect gut mucosa to worsen stomach ulcers if taken chronically.

As part of preparing a 10-year-old client for surgery, the nurse needs to insert an indwelling urinary catheter. Which best describes the point at which the nurse should insert the catheter? After the surgery has started After the child is in the OR and has been sedated As part of vital signs just before surgery Just after admission to the unit when changing into a gown

After the child is in the OR and has been sedated Surgery can be scary for a child, even if the healthcare staff takes the time to explain what will happen and fully prepares the child. The nurse should minimize the frightening aspects of surgery for a child by waiting to put in an indwelling catheter until the child has been sedated. By waiting until the child has been sedated, the nurse eliminates the trauma of inserting the catheter when the child is alert and aware of what is happening.

he post-anesthesia care unit (PACU) nurse caring for a client who just underwent a carpal tunnel procedure. The nurse completed the immediate admission assessment, initial assessment, implementation of interventions, and evaluation. The nurse knows that which of the following is one tool to evaluate the client's readiness for discharge? Glasgow coma score Aldrete score ASA classification system ACE score

Aldrete score This is a scoring system used to determine if a client can be discharged from the PACU safely.

The perioperative nurse who is monitoring the client during the procedure has a good understanding of signs and symptoms associated with local anesthesia including local anesthesia systemic toxicity. The nurse knows that which of the following are signs of this issue? Select all that apply. A) Numbness of lips B) Shivering C) Tachycardia D) Bradycardia E) Metallic taste

All of the options

An 89-year old client has been diagnosed with a urinary tract infection. Which of the following is the first sign of a urinary tract infection in the older adult? Paranoid state Easily Agitated Mild depression Altered mental status

Altered mental status A urinary tract infection can cause symptoms of urinary frequency and pelvic pain for many clients. In many older adults, altered mental status and lethargy are the only symptoms of a urinary tract infection. The nurse should look for signs of cognitive changes in older adult clients and assess for possible infection when they occur.

The nurse is caring for a client with peptic ulcer disease due to H. pylori. Which drug combinations should be given along with a macrolide antibiotic? Penicillin and Axid Amoxicillin and Prilosec Tetracycline and sodium bicarbonate Flagyl and Amphogel

Amoxicillin and Prilosec Amoxicillin and Prilosec H. pylori can be complicated to treat, because the bacteria quickly becomes resistant to antibiotics. Therefore, "triple therapy" is used. (When triple therapy fails, "quadruple therapy" is recommended.) Triple therapy consists of a macrolide antibiotic, a proton pump inhibitor, and a penicillin-related antibiotic. Tetracycline and sodium bicarbonate While tetracycline is one of the drugs utilized with quadruple therapy, sodium bicarbonate is an antacid that is not used to treat H. pylori. Flagyl and Amphogel Flagyl is not used for H. pylori, and amphogel is an antacid which is also not utilized in the treatment for H. pylori. Penicillin and Axid Penicillin is part of the triple therapy. Nizatidine is a histamine 2 blocker which reduces acid but is not included in the triple therapy.

The client has a chronic peptic ulcer and wants to know the difference between an acute and chronic peptic ulcer. How does the nurse educate the client? An acute ulcer is treated with H2 blockers while a chronic ulcer is treated with proton pump inhibitors An acute ulcer is a superficial erosion, while a chronic ulcer extends through the muscular wall of the stomach H. pylori is present with a chronic ulcer but not with an acute ulcer An acute ulcer lasts only a month and a chronic ulcer lasts greater than one month

An acute ulcer is a superficial erosion, while a chronic ulcer extends through the muscular wall of the stomach When the erosion in the lining of the GI tract extends through the mucosal wall and muscle in a portion of the GI tract accessible to gastric secretions, it is called a chronic ulcer. Locations include the stomach, pylorus, duodenum and esophagus. An acute ulcer is in the same locations, but is a superficial erosion through the mucosal wall only. An acute ulcer can take up to three months to heal, but if the ulceration extends through the mucosal wall and the muscle, it can take much longer to heal. Both types of medication may be prescribed for any ulcer. H. pylori is a predisposing factor for either type of ulcer.

What information should the nurse include when teaching a client about the prostate specific antigen (PSA) test? An elevated PSA may indicate inflammation. The patient must urinate in a sterile cup. This is a physical exam of the rectum. It is important to fast before this test.

An elevated PSA may indicate inflammation. Prostate specific antigen (PSA) is a protein produced by the prostate. Elevations in this blood test may indicate enlargement or inflammation of the prostate

A 10-year-old child is going to be sent home from the hospital with an indwelling urinary catheter. Which of the following information should the nurse give to the parents about caring for the catheter and the tubing? Empty the drainage bag when it is three-quarters full The child can continue with normal daily activities, including exercise and recess Anchor the tubing to the child's leg so that the catheter will not be pulled out Check the tubing at least every 24 hours to ensure that the catheter is draining correctly

Anchor the tubing to the child's leg so that the catheter will not be pulled out An indwelling urinary catheter requires care and maintenance to prevent infection and to avoid the catheter being pulled out. When a child must have an indwelling catheter, the parents should be taught about the special precautions needed for catheter care. The child may have to limit activities, such as recess games and bike riding while the catheter is in place. The tubing should be checked for adequate drainage at least every 4 hours. The tubing should be anchored to the child's leg so that there is less risk of the catheter accidentally being pulled out. The catheter should be checked every four hours to ensure it is draining correctly. The drainage bag should be emptied when it becomes half full. The child should not engage in strenuous activity while the catheter is in place, so as to not dislodge, kink, or cause damage to the catheter system.

A client is asking about surgical history and assessed prior to surgery. The intraoperative nurse is aware that a thorough preoperative assessment is critical in decreasing the risk of which of the following? Anesthesia reactions Retained surgical item Intraoperative infection Perioperative hypothermia

Anesthesia reactions As a thorough preoperative assessment can decrease this risk. It is important to understand the risk of any anesthesia reaction to decrease the clients' risk during the procedure.

Postoperative nausea and vomiting (PONV) is a common complication in surgical clients and the nurse knows that all except which of the following increase the risk of PONV? Opioids Antiemetics History of PONV Anesthesia

Antiemetics Antiemetics help to prevent and treat PONV. An antiemetic is an anti-nausea medication. This will help prevent nausea and vomiting.

A client who is bedridden is complaining of joint pain. Which of the following interventions would be most helpful for providing comfort? Apply a cold pack or an ice bag to the affected joints Administer anticonvulsant medications to use as an adjuvant therapy Encourage the client to lie still and do not move the affected joints Apply a warm water bath for 15 minutes to painful joints

Apply a warm water bath for 15 minutes to painful joints An immobile client may be more likely to have joint pain from lack of movement. A non-pharmacological form of therapy is warmth from a warm water bath to the affected areas. Warm water improves circulation and can provide comfort to the site. The nurse should use a basin with warm water carefully and only for a few minutes at a time to avoid burning the client's skin. In some cases a heating pad can be substituted for the warm water.

A client who is bedridden is complaining of joint pain. Which of the following interventions would be most helpful for providing comfort? Encourage the client to lie still and do not move the affected joints Apply a warm water bath for 15 minutes to painful joints Administer anticonvulsant medications to use as an adjuvant therapy Apply a cold pack or an ice bag to the affected joints

Apply a warm water bath for 15 minutes to painful joints An immobile client may be more likely to have joint pain from lack of movement. A non-pharmacological form of therapy is warmth from a warm water bath to the affected areas. Warm water improves circulation and can provide comfort to the site. The nurse should use a basin with warm water carefully and only for a few minutes at a time to avoid burning the client's skin. In some cases a heating pad can be substituted for the warm water.

The preoperative nurse assessing a client for a mass removal of the foot is reviewing allergies and the client states they are only allergic to bananas. The nurse knows that which of the following would be the most appropriate next action? Ask if they are allergic to latex, report this finding to the anesthesiologist and the OR staff Ask the client the reaction they have from bananas and document it Ask how serious the reaction is since banana allergies are often associated with a penicillin allergy Continue with the preoperative assessment, since food allergies are not significant to the surgery

Ask if they are allergic to latex, report this finding to the anesthesiologist and the OR staff There is an association between latex and foods like bananas, kiwi, and avocados. True latex allergies can be very dangerous so anesthesia should be aware. The OR staff must also be informed so no latex is used during the surgery. here is no association between a banana allergy and penicillin allergy.

