PrepU unit 1

Which is a benefit of a continuous passive motion (CPM) device when applied after knee surgery?

It promotes healing by increasing circulation and movement of the knee joint. A CPM device applied after knee surgery promotes healing by increasing circulation and movement of the knee joint.

Which part of the retina is responsible for central vision?

Macula

The nurse is caring for a patient who had a total hip replacement. What lethal postoperative complication should the nurse closely monitor for?

Pulmonary embolism

The circulating nurse is unsure whether proper technique was followed when an object was placed in the sterile field during a surgical procedure. What is the best action by the nurse?

Remove the entire sterile field from use.

As a nurse working in an ambulatory surgery center, you are admitting a client who is going to have a biopsy of a skin lesion. What is an important part of the preoperative process?

Review preoperative instructions. On admission, the nurse reviews preoperative instructions, such as diet restrictions and skin preparations, to ensure the client has followed them. The preoperative nurse does not give postoperative instructions; teach dressing changes or give instructions to caregivers.

The client is undergoing a surgical procedure that is expected to last several hours. Which nursing diagnosis is most related to the duration of the procedure?

Risk for perioperative positioning injury related to positioning in the OR

A nurse who is part of the surgical team is involved in setting up the sterile tables. The nurse is functioning in which role?

Scrub role

When the patient tells the nurse that his vision is 20/200, and asks what that means, the nurse informs the patient that a person with 20/200 vision:

Sees an object from 20 feet away that a person with normal vision sees from 200 feet away.

A client arrives in the emergency department with a suspected bone fracture of the right arm. How does the nurse expect the client to describe the pain?

Sharp and piercing

The nurse is assessing an older client's vision. The nurse integrates knowledge of which of the following during the assessment?

The power of the lens to accommodate will be decreasedincreased risk for this disorder?

A client had a nephrectomy 2 days ago and is now complaining of abdominal pressure and nausea. The first nursing action should be to:

auscultate bowel sound

Which term refers to an altered sensation of orientation in space?

dizziness

A nurse is caring for a client who is three hours post op from open abdominal surgery. During routine assessment, the nurse notes the previously stable client now appears anxious, apprehensive, and has a blood pressure of 90/56. What does the nurse consider is the most likely cause of the client's change in condition?

early signs of shock

emergent

just coming into being

The nurse recognizes the client has reached stage III of general anesthesia when the client:

lies quietly on the table

urgent

needing quick action or attention

A fracture is considered pathologic when it

occurs through an area of diseased bone.

A variety of complications can occur after a leg amputation. Which is not a possibility in the immediate postoperative period?

osteomyelitis

A client with multiple sclerosis is being seen by a neuro-ophthalmologist for a routine eye exam. The nurse explains to the client that during the examination, the client will be asked to maintain a fixed gaze on a stationary point while an object is moved from a point on the side, where it can't be seen, toward the center. The client will indicate when the object becomes visible The nurse further explains that the test being performed is called a:

perimetry test

A client has noticed needing to hold printed material at arms length to make the print readable. What is the term used to describe this visual condition?

presbyopia

A nurse notices that a client's left upper eyelid is drooping. The nurse has observed:

ptosis

After surgery for removal of cataract, a client is being discharged, and the nurse has completed discharge instruction. Which client statement indicates that the outcome of the teaching plan has been met?

"I should avoid pulling or pushing any object that weighs more than 15 lbs."

A client is diagnosed with otitis externa. Which instruction is most appropriate for the nurse to give?

Avoid swimming for 7 to 10 days.

A client has undergone tonometry to evaluate for possible glaucoma. Which result would the nurse record as abnormal?

25 mm Hg

The client displays manifestations of compartment syndrome. What treatment will the nurse expect the client to be scheduled for?

A fasciotomy

The nurse is assisting the client in planning care during exacerbations of Ménière's disease. Which diet would the nurse identify as appropriate at this time?

A low-sodium diet

A patient comes to the clinic with a suspected eye infection. The nurse recognizes that the patient most likely has conjunctivitis, as evidenced by what symptom?

A mucopurulent ocular discharge

The nurse is teaching a class on diseases of the ear. What would the nurse teach the class is the most characteristic symptom of otosclerosis?

A progressive, bilateral loss of hearing

Which term refers to the absence of the natural lens?

Aphakia

A client undergoing coronary artery bypass surgery is subjected to intentional hypothermia. The client is ready for rewarming procedures. Which action by the nurse is appropriate?

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

High doses of which medication can produce bilateral tinnitus?

Aspirin

A client you are caring for has a hearing loss. The client tells you he is self-conscious about his hearing loss. What advice should the nurse give a self-conscious client with hearing loss to protect his self-esteem?

Be forthright and inform others about the hearing deficit. The nurse should encourage clients with a hearing loss to be forthright and inform others about their hearing deficit. Clients should be advised not to hide the fact that they do not understand what has been said and should be encouraged to maintain friendships because a physical impairment is unlikely to affect genuine friendships.

The nurse is completing a postoperative assessment for a patient who has received a depolarizing neuromuscular blocking agent. The nursing assessment includes careful monitoring of which body system?

Cardiovascular system Depolarizing muscle relaxants can cause cardiac dysrhythmias.

Which of the following brain structures is responsible for equilibrium?

Cerebellum

Which is an inappropriate use of traction?

Decrease space between opposing structures

A 70-year-old patient who is to undergo surgery arrives at the operating room (OR). The nurse, when reviewing the patient's medical record, understands that this patient will require a lower dose of anesthetic agent because of which of the following?

Decreased lean tissue mass

Which of the following would lead a nurse to suspect that a client has a rotator cuff tear?

Difficulty lying on affected side Clients with a rotator cuff tear experience pain with movement and limited mobility of the shoulder and arm. They especially have difficulty with activities that involve stretching their arm above their head. Many clients find that the pain is worse at night and that they are unable to sleep on the affected side.

The nurse is aware that loss of consciousness occurs with which type of anesthesia?

General A therapeutic effect of general anesthesia is loss of consciousness.

The nurse should monitor for which manifestation in a client who has undergone LASIK?

Halos and glare

Which stage of surgical anesthesia is also known as excitement?

II Stage II is the excitement stage, which is characterized by struggling, shouting, and laughing. Stage II is often avoided if the anesthetic is administered smoothly and quickly. Stage I is the beginning of anesthesia, during which the client breathes in the anesthetic mixture and feelings of warmth, dizziness, and detachment occur. Stage III is surgical anesthesia, which is achieved by continued administration of anesthetic vapor and gas. Stage IV is medullary depression, in which the client is unconscious and lies quietly on the table.

Which nursing diagnosis takes highest priority for a client with a compound fracture?

Infection related to effects of trauma

The nurse is caring for a patient with Ménière's disease who is hospitalized with severe vertigo. What medication does the nurse anticipate administering to shorten the attack?

Meclizine (antivert)

The nurse is providing instructions to the client who is being prepared for skeletal traction. Which statement by the client indicates teaching was effective?

Metal pins will go through my skin to the bone.

To avoid the side effects of corticosteroids, which medication classification is used as an alternative to treat inflammatory conditions of the eyes?

NSAIDs

Which is an inaccurate principle of traction?

Skeletal traction is interrupted to turn and reposition the client.

Which of the following techniques least exhibits surgical asepsis?

Suctioning the nasopharyngeal cavity of a client

A young client is being seen by a pediatric ophthalmologist due to a recent skateboarding accident that resulted in trauma to the right cornea, and is now at risk of developing an infection. Which nursing intervention would be contraindicated for a client at risk for infection?

To ensure correct application of antibiotic ointment, gently drag tip of tube along lower lid while squeezing ointment on to lid

A client accidentally splashes chemicals into one eye. The nurse knows that eye irrigation with plain tap water should begin immediately and continue for 15 to 20 minutes. What is the primary purpose of this first aid treatment?

To prevent vision loss

The nurse is educating a community group about types of surgery. A member of the group asks the nurse to describe a type of surgery that is curative. What response by the nurse is true?

Tumor excision

When a client with a history of chronic alcoholism is admitted to the hospital for surgery, the nurse anticipates that the client may show signs of alcohol withdrawal delirium during which time period?

Up to 72 hours after alcohol withdrawal Alcohol withdrawal delirium is associated with a significant mortality rate when it occurs postoperatively. Onset of symptoms depends on when alcohol was last consumed. Twenty-four hours is too short a time frame to consider alcohol withdrawal delirium as no longer a threat to a chronic alcoholic.

When caring for a client after ear surgery, what is an important aspect of nursing care?

Validate client's feelings of discomfort.

Which of the following types of conjunctivitis is preceded by symptoms of an upper respiratory infection?

Viral

Select the nutrient that is important for postoperative wound healing because it helps form collagen.