A nurse is working with a client who has been wearing a fiberglass cast for an arm fracture for the past six weeks. Which intervention should the nurse perform after the cast has been removed? Ask the client to push against a solid object Perform the Weber-Rinne test with a tuning fork on the wrist Assess capillary refill and skin color in the distal extremity Obtain an x-ray of the arm

Assess capillary refill and skin color in the distal extremity When preparing to remove a client's cast, the provider may first order an x-ray to assess the fracture site. After the cast has been removed, the nurse should assess capillary refill in the area distal to the cast site and check the client's skin color to assess for good circulation. The newly exposed skin may itch, and the client should be instructed not to scratch it because this can cause damage to the skin. This would have been done prior to cast removal to ensure the bone was healed enough to remove the cast.

The PACU nurse is waiting for the client to arrive to the recovery unit from surgery. Based on nursing knowledge of postoperative clients, which of the following is the most important nursing action to perform first? Assess the client's surgical site Assess the client's respirations and pulse oximetry Call the client's family member Provide discharge education

Assess the client's respirations and pulse oximetry This is correct. This would be the most important initial nursing action when the client is first entering the post-anesthesia recovery unit. We must assess that the airway is patent, remember ABCs.

A nurse is caring for a client with joint stiffness and limited range of motion. Which of the following nursing intervention would be most appropriate when caring for this client? Assess the client's relationship with the spouse Assist with range-of-motion exercises, as tolerated Monitor for changes in the client's affect that indicate anxiety or panic Ensure that the client receives enough food and fluids

Assist with range-of-motion exercises, as tolerated A client with limited mobility requires help and assistance with movement and with increasing the ability to perform daily functions, as appropriate. Assisting the client with ROM exercises - either passive or active - will help the client to experience increased mobility. Pre-medicating the client for this nursing intervention will help increase comfort during the exercise.

he staff in the emergency room provide care and treatment for an unconscious client who was brought in by ambulance with no family present. In this emergency situation, the law allows for implied consent, which means which of the following? The client is a minor and has a legal guardian Assume the client would consent under normal circumstances The client does not have the cognitive capacity to make the decision The client would need surgery

Assume the client would consent under normal circumstances Implied consent refers to a situation in which a client is unable to give consent because he or she is unconscious or is otherwise unable to verbalize the choice. Implied consent means that if a client's condition is life-threatening, providers will intervene under the assumption that he or she would normally provide consent. Caregivers are allowed to provide care for life-threatening injuries for clients through implied consent when they cannot say so. Incapacity does not fall under implied consent as it is unclear if the client would have consented for themselves. In this case, next of kin should be contacted for consent. Implied consent only applies when a client is brought in unconscious and needs treatment, and there is no one present with the legal authority to consent for the client.

The nurse is providing teaching about nutrition to a client with diverticulitis. Which of the following statements is NOT an appropriate teaching point? Consider taking a probiotic Avoid high-fiber foods Report a fever to the provider Stay adequately hydrated

Avoid high-fiber foods Avoid high-fiber foods The opposite is true. The client with diverticulitis should consume high-fiber foods in order to keep the stool moving through the GI tract. Foods high in fats and sugar and low in fiber have been known to trigger flare-ups. Stay adequately hydrated This is an appropriate teaching point. Maintaining adequate hydration helps avoid constipation, which improves intestinal motility. Consider taking a probiotic This is an appropriate teaching point. Probiotics help regulate intestinal flora, which can reduce flare-ups. Report a fever to the provider A fever and/or chills are signs of infection, and should be reported to the provider right away. Infection can progress to peritonitis if not promptly treated.

A nurse is caring for a client postoperatively that has just had abdominal surgery. The nurse knows that surgical clients are at risk for certain surgical issues like dehiscence. The nurse knows that which of the following statements are true regarding dehiscence? Select all that apply. A) The healthcare provider should be notified within 2 days of dehiscence B) Dehiscence is the separation of a surgical incision C) Infection increases the risk of wound dehiscence D) Clients with a low BMI have increased risk E) Decreases in abdominal pressure increase risk

B, C Infection increases the risk of wound dehiscence This is true regarding wound dehiscence. If there is an infection it can cause swelling and inflammation and an irritated wound site that could dehisce. Dehiscence is the separation of a surgical incision This is a true statement. Dehiscence is when a surgical wound separates and opens.

The nurse is caring for a client who is recovering from a gastric resection. The nurse provides teaching about how to prevent dumping syndrome. Which of the following statements are correct? Select all that apply. A) Eat two large meals each day B) Lie down after each meal C) Avoid consuming sugar, salt and milk D) Do not consume fluids with meals E) Increase carbohydrate intake

B, C, D Avoid consuming sugar, salt and milk One measure to prevent dumping syndrome is to avoid sugar, salt, and milk. When these elements move too quickly into the small intestine, dumping occurs. Do not consume fluids with meals Fluids cause the intestines to rapidly push food through, causing an episode of dumping. Lie down after each meal Dumping syndrome can occur after gastric resections when the contents of the stomach are rapidly moved into the small intestine. Symptoms of dumping syndrome include nausea, vomiting, cramping, sweating, and diarrhea. Measures to prevent dumping syndrome include consuming a low carb, high fat, high protein diet, avoiding fluid consumption with meals, avoiding sugar, salt and milk, and lying down after each meal. The patient may also take antispasmodic drugs to delay gastric emptying, if prescribed. Eat two large meals each day Large quantities of food will stimulate the bowel into dumping syndrome and should be avoided. Increase carbohydrate intake Small meals reduce the risk of dumping syndrome, while carbohydrate intake increases the risk.

The nurse is caring for a client who is signing informed consent for a procedure. The nurse knows that the client needs to understand which of the following relating to informed consent? Select all that apply. A) Privacy rights according to HIPAA B) The potential consequences if the client does not get the procedure C) Alternative treatment options D) The benefits of the procedure E) Why the procedure is being performed

B, C, D, E

The pre-operative nurse is preparing a client for surgery. Which of the following actions should the nurse perform to ensure client readiness? Select all that apply. A) Provide discharge teaching B) Assess lab values C) Identify drug allergies D) Obtain vital signs E) Review past medical history

B, C, D, E

A post anesthesia care unit (PACU) nurse knows that confusion and agitation can be common after anesthesia postoperatively. The nurse know that which of the following can contribute to these issues? Select all that apply. A) Hypertension B) Hypoxemia C) Anesthesia D) Pain E) Anxiety

B, C, D, E Pain This can cause confusion and agitation after surgery. The client might not be fully awake and feeling pain can cause the client to be confused as to where this is coming from and unsure what is happening. Hypoxemia This can cause confusion and agitation after surgery. If a client's oxygen level is low then they are not going to be thinking correctly. Anxiety This can cause confusion and agitation after surgery. Anxiety can lead to poor concentration and cause frustration. Anesthesia This can cause confusion and agitation after surgery. Anesthesia is still in the system so this would make the client not be fully "awake".

The nurse witnessed a non-English-speaking client sign informed consent utilizing the interpreter phone. Which of the following actions are appropriate for the nurse to take? Select all that apply. A) Make sure the document was signed with a ball point pen B) Make sure that the informed consent is on the paper chart C) Touch base with the client to ensure understanding of the procedure and informed consent D) Document the use of an interpreter E) Document that the client was fully informed before the document was signed

B, C, D, E Document the use of an interpreter The nurse is responsible for reinforcing teaching of the information that the provider gives the client, as well as documenting that the consent was signed by the client and that the client had all the information needed to sign the consent. If an interpreter was used, the nurse should document this as well. All documentation should be placed on the clients chart. Touch base with the client to ensure understanding of the procedure and informed consent This is an appropriate nursing action. Document that the client was fully informed before the document was signed This is an appropriate nursing action. Make sure the document was signed with a ball point pen Signing the document does not require a specific pen. Make sure that the informed consent is on the paper chart This is an appropriate nursing action.

A client was in a motor vehicle accident in which he suffered a traumatic fracture in his lower leg. The nurse knows that the client is at risk for a fat embolism. What are signs and symptoms for the nurse to look for that indicate fat embolism syndrome (FES)? Select all that apply. A) Low body temperature B) Renal dysfunction C) Respiratory distress D) Tachycardia E) Upper body petechiae

B, C, D, E Respiratory distress A fat embolism occurs when a small piece of fat enters the bloodstream and lodges into a vein, potentially obstructing blood flow. A client who has had a traumatic fracture is at high risk of FES. Signs and symptoms of FES include respiratory distress, tachycardia, petechiae on the upper body, fever, renal dysfunction, and jaundice. Nursing care for the client in FES includes IV fluid therapy, oxygen administration, DVT prophylaxis, and supportive care. Tachycardia Tachycardia is one of the signs of a fat embolism. Renal dysfunction FES can cause renal dysfunction. Low body temperature One sign of fat embolism syndrome is fever, but not a low temperature. Upper body petechiae

A client is scheduled for a procedure that requires stirrup positioning. The perioperative nurse is aware that certain complications occur. Which of the following can result from this positioning? Select all that apply A) Excessive blood loss B) Pressure injury C) Nerve injury to the extremities D) Deep vein thrombosis E) Shearing

B, C, D, E Shearing This is a complication of positioning. Shearing is caused by friction as the client slides. Nerve injury occurs because the stirrups can pinch a nerve. Nerve injury to the extremities This is a complication of positioning. Nerve injury can occur from legs s being in a still bent position that could pinch a nerve Deep vein thrombosis This is a complication of positioning. Deep vein thrombosis occurs because of the legs being in a still bent position. Pressure injury This is a complication of positioning. Pressure injuries can occur from positions being used that cause a lack of blood flow and the client is not moving to relieve that pressure.

The client has a sudden onset of decreased urine output, proteinuria, increased serum BUN, and increased creatinine. What are some potential causes? Select all that apply. A) Hypertension B) BPH C) Ureteral stone D) Nephrotoxic drugs E) Acute glomerulonephritis

B, C, D, E Ureteral stone This symptom is related to the urinary tract and kidney dysfunction. Causes include stones, acute glomerulonephritis, BPH, and nephrotoxic drugs, but other causes are cancer of the prostate or kidneys. Acute glomerulonephritis This symptom is related to the urinary tract and kidney dysfunction. Causes include stones, acute glomerulonephritis, BPH and nephrotoxic drugs, but other causes are cancer of the prostate or kidneys. BPH This symptom is related to the urinary tract and kidney dysfunction. Causes include stones, acute glomerulonephritis, BPH, and nephrotoxic drugs, but other causes are cancer of the prostate or kidneys. Nephrotoxic drugs This symptom is related to the urinary tract and kidney dysfunction. Causes include stones, acute glomerulonephritis, BPH and nephrotoxic drugs, but other causes are cancer of the prostate or kidneys.

Which of the following changes in elimination would most likely occur in a client who is unable to get out of bed and is immobile? Select all that apply. A) Diarrhea B) Urinary stasis C) Urinary tract infections D) Positive nitrogen balance E) Increased risk of kidney stones

B, C, E

The nurse receives report on a client who will be coming to the floor following a TURP (transurethral resection of the prostate). The nurse prepares for the client's arrival by gathering which of the following supplies for continuous bladder irrigation? Select all that apply. A) 3-way blood tubing B) Infusion pump C) 3,000 mL bags of 0.9% saline D) A urinal E) IV pole

B, C, E 3,000 mL bags of 0.9% saline This is the most common size and solution of bladder irrigant. IV pole The client will have continuous bladder irrigation, and will need an IV pole for hanging the bags of normal saline irrigant. 3-way blood tubing It is not expected that the post-operative TURP client will receive a blood transfusion. The catheter and tubing will be 3-way urinary catheter tubing. Infusion pump An infusion pump is not used for CBI. The irrigation bags hang to gravity and the rate is controlled with a roller clamp rather than an infusion pump. A urinal Since the client will have a catheter in place, there is no need for a urinal. However, a graduated container should be obtained to empty the foley bag.

A nurse is preparing to apply sequential compression devices to her client who has just returned from surgery. The nurse performs an assessment prior to applying the devices. Which of the following is a component of using sequential compression devices (SCDs)? Select all that apply. A) SCDs are one size fits all B) The nurse should periodically assess the client's circulation, pain, and edema when SCDs are in place C) SCDs should not be used in clients who have deep vein thromboses D) The nurse can initiate the order for SCDs E) Most SCDs are knee length unless thigh-length devices are ordered

B, C, E The nurse can initiate the order for SCDs The order for SCDs is made by the advanced provider, and there are some medical conditions in which SCDs are contraindicated. Most SCDs are knee length unless thigh-length devices are ordered The most common SCDs ordered by a provider are knee-length, but they may extend up to the thighs. SCDs should not be used in clients who have deep vein thromboses A DVT is a contraindication for using SCDs. The nurse should periodically assess the client's circulation, pain, and edema when SCDs are in place Sequential compression devices are placed on clients to promote circulation and are commonly used after surgery. The nurse should periodically assess the client for pain, pallor, pulses, and edema while the client is wearing SCDs. SCDs are one size fits all SCDs come in several different sizes from medium to XXL, based on the circumference of the calf.

A 57-year-old client with peptic ulcer disease is being seen for abdominal pain. Which of the following are assessments for hemorrhage in this client? Select all that apply. A) Recording hourly urinary output B) Monitoring the client's hemoglobin and hematocrit levels C) Speaking calmly to the client to reduce anxiety D) Assessing for symptoms of dizziness or nausea E) Administering stool softeners

B, D Speaking calmly to the client to reduce anxiety As a nurse, speaking calmly is therapeutic in most situations, but it is not a way to gain information about whether the client is hemorrhaging or not. Assessing for symptoms of dizziness or nausea A client with peptic ulcer disease is at higher risk of bleeding because of the disease process. The nurse can assess for bleeding by monitoring hemoglobin and hematocrit levels and assessing for signs of low blood pressure such as dizziness or nausea. Monitoring the client's hemoglobin and hematocrit levels A client with peptic ulcer disease is at higher risk of bleeding because of the disease process. The nurse can assess for bleeding by monitoring hemoglobin and hematocrit levels and assessing for signs of low blood pressure such as dizziness or nausea. Recording hourly urinary output This is not used as an indication of hemorrhage in peptic ulcer disease. While urinary output drops in situations where the cardiac output is decreased from hemorrhagic shock, this is not a good indication of bleeding in a case of peptic ulcer disease, because the bleeding does not usually result in shock. Therefore, the reduction in urine may be nominal. Administering stool softeners This intervention is unrelated to assessing for hemorrhage

A 34-year-old client has suffered a femur fracture and is using skeletal traction while in bed. Which nursing diagnoses would be most applicable in this situation? Select all that apply. A) Risk for Bowel Incontinence B) Acute Pain C) Fluid Volume Excess D) Risk for Peripheral Vascular Dysfunction E) Risk for Impaired Gas Exchange

B, D, E Acute Pain The femur is such a large bone that a femur fracture has the potential to cause several complications for the affected client. The client may have activity intolerance and the nurse will need to be vigilant with pain control for this client as well. Risk for Peripheral Vascular Dysfunction The client may have activity intolerance and would be at risk of poor tissue perfusion due to potential swelling and circulatory compromise in the affected leg. Risk for Impaired Gas Exchange The client may have activity intolerance and would be at risk of impaired gas exchange due to immobility.

A nurse is caring for a client in the recovery room who has developed post-operative nausea and vomiting as a result of anesthesia. Which of the following is a complication of post-operative nausea and vomiting? Select all that apply. A) Blood clots B) Pulmonary aspiration C) Increased intracranial pressure D) Cardiac arrhythmias E) Dehydration

B, D, E Dehydration Some clients who undergo anesthesia develop nausea and vomiting after the procedure. The condition can lead to dehydration, cardiac arrhythmias, and the potential for pulmonary aspiration. These risks are lessened with proper nursing care. If a client is vomiting postoperatively, the nurse should reposition the client in a side-lying position to prevent aspiration. The client may also be connected to IV fluids and/or telemetry to monitor cardiac status, as ordered. Cardiac arrhythmias can develop when the client's electrolyte balance is compromised due to excessive vomiting. Pulmonary aspiration Some clients who undergo anesthesia develop nausea and vomiting after the procedure. There is potential for pulmonary aspiration. If a client is vomiting postoperatively, the nurse should reposition the client in a side-lying position to prevent aspiration. Cardiac arrhythmias Cardiac arrhythmias can develop when the client's electrolyte balance is compromised due to excessive vomiting.

A client has reported being physically abused. The patient reports head pain after repeated blows to the head. Which sign should be looked for immediately in this case? Murphy's sign Grey-Turner sign Cullen's sign Battle's sign

Battle's sign Battle sign is bruising on the mastoid process and indicates a fracture of the middle cranial fossa and potential brain damage. If this sign is present, this client will need immediate treatment.