Vitamin C

A client is seen in the emergency department for an injury acquired from falling off of a bicycle and fracturing the arm. The client also has a long laceration that has been sutured in the same area. The client asks the nurse why a splint is applied and not a cast. What is the best explanation by the nurse?

We will need to monitor the status of the laceration to be sure it does not get infected

Which of the following is an inappropriate nursing action by the surgical nurse?

Wearing sterile gloves over artificial nails

The nurse is giving a visual field examination to a 55-year-old male client. The client asks what this test is for. What would be the nurse's best answer?

"This test measures peripheral vision and detects gaps in the visual field."

A major role for nursing in the management of glaucoma is health education. Which of the following is the most important teaching point that the nurse should advise the patient of?

Adhere to the medication regimen

A 78-year-old client is undergoing surgery to repair a right hip fracture. What nursing action is appropriate during the intraoperative phase?

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

A client is postoperative day 3 after surgical repair of an open abdominal wound and traumatic amputation of the right lower leg following a motorcycle crash. What is the highest priority nursing intervention?

Assessing WBC count, temperature, and wound appearance The client has an increased risk for infection related to the surgical wound, which is classified as dirty. Assessing the WBC count, temperature, and wound appearance allows the nurse to intervene at the earliest sign of infection. The client will have special nutritional needs during wound healing and needs education on safe transfer procedures, but the need to monitor for infection is a higher priority. The client should receive pain medication as soon as possible after asking, but the latest literature suggests that pain medication should be given on a schedule versus "as needed."

A nurse is caring for a client placed in traction to treat a fractured femur. Which nursing intervention has the highest priority?

Assessing the extremity for neurovascular integrity Although all measures are correct, assessing neurovascular integrity takes priority because a decrease in neurovascular integrity could compromise the limb. The pull of the traction must be continuous to keep the client from sliding. Sufficient countertraction must be maintained at all times by keeping the ropes over the center of the pulley. The line of pull is maintained by allowing the weights to hang free.

If a dislocation is not treated promptly, tissue death due to anoxia can occur. This would be documented as which of the following?

Avascular necrosis (AVN)

Following cataract removal, discharge instructions will be provided to the client. Which of the following instructions is most important?

Avoid any activity that can increase intraocular pressure

A group of students is reviewing information about cast composition in preparation for a discussion on the advantages and disadvantages of each. The students demonstrate understanding of the topic when they cite which of the following as an advantage of a plaster cast?

Better molding to the client

A client who is undergoing skeletal traction reports pressure on bony areas. Which action would be most appropriate to provide comfort for the client?

Changing the client's position within prescribed limits

The OR personnel responsible for maintaining the safety of the client and the surgical environment is the:

Circulating nurse

Two days after application of a cast to treat a fractured femur, the client reports severe, deep, and constant pain in the leg. What will the nurse suspect?

Compartment Syndrome Compartment syndrome refers to the compression of nerves, blood vessels, and muscle within a closed space. This leads to tissue death from lack of oxygenation.

A client comes to the emergency department and reports localized pain and swelling in the lower leg. Ecchymotic areas are noted. History reveals that the client got hit in the leg with a baseball bat. What will the nurse most likely suspect?

Contusion The client's description of blunt trauma by a baseball bat and localized pain in conjunction with swelling and ecchymosis would most likely suggest a contusion. A fracture would be manifested by pain, loss of function, deformity, swelling, and spasm. A sprain would be manifested by pain and swelling; ecchymosis may appear later. A strain is characterized by inflammation, local tenderness, and muscle spasms.

Which of the following medications needs to be withheld for 5 to 7 days prior to cataract surgery?

Coumadin

Which would be contraindicated as a component of self-care activities for the client with a cast?

Cover the cast with plastic to insulate it

A nursing measure for evisceration is to:

Cover the protruding coils of intestines with sterile dressings moistened with sterile saline solution.

A client has a cast applied to the leg for treatment of a tibia fracture and also has a wound on the leg that requires dressing changes due to drainage. For what should the nurse prepare the client?

Cutting a cast window

After undergoing surgery the previous day for a total knee replacement, a client states, "I am not ready to ambulate yet." What should the nurse do?

Discuss the complications that the client may experience if there is lack of cooperation with the care plan.

Which action by the nurse has the highest priority when caring for a client diagnosed with vertigo?

Educate the client on using the call light for assistance with ambulation.

A client with arterial insufficiency undergoes below-knee amputation of the right leg. Which action should the nurse include in the postoperative care plan?

Elevating the stump for the first 24 hours Stump elevation for the first 24 hours after surgery helps reduce edema and pain by increasing venous