Which of the following is a sign of a basilar skull fracture? Dysarthria Blurry vision Hemiparesis Battle's sign

Battle's sign Battle's sign, also known as mastoid ecchymosis, is bruising over the mastoid process behind the ears and is a sign of a basilar skull fracture

The circulating nurse understands the importance of intraoperative positioning and knows that which of the following is important to remember when positioning the client for surgery? Select all that apply A) The circulating nurse chooses the position B) The safety strap must be applied over the knees C) All bony areas must be padded D) The client must be protected from injury E) The operative site must be accessible

C, D, E

The client has an acute flare up of diverticulitis. Nursing interventions to prevent complications include which of the following? Select all that apply. A) Give the client an enema B) Give antispasmodics C) Provide IV fluids D) Maintain NPO status E) Give antibiotics by IV

C, D, E Give the client an enema Enemas are contraindicated in acute diverticulitis but are allowed when the client is not having an acute flare. Give antispasmodics Antispasmodics may be given if the client is not having an acute flare-up, but are contraindicated during a flare-up. Provide IV fluids IV fluids are necessary when the client is NPO to avoid dehydration. Maintain NPO status During an acute flare up of diverticulitis, the client should have IV fluids and be placed on bowel rest with IV antibiotics. Give antibiotics by IV IV antibiotics are necessary to reduce infection during a flare-up.

The nurse is caring for a client with a broken femur. The client is at higher risk for which of the following due to this specific bone fracture? Select all that apply. A) Deep vein thrombosis B) Pneumonia C) Pulmonary embolism D) Stroke E) Heart attack

C, D, E Stroke Long bone fractures such as the femur, tibia, and pelvis, put the client at risk for a fat embolism. This embolism can travel to the heart, lungs, or brain and cause obstructed blood flow to these areas. Heart attack A fat embolism is possible following a long bone fracture. If this particle of fat becomes lodged in the vessels of the heart, it can cause the client a heart attack. Pulmonary embolism The femur is a long bone. Fractures to long bones increase the risk of a fat embolism, which can travel to the lungs and cause a pulmonary embolism. Deep vein thrombosis A deep vein thrombosis occurs when a clot develops in a deep vein. A fat embolism is different, because it originates in the long bone, and travels into the pulmonary circulation. Long bone fractures do not increase the risk for a DVT more than any other fracture. Pneumonia A fat embolism does not cause pneumonia.

A nurse is caring for a client and is preparing to administer an intramuscular injection of pain medication in the deltoid. Which of the following would be a contraindication to administering medication with this route? Select all that apply. A) The client is obese. B) The dose of the drug is 1 mL. C) The client is on thrombolytic therapy. D) The client says, "I think that medicine made me really sick before." E) There is an open wound around the injection site.

C, D, E The client says, "I think that medicine made me really sick before." This is a contraindication because the nurse should investigate this statement further to see if the client is referring to a side effect or an allergy. The client is on thrombolytic therapy. If the patient has received thrombolytic therapy, an IM injection is contraindicated because of the increased bleeding potential. There is an open wound around the injection site. Other situations in which the nurse should not give an IM injection include if there is redness, inflammation, bleeding, or a birthmark over the injection site.

the nurse is assessing a client in the urgent care clinic who is complaining of burning with urination. The urinalysis shows that the client has a urinary tract infection (UTI). Which of the following medications is an appropriate medication to treat this client's UTI? Captopril Cimetidine Clopidogrel Cephalexin

Cephalexin This is an anti-infective medication used for skin infections, pneumonia, UTIs, and otitis media.

An adult client presents to the emergency department with a chief complaint of heartburn. What is the nurse's immediate priority? Start an IV Inspect the client's mouth Find out the last time the client had oral intake Call for an EKG

Call for an EKG When a client has complaints of discomfort or pain in the chest area, including heartburn, the client will need an EKG. This client will be simultaneously having vital signs taken and the EKG will be ready shortly after, but calling for the EKG can occur as soon as the healthcare team learns of the chief complaint.

Which of the following is an example of a topical agent that may be applied for arthritis relief? Zinc oxide Capsaicin Lanolin Dexpanthenol

Capsaicin Capsaicin (Salonpas Hot) is a type of compound that comes from chili peppers and is used for relief of some types of pain. This is usually applied topically, where it first stimulates pain receptors and then diminishes the intensity of pain signals in the body to provide some relief from pain.

A client is recovering from surgery for a trans-urethral resection of the prostate (TURP) and has continuous bladder irrigation in place. The nurse notes that the system has a triple-lumen catheter and knows that one of the lumens allows inflow of the irrigation solution. What best describes the purposes of the other two lumens in this situation? Catheter balloon inflation and continuous outflow Instillation of medications and urine sampling Outflow of irrigation solution and clot prevention methods Hemorrhage control solution and bladder pressure measurement

Catheter balloon inflation and continuous outflow A setup for continuous bladder irrigation typically involves a catheter with three lumens. One is for infusion of irrigation solution and one for the outflow of solution from the bladder. The third lumen is to inflate the balloon to keep the catheter in place.

A client who is recovering from surgery has developed a fever and the nurse notes that the client has significant pain and the incision site is red and warm. Which response from the nurse is most appropriate? Remove the sutures from the incision site Clean the incision site with chlorhexidine Check the client's CBC Apply gentle suction to the incision site

Check the client's CBC The client may have developed a surgical site infection (SSI) based on the symptoms demonstrated. An SSI is an infection that develops at the site within 30 days of surgery. If the client develops signs of infection, the nurse should first check a CBC to determine if white blood cells are elevated.

The nurse is caring for a client with poorly controlled GERD. The nurse is providing education regarding foods that can exacerbate the condition. Which of the following would be an appropriate food for this client to eliminate? Purine-containing foods like organ meats (liver, kidneys) Whole grain foods Chocolate Gluten-containing foods

Chocolate Chocolate contributes to GERD symptoms, because it decreases the tone of the esophageal sphincter which worsens the reflux. Other foods that have this effect include coffee, soda, tea, peppermint, and fried or fatty foods.

A client presents to the emergency department with chest pain. The EKG and troponin labs are all within normal limits. Upon reviewing the client's medication list, the nurse notes a medication for acid reflux. Which of the following medications is indicated for this condition? Cimetidine Captopril Clopidogrel Cephalexin

Cimetidine Cimetidine is an anti-ulcer H2 antagonist that treats GERD, ulcers and is used to prevent GI bleeding. When a client with chest pain has negative troponins and a normal EKG, acid reflux is sometimes found to be the cause of the chest pain.

A nurse is applying for a position as a pre-operative nurse. Which of the following tasks would be appropriate for the nurse to learn? indicate working in the preoperative area? Complete the "time-out" process and count needles and instruments Use the Aldrete score, discusses post-operative instructions and assess the client's pain Sterile field preparation and pass instruments to the surgeon Complete patient education and witness the informed consent process

Complete patient education and witness the informed consent process Use the Aldrete score, discusses post-operative instructions and assess the client's pain This describes a post anesthesia care unit (PACU) nurse. Complete the "time-out" process and count needles and instruments This describes a circulator nurse. Complete patient education and witness the informed consent process These are roles of the preoperative nurse. The client will receive education about what to expect from the surgery and caring for any incision as well as signs to report. Sterile field preparation and pass instruments to the surgeon This describes a scrub nurse.

The nurse is caring for a client who has been diagnosed with nephrotic syndrome. Which of the following assessment findings would be inconsistent with this diagnosis? Hypoalbuminemia Proteinurea Edema Hyperalbuminemia

Hyperalbuminemia This question is asking for which assessment finding is NOT expected in the client with nephrotic syndrome. The client with nephrotic syndrome will have a LACK of serum protein. This is due to excessive loss of protein through the urine due to damaged kidneys. Hyperalbuminemia is an excess of protein in the blood, which is inconsistent with nephrotic syndrome

A nurse checks the contents of a client's indwelling catheter and notes that the urine output has been 10 mL/hr for the last four hours. Which response of the nurse is most appropriate? Help the client to increase oral fluid intake Assess the specific gravity of the client's urine Remove the catheter and irrigate the bladder Contact the provider and document the information

Contact the provider and document the information Most clients should have an hourly urine output of at least 30 mL per hour. Following surgery or when a client has an indwelling catheter, the nurse should regularly assess urine output to ensure that the client has normal kidney function. If the urine output falls well below the normal range of 30 mL per hour, the nurse should contact the provider for further orders.

A client is brought into the hospital after suffering a mid-shaft femur fracture in a motorcycle accident. After surgery to nail the broken femur, the client is stabilized and brought to the hospital room. The client begins to complain of severe pain in the femur, and numbness and tingling in the lower extremity of the affected leg. The nurse gives pain medication but the pain continues to increase. Which of the following actions should the nurse take? Utilize non-pharmacological measures, such as ice packs and guided imagery Ask the client to contact the nurse if the pain medication does not begin to work in thirty minutes Contact the surgeon immediately and prepare the client for surgery Find out when the client last had a bowel movement, and offer a stool softener or laxative

Contact the surgeon immediately and prepare the client for surgery A femur fracture is a significant injury that often occurs as a result of severe trauma. Because of its large size, a broken femur can also lead to extensive complications, including compartment syndrome. Signs and symptoms of compartment syndrome include numbness and tingling on the affected leg, severe pain that is unrelieved by pain medication, pallor, and an inability to move the leg. If the nurse sees these signs, it is a medical emergency, and the client will need surgery as soon as possible.

The nurse is speaking with a client in the preoperative area before their scheduled cervical fusion. The client states they are planning on completing a triathlon next week. Which of the following is the best action for the nurse to take? Review the side effects, risks, alternatives, and reason for the surgery with the client Wish the client good luck on this goal for after a cervical fusion Coordinate a conversation with the client and the provider before surgery Tell the client they should postpone the surgery if they really want to do this triathlon

Coordinate a conversation with the client and the provider before surgery As the registered nurse, it is your responsibility to confirm that informed consent is given.

A client has just been admitted to the unit after a transurethral resection of the prostate (TURP) and has an order for continuous bladder irrigation (CBI). Which electrolyte imbalance should the nurse be monitoring most closely for? Hypocalcemia Hypernatremia Hyponatremia Hyperkalemia

Hyponatremia This client is at risk for TURP Syndrome. This complication occurs due to significant absorption of fluids used to irrigate the bladder. This causes significant volume overload and a resulting hyponatremia.

The nurse caring for a child with nephrotic syndrome knows that which of the following medications are considered first line therapy for this diagnosis? Diuretics Statins Corticosteroids ACE inhibitors

Corticosteroids They are the first line of therapy for managing the inflammation associated with nephrotic syndrome.

A 68-year-old client suffers from rheumatoid arthritis in the joints of her arms, legs, and hands. The doctor has prescribed oral corticosteroid treatment for the client's condition. Which information should the nurse include about how this medication works to treat arthritis? Corticosteroids prevent the body from releasing the stress hormone cortisol Corticosteroids counteract many neurotransmitters secreted by the brain Corticosteroids stimulate opioid receptors to increase pain control Corticosteroids decrease prostaglandin levels that affect inflammation

Corticosteroids decrease prostaglandin levels that affect inflammation Corticosteroids are drugs commonly prescribed for the management of inflammatory conditions such as rheumatoid arthritis. They mimic the effects of the hormone cortisol in the body and decrease in prostaglandin levels, which are responsible for inflammation. They may be taken as oral tablets, used as topical treatments, or injected for relief of arthritis symptoms.

If the client provides informed consent the nurse knows that the client can explain all of the following regarding their procedure except which of the following? Alternative procedure Risks Reason for procedure Cost

Cost This is not an element that is necessary to discuss with informed consent.

Perioperative hypothermia is a complication that all surgical clients are at risk for and the nurse is aware of the importance of decreasing these complications because all except which of the following can occur? Extended PACU stay Coagulopathy Increased risk of infection Decreased vasoconstriction

Decreased vasoconstriction Increased vasoconstriction is a risk of perioperative hypothermia, not decreased vasoconstriction. Remember in hypothermia our bodies will vasoconstrict to keep the heat in closer to the core body.

The nurse is caring for a client who is newly diagnosed with diverticulosis. The nurse explains that an important difference between diverticulosis and diverticulitis is which of the following? Diverticulosis is an advanced form of diverticulitis Diverticulitis involves pouches in the intestines, while diverticulosis does not Diverticulosis does not include infection, while diverticulitis includes infection Diverticulitis treatment includes encouraging fluids, while diverticulosis includes a fluid restriction

Diverticulosis does not include infection, while diverticulitis includes infection This is an important difference between the two conditions. Diverticulosis involves the formation of diverticula (pouches) in the intestines. This can progress to diverticulitis once fecal matter gets stuck in the diverticula, bacterial overgrowth occurs, and an inflammatory response occurs.

A nurse is caring for a client who has suffered an arm fracture and has a fiberglass cast applied. Which information should the nurse give to the client to help him reduce swelling in the extremity? Apply heat to the fingertips, such as with a heating pad Check peripheral circulation by assessing capillary refill Keep the fingers at rest to prevent increased circulation Elevate the cast and extremity

Elevate the cast and extremity The client with a cast in place may develop swelling in the affected extremity. Part of cast care is to teach the client how to prevent complications such as swelling and muscle atrophy. The nurse should encourage the client to keep the arm elevated and apply ice packs as needed. The client may check capillary refill, but this will not necessarily reduce swelling. Gentle exercise, such as range of motion activities, can also improve circulation and reduce swelling.

The nurse is reviewing a medication list for a client who reports they take a medication for gastroesophageal reflux. The client asks the nurse to confirm which medication is used for this condition. Which of the following medications is taken for reflux? Famotidine Furosemide Fentanyl Fluoxetine

Famotidine This is an anti-ulcer H2 histamine blocker, used to treat ulcers, gastroesophageal reflux (GERD), and over-production of acid in the GI system.

The nurse is caring for a client who presented to the emergency room with a broken leg after falling out of a tree. The client rates pain at a 10/10. Which of the following medications would be appropriate for this client? Hydrochlorothiazide Humalog Heparin Hydromorphone

Hydromorphone Hydromorphone is an opioid analgesic used for extreme pain in a client.

The nurse is caring for a client with glomerulonephritis. Which of the following orders would the nurse question for this client? Protein restriction Plasmapheresis Fluid resuscitation of 30 ml/kg of 0.9% normal saline Dialysis

Fluid resuscitation of 30 ml/kg of 0.9% normal saline A client with glomerulonephritis will retain fluid, so IV fluids would not be indicated.

The client is scheduled for laparoscopic surgery and the surgeon wants to place the client in reverse trendelenburg. The nurse knows that which of the following positioning devices are useful to prevent shearing in this position? Beanbag Stirrups Footboard Foot roll

Footboard This device is helpful in preventing shearing when the client is in reverse trendelenburg. Shearing is done when the client is not positioned correctly causing pulling and injury.

The nurse is caring for a client who has had an indwelling urinary catheter for 2 weeks. The nurse suspects that the client is developing a urinary tract infection. Which of the following assessment findings is inconsistent with this disease process? Malodorous urine Urinary urgency Fruity breath Confusion

Fruity breath This is NOT a finding associated with a urinary tract infection (UTI). Fruity breath is seen with hyperglycemia.

The nurse is reviewing medications ordered for a client with diverticulitis. Which of the following medications would the nurse question? Psyllium Acetaminophen Levofloxacin Furosemide

Furosemide Furosemide is a diuretic, which rids the body of fluids. A client with diverticulitis needs to be adequately hydrated in order to keep stool moving through the intestinal tract. The nurse would question this order. Psyllium This is a bulk-forming laxative, which is helpful for the client with diverticulitis to continue to move stool through the GI tract and avoid constipation. cancel Acetaminophen Acetaminophen is an appropriate medication to relieve pain associated with diverticulitis. The nurse would question an order for an NSAID such as ibuprofen or aspirin due to their associated increased risk for bleeding, but acetaminophen is appropriate. Levofloxacin This is an antibiotic that is indicated to treat infections related to diverticulitis. The nurse would not question this order.

The nurse is caring for a client who is taking esomeprazole. The nurse knows that this medication is used to treat which of the following? Gastroparesis Irritable Bowel Syndrome (IBS) Candidiasis Gastroesophageal reflux disorder (GERD)

Gastroesophageal reflux disorder (GERD) Esomeprazole (Nexium) is a proton pump inhibitor used to treat gastroesophageal reflux disorder (GERD) and heartburn.

The nurse is working with a client who has peptic ulcer disease. Which of the following labs is important to monitor with this condition? Procalcitonin Lactic acid H/H Magnesium

H/H H/H In PUD, bleeding is a concern, so monitoring the H/H will alert the clinician of developing or worsening bleeding. Procalcitonin This is not a lab value related to peptic ulcer disease. Lactic acid This is measured in clients who may be in heart failure, sepsis and shock. It's not related to peptic ulcer disease. Magnesium This level would not reveal any information about peptic ulcer disease.

The nurse working on an orthopedic floor is reviewing the four clients that were assigned and knows that the client with which of the following is the priority? Left calcaneouss green stick fracture in a walking boot Hip fracture and a hip posey in place Right ulnar fracture in a cast A total right knee replacement in TED hose

Hip fracture and a hip posey in place The hip fracture client has the most restriction of movement and needs to be checked for their personal needs such as bathroom, and also needs to be checked for positioning to prevent pressure ulcers.

Which of the following is an example of a short-acting corticosteroid used for the management of arthritis? Hydrocortisone Dexamethasone Triamcinolone Prednisone

Hydrocortisone Hydrocortisone is a short-acting, low potency corticosteroid that may be used as an oral tablet in the treatment of arthritis. Hydrocortisone can work quickly to reduce inflammation by mimicking the effects of the hormone cortisol in the body. The risk of adverse side effects increases as the potency and duration of treatment increases with corticosteroids. Therefore, the goal of steroid therapy is to maintain the lowest dosage that results in adequate symptom control and to taper off when the client's condition allows.

A nurse is educating a client about osteoarthritis and how best to manage the condition at home. Which of the following statements made by the client indicates that more teaching is necessary? I play football, but I am going to switch to walking instead I'm going to work on losing weight I can sit at my computer and perform my data entry job like I usually do I am going to quit smoking because it will help with my disease

I can sit at my computer and perform my data entry job like I usually do Osteoarthritis is a type of joint disease in which the cartilage between the bones and joints breaks down, causing pain and deformity in the affected areas. A client who has osteoarthritis can make some lifestyle changes that will improve quality of life and help to control pain and disability. The client should be taught to quit smoking if he does smoke and to limit activities that cause significant pressure or damage to the joints, such as with certain contact sports. The client should also avoid or modify activities that involve repetitive actions, like data entry, which can cause further damage from repeated stress to the joints.

Based on the nurse's knowledge of local anesthesia the nurse realizes that the type of local anesthesia is chosen by the provider with all of the following in mind except which of the following? Desired action Patient's health status Surgical site Immunization status

Immunization status The choice of local anesthesia is not based on a client's immunization status.

A nurse is caring for a client who has suffered a fracture to the humerus after falling on their outstretched arm. The ends of the bone were driven into each other during the fall. This type of fracture is best described as which of the following? Greenstick fracture Impacted fracture Comminuted fracture Oblique fracture

Impacted fracture An impacted fracture is one in which the ends of the bone in a fracture are driven into each other. This type of fracture is most likely the result of a fall, such as onto an outstretched arm. It may also occur when the bone breaks from collapse of the structure, which is known as a buckle fracture.

An unconscious client is brought in to the emergency room and needs immediate surgery for bleeding from the chest. A staff member explains that surgery cannot be done because the client cannot consent. Which of the following is the best response by the nurse? "Hopefully someone who knows this client will show up soon and the procedure can start" "Consent is never a requirement in the emergency room if the client is conscious or not" "I can provide the consent for the client as a registered nurse" "Implied consent applies to this situation"

Implied consent applies to this situation" If a client's life is depending on a procedure it is assumed that the client would consent if possible.

A perioperative nurse is aware that surgical clients are at risk for injuries related to positioning. Decreasing this risk is an intraoperative nursing priority and the nurse knows that all except which of the following can be a result of improper positioning of the client? Increased risk of infection Shearing Pressure related injuries Nerve injury

Increased risk of infection This is not a risk of improper positioning.

A client takes medication for rheumatoid arthritis. The nurse reviews the client's list of medications and knows that which of the following medications is used to treat and manage rheumatoid arthritis? Loperamide Indomethacin Isosorbide mononitrate Propanolol

Indomethacin Correct. Indomethacin, or Indocin, is an antirheumatic medication used most often for clients with rheumatoid arthritis.

The nurse is having a conversation with the client who is scheduled to start their third round of chemotherapy. The client states "I do not want to do this, my spouse is forcing me." The nurse knows that which of the following components of informed consent is being broken? Informed consent is always a family decision Informed consent must be voluntary Certain procedures like chemotherapy do not require informed consent The provider determines if the client is able to provide informed consent

Informed consent must be voluntary The decision must be voluntary and in this instance, the client is stating they are being forced.

The nurse is caring for a client with urinary retention due to an enlarged prostate. The nurse is inserting a Foley catheter, and has advanced the catheter through the urethra but meets resistance and cannot advance further. What is the next step for the nurse to take? Insert a Coude catheter Utilizing sterile scissors, cut the tip of the Foley catheter in half to enable passage past the prostate Place an external urinary drainage device instead Discuss suprapubic catheter placement with the provider

Insert a Coude catheter A Coude catheter has a slanted tip and is used for difficult catheter insertions. The construction of a Coude catheter enables it to pass by smaller openings and curve around the prostate for successful insertion. A suprapubic catheter is not indicated. Suprapubic catheters are used in situations where a regular urinary catheter cannot be inserted. A Coude catheter is attempted before a suprapubic catheter.

A nurse is caring for a client with continuous bladder irrigation in place. The nurse uses a three-way catheter for the irrigation system. Which best describes the purpose of this type of catheter? It allows the nurse to determine if the client is bleeding from the bladder neck It is divided in its uses for fluid administration and for medication administration It prevents the client from experiencing pain from the procedure It allows for irrigant to flow in and out of the bladder

It allows for irrigant to flow in and out of the bladder A continuous bladder irrigation system is used to infuse irrigant or medication into the bladder and to clear the bladder of clots, debris, and tissue following surgery. The system uses a three-way catheter: one lumen is used for inflating the balloon of the catheter to keep it in place, one is used to infuse fluid into the bladder, and one is used to drain the fluid from the bladder.

The client is scheduled for a gastric emptying study. Which of the following best describes a gastric emptying study? It involves a contrast medium taken orally to assess stomach emptying It involves drinking barium and watching the stomach empty It involves a small camera at the end of a flexible tube It is a radionuclide study that scans the stomach emptying

It is a radionuclide study that scans the stomach emptying This type of test is performed when a client experiences vomiting, abdominal pain or gastroparesis. It is a radionuclide study in which the individual consumes a liquid or solid meal that contains a radioactive isotope for visualization. The test involves timing how long the meal takes to get through the stomach. This is called a barium swallow, and is done to determine the cause of painful swallowing, unexplained weight loss, or other abnormalities in the upper GI tract.

A client delivered her third baby via cesarean section 1 day ago. The client needed an indwelling urinary catheter placed because she had an epidural for the procedure. Which nursing intervention would best prevent a catheter-associated urinary tract infection (CAUTI) in this client? Keep the drainage bag at the level of the client's hip Open the drainage system only to empty the catheter bag Apply antibiotic ointment to the catheter insertion site once per shift Keep the catheter in place only for the least amount of time necessary

Keep the catheter in place only for the least amount of time necessary A catheter-associated urinary tract infection (CAUTI) occurs when an infection develops in an indwelling catheter and is a source of significant expense and disability as a type of hospital-acquired infection. The nurse can take steps to reduce the risk of a CAUTI by using aseptic technique with the catheter, keeping the drainage bag closed and below the level of the client's bladder, and only using the catheter for the least amount of time necessary. Catheter care should be performed once per shift, which includes cleaning the tube and perineal area with chlorhexidine or warm water and soap, depending on facility policy. Antibiotic ointment is not used.

A pediatric nurse is caring for a 2-year-old child who suffered a femur fracture. The child has a cast on the leg and has been placed in Bryant's traction. Which of the following considerations must the nurse implement when working with a child who uses this traction? Provide the child with a liquid or mechanical soft diet Perform range-of-motion of the affected hip every 4 hours Maintain the buttocks at a level just above the mattress of the bed The knee must be maintained at a 90-degree angle

Maintain the buttocks at a level just above the mattress of the bed Bryant's traction is used for a fracture of the femur in some children. A child who uses Bryant's traction is typically less than 2 years old and weighs less than 30 pounds. While caring for this child, the nurse should ensure that the buttocks are at a level just above the mattress of the bed, as this form of traction pulls the legs and hips straight up off the bed.

The nurse caring for a 4-year-old with symptoms of periorbital edema, decreased urine output and excessive proteinuria, knows that these symptoms are related to which of the following diagnosis? Hemolytic uremic syndrome Seasonal allergies Nephrotic syndrome Ventricular septal defect

Nephrotic syndrome Nephrotic Syndrome is a diagnosis in which the glomerular membrane in the kidneys are damaged allowing excessive amounts of protein to be excreted in the urine. Urine output is diminished and the decrease in serum protein and serum albumin allows fluids to shift out of cells causing edema.

A client is scheduled for a gynecological procedure and will be placed in the lithotomy position. The nurse knows that which of the following concerns is specific to this type of positioning? Nerve damage to lower extremities Nerve damage to upper extremities Shearing to upper and lower extremities Pressure ulcers to lower extremities

Nerve damage to lower extremities This presents the biggest concern when the client is in lithotomy. The lithotomy position is when the client is in stirrups so this can cause nerve damage and damage to lower extremities.

The nurse identifies which of the following as a common symptom of benign prostatic hyperplasia (BPH)? Hematuria Nocturia Bacteriuria Micturition

Nocturia The enlargement of the prostate may cause difficulty urinating, having to urinate more often, especially at night, and a weak urine stream. Urinating at night is nocturia

A nurse is preparing a client for a surgical procedure. At the last minute, the nurse realizes that the client has not signed an informed consent for the procedure. Which of the following actions of the nurse is most appropriate? Contact the house supervisor to reschedule the surgery Notify the family and ask them what they would want Have the client sign the consent in arrears after the surgery Notify the provider and ask about the consent

Notify the provider and ask about the consent If a nurse notices that a client has not signed an informed consent prior to a procedure, the nurse is obligated to notify the provider before going ahead with the process. The nurse could be held legally responsible and charged with negligence or battery for failing to notify the healthcare provider if the nurse knew that the client did not sign consent.

The nurse receives a client to the unit from the post-anesthesia care unit for a craniotomy for a tumor biposy. The client was extubated approximately 45 minutes before arrival to the unit. The client has a right internal jugular central venous catheter and left radial arterial line that were placed during the case. The client's vitals are SpO2 89%, BP 95/60, HR 123, temp 97.5F oral, and RR 29. The client reports moderate chest discomfort, rating 6/10. As the nurse completes the client assessment, accessory muscle use during inspiration and expiration is noted. What is should be the nurse's first action? Discontinuation of the radial arterial line STAT CBC Notifying the provider of a possible pulmonary embolism STAT head CT without contrast

Notifying the provider of a possible pulmonary embolism This client has the classic presentation of a pulmonary embolism, including chest pain, accessory muscle use, and oxygen level <90%. The provider must be notified immediately for appropriate orders.

The nurse is discharging a client who is newly diagnosed with GERD. Which of the following medication prescriptions indicate the presence of this condition? Oxytocin Oxycodone Omeprazole Olanzapine

Omeprazole This medication is a proton pump inhibitor used to treat GERD and ulcers.

The nurse suspects that a client has a duodenal ulcer. Which of the following signs would indicate this condition? Pain 1.5-3 hours after eating, relieved by eating Hematemesis Gnawing, sharp pain 30-60 min after eating Pain immediately after eating

Pain 1.5-3 hours after eating, relieved by eating Pain 1.5-3 hours after eating, relieved by eating Pain 1.5-3 hours after eating that is relieved by eating is indicative of a duodenal ulcer. Gnawing, sharp pain 30-60 min after eating Pain 30-60 min after eating is indicative of a gastric ulcer, rather than a duodenal ulcer. Pain immediately after eating This could be due to gallstones, but is not indicative of a duodenal ulcer. Hematemesis This is indicative of a gastric ulcer, not a duodenal ulcer.

A client is being seen for treatment of gout. The client is in the acute stage of an attack of gouty arthritis. For which of the following signs or symptoms should the nurse assess? Uric acid crystals under the skin Bloody urine Pain and inflammation Kidney stones

Pain and inflammation Gout is a type of arthritis that develops when uric acid crystals accumulate and inflame the joints. Gout may be considered acute or chronic. During the acute stage of gout, the client may have severe pain and joints that are inflamed, red, and tender. If left untreated, gout can become chronic which leads to kidney stones, blood in the urine, and collections of uric acid crystals under the skin. Chronic gout causes uric acid crystals to form, but not acute gout.

Which one of the following medications treats the symptoms of a UTI but does not cure the infection? Bactrim DS Phenazopyridine Septra DS Ciprofloxacin

Phenazopyridine This is a medication that numbs the urinary tract. This relieves symptoms of a urinary tract infection but is not an antibiotic and does NOT treat the infection

The nurse caring for a 3-year-old diagnosed with nephrotic syndrome knows that which of the following is the most common complications for this diagnosis? Seizures Pneumonia Weight loss Hemorrhage

Pneumonia The increases in a fluid along with long term corticosteroid therapy increases their risk for infection. Clients with nephrotic syndrome are more likely to gain weight due to fluid retention, but appetite loss can occur with relapses so it is important to monitor for signs of malnutrition.

A client is planning to undergo surgery in the morning. The provider writes an order that says, "Prepare client for upcoming TURP." Based on this order, the nurse knows that the client will be having surgery on which of the following? Pancreas Prostate Liver Spleen

Prostate Providers frequently use abbreviations to place orders for nurses to carry out, and it is part of the nursing profession to be familiar with appropriate abbreviations for provider orders and to know which abbreviations are not approved for use. A nurse often becomes accustomed to common orders placed in the nurse's area of practice. In this situation, the abbreviation for TURP stands for trans-urethral resection of the prostate.

The nurse is teaching a client who has been diagnosed with peptic ulcer disease about what foods to eat. Which of the following is a food that the client is allowed to eat with this diagnosis? Coffee Tea Chocolate Purine containing foods

Purine containing foods Tea Clients with peptic ulcer disease (PUD) should avoid tea, coffee, chocolate, spicy foods, high-sodium foods, and cola because these cause irritation to ulcers. Coffee This is one of the foods to avoid with PUD, because it causes irritation. Chocolate Chocolate causes irritation so it must be avoided by clients with peptic ulcer disease. Purine containing foods Purines are avoided for gout, but not peptic ulcer disease.

An 80-year-old client is confused because he has developed a urinary tract infection. The client cowers and screams when the nurse enters the room. Which action of the nurse best demonstrates that she is attempting to minimize the client's fear in this situation? Help the client to verbalize that he is not afraid of the nurse Explain to the client about his condition and provide information in printed form Tell the client that everything is okay and he will be just fine Remain calm and continue to try to reorient the client

Remain calm and continue to try to reorient the client A client who is confused may be afraid of once-familiar people or the healthcare providers caring for him. In this case, the nurse probably cannot reach the client by giving him information to read that will help him with his diagnosis. Instead, the nurse should talk to the client calmly and try to reorient them if possible.

The nurse has a discharge order for your postoperative client who is verbally expressing their want to be discharged as soon as possible. The client needs to be evaluated to see if they are ready for discharge. The nurse knows that all except which of the following assessment findings would indicate it is safe for discharge the client? Exhibits adequate ventilation Understanding of nonpharmacologic interventions Understanding discharge instructions Reports pain 0 out of 10

Reports pain 0 out of 10 Most clients will have some amount of pain when they are discharged. If a client is feeling no pain post-anesthesia then they might still have anesthesia in their system and not be ready for discharge this soon. This could indicate that it is unsafe to discharge.

A client is scheduled for a thyroidectomy and the nurse knows that which of the following positions would be expected for surgical positioning? Trendelenburg Left lateral Right lateral Reverse trendelenburg

Reverse trendelenburg This position is common for head and neck surgeries to allow for better access to the surgical site.

The circulating nurse is taking a client to the operating room for a right knee replacement. The nurse is verifying everyone is ready for the procedure. Which of the following would cause a delay in surgery? Client pain rating of 7 out of 10 Right knee not marked by surgeon Client states they are anxious about the surgery Allergy to penicillin

Right knee not marked by surgeon As this is necessary and a critical assessment made by the circulating nurse to ensure client safety and prevent wrong site surgery. The site must be marked before going to surgery, this would cause a surgical delay.

A nurse is assessing a client's health history as the client prepares to undergo surgery. The nurse learns that the client takes St. John's wort. Which best describes why the client should not use this supplement before surgery? St. John's wort leads to hypovolemia and a drop in blood pressure St. John's wort causes electrolyte imbalance St. John's wort can cause excess bleeding St. John's wort may prolong the effects of anesthesia

St. John's wort may prolong the effects of anesthesia A client who takes herbal supplements may need to stop taking them a certain amount of time prior to having a surgical procedure. Some supplements can cause complications with surgery and can react negatively to the effects of anesthesia. St. John's wort has been shown to delay emergence from anesthesia and it should be stopped at least 5 days before surgery.

A nurse is caring for a client who has fallen out of a tree stand and has an obvious deformity to the right upper leg. What is the priority nursing action for this client? Stabilize the right leg Administer morphine Place the leg in traction Give the client oxygen

Stabilize the right leg The leg should be stabilized to prevent further trauma, severe pain, and fat emboli. Basic stabilization is always the first step. If the client doesn't require surgery, traction would occur after this, otherwise the client will go to surgery for fixation.

The nurse is caring for a client who has been diagnosed with a urinary tract infection. Which of the following isolation precautions should be implemented? Airborne Contact Standard Droplet

Standard A client with a UTI should be placed on standard precautions, since the question does not state the type of bacteria that is present. If the bacteria was a resistant drug organism such as methilicin-resistant staph aureus (MRSA), the client would be placed on contact precautions. Since the question does not specify the pathogen, contact precautions is incorrect.

A nurse is assessing a client with an indwelling urinary catheter for signs of a catheter-associated urinary tract infection (CAUTI). Which assessment finding would best help to identify a CAUTI? Suprapubic pressure and pain Frequent diarrhea Temperature of 99.0 F Excess urine output

Suprapubic pressure and pain A catheter-associated urinary tract infection (CAUTI) is a potential complication of indwelling catheter use that refers to a bacterial infection that would not have occurred if the catheter were not present. The nurse can assess for signs or symptoms of a CAUTI by checking the catheter site and assessing urine output. The client may complain of suprapubic tenderness or pressure, the urine may be cloudy or bloody with a strong odor, and the client may have a fever over 100.0 F. Temperature of 99.0 F

A client is admitted to the unit with glomerulonephritis. Which of the following answers is a common cause of this condition? Bacteremia Staphylococcus infection Acute cystitis Systemic lupus erythematosus

Systemic lupus erythematosus Glomerulonephritis is a term used to describe an inflammatory injury to the glomerulus. This is most commonly caused by an immunological reaction, such as from systemic lupus erythematosus or scleroderma. B-hemolytic streptococcal invasion of the skin or pharynx and history of pharyngitis or tonsillitis can also predispose a person to develop glomerulonephritis. Loss of kidney function develops as a result of this condition. Glomerulonephritis is a term used to describe an inflammatory injury to the glomerulus. A staphylococcus infection does not predispose a person to develop glomerulonephritis.

A client who had an indwelling catheter has developed a urinary tract infection that has spread to the kidneys. The nurse should include which of the following information as part of her teaching? The client will need surgery for removal of infected tissue The client should restrict fluids until the infection has cleared The client will need to confirm the diagnosis with urine testing, kidney x-ray, and a voiding cystourethrogram The client can continue to recover with antibiotics at home

The client can continue to recover with antibiotics at home An indwelling catheter places a client at a higher risk of a urinary tract infection (UTI). A kidney infection can develop if the UTI is left untreated, when the bacteria ascend from the lower urinary tract. While a kidney infection, or pyelonephritis, can be very serious and may require hospitalization if complications develop, most clients can recover at home on oral medication after a loading dose of IV antibiotics. A kidney infection is usually diagnosed with a urine culture and possible blood cultures.

A nurse is assisting a provider with obtaining informed consent about a medical procedure. Which of the following best describes the nurse's role in obtaining informed consent? The nurse only acts as a witness to the client's signature The provider fills out the consent form and the nurse asks the client if he has any questions about the procedure The nurse describes the process of the surgical procedure as well as its risks and benefits The nurse acts as a legal representative for the client to stand by if he does not understand the consent

The nurse only acts as a witness to the client's signature Informed consent means that when a client signs a consent form, he or she has been fully informed about the procedure, as well as its risks and benefits. The nurse's role in the informed consent process is to act as a witness and to ensure that the client seems to understand what the provider is saying. It is the provider's responsibility to explain the procedure and its risks to the client. **Test-taking tip: Sometimes seeing "only" as an absolute word will make you think this answer can't be right. However, in this case it is TRUE - always use your contextual knowledge as well!** The nurse does not describes the process of the surgical procedure as well as its risks and benefits This is the responsibility of the provider. The nurse does not have to fill out the form, many times the provider will complete the form before obtaining consent. It IS a responsibility of the nurse to confirm that the client understands what they are signing, but answering those questions is the responsibility of the provider. The nurse does not act as a legal representative. If the client doesn't understand, the nurse should advocate and have the provider return to answer more questions.

A client with potential rheumatoid arthritis is having laboratory testing and requires an ESR blood test. Which of the following best describes the ESR? The level of antibodies present in response to an inflammatory antigen The rate at which blood cells settle to the bottom of a tube containing blood The amount of by-product produced with muscle breakdown The presence of a gene that increases rheumatoid factor

The rate at which blood cells settle to the bottom of a tube containing blood A client with rheumatoid arthritis may have a laboratory test of an ESR (erythrocyte sedimentation rate), or 'sed rate' to determine the amount of inflammation present. Inflammation causes red blood cells to clump. When the cells clump, they become denser and sink to the bottom of the tube more quickly. The ESR is the rate at which blood cells settle to the bottom of a tube containing blood.

A nurse is caring for a client who is undergoing prostate surgery. Which best describes the elements of informed consent? Whether the client approves of staying in the hospital for the procedure Whether the client understands what the procedure involves The provider's view of whether the client should have the procedure The risks, benefits, and alternatives to having the procedure

The risks, benefits, and alternatives to having the procedure An informed consent basically describes a consent that the client signs that says the client understands and agrees to having the procedure. The term "informed" means that the client has been educated about the procedure, its risks and benefits, and choices that the client has if the client wants to seek another opinion or have a different procedure.

The circulating nurse is prepping a client's abdomen prior to an abdominal hysterectomy and notices there is a pool of betadine prep that ran under the client. Based on the nurse's knowledge of intraoperative complications which of the following might the client be at risk for? Pressure injury Shearing Tissue breakdown Fluid volume imbalance

Tissue breakdown This is a complication associated with the pooling of prep solutions around the client.

The nurse is caring for a client who is experiencing urinary retention. Which nursing intervention is appropriate to help this client to void? Perform abdominal exercises Train the bladder by setting up routine times to urinate. Be patient with the client while the client attempts to void Set a goal with the client to recognize urinary urge and delay urinating

Train the bladder by setting up routine times to urinate. This is correct. Your health care professional may suggest timed voiding—urinating at set times—to help prevent your bladder from becoming too full.

The nurse is educating the parents of a 5-year-old with nephrotic syndrome and informs them that which of the following can trigger relapse? Stress and anxiety Weight gain Viral or bacterial infections Headaches

Viral or bacterial infections A relapse of nephrotic syndrome can be caused by an infection.

A client is being taken back to the operating room when they surprisingly tell the nurse that they haven't seen their surgeon since the first office visit. The nurse knows that which of the following is a risk for the client? Anesthesia reactions Postoperative infection Wrong site surgery Retained surgical item

Wrong site surgery If the client hasn't seen the surgeon than the surgical site has not been marked and increases the risk of wrong-site surgery.

The circulating nurse is orienting a new nurse who asks what a "time-out" is. The circulating nurse explains that the "time out" is a nursing priority that decreases the risk of which of the following? Deep vein thrombosis Anesthesia reaction Perioperative hypothermia Wrong-site surgery

Wrong-site surgery The "time out" is utilized to decrease the risk of wrong-site/wrong surgery/wrong person.

The preoperative nurse is preparing the client for surgery and the client asks you what will happen during surgery with local anesthesia. Which of the following is the best response by the nurse? "You will be hooked up to monitors when you enter the operating room by the monitoring nurse. The nurse will watch your vital signs and make sure you are comfortable during the procedure" "When you enter the operating room you will be given medication to make you go to sleep. The nurse anesthetist will place a breathing tube into your trachea to make sure you are ventilated" "You will be hooked up to monitors when you enter the operating room, given sedative and pain medications while the monitor nurse makes sure you are stable" "You will be given sedative and pain medications to make sure you do not know what is going on so the surgeon can operate"

You will be hooked up to monitors when you enter the operating room by the monitoring nurse. The nurse will watch your vital signs and make sure you are comfortable during the procedure"

A client has GERD. What changes should the nurse recommend to improve symptoms? Select all that apply. a) Raise the foot of the bed 4-6 inches b) Lose weight c) Quit drinking alcohol d) Eat large meals e) Quit smoking

b, c, e The head of the bed should be raised not the foot of the bed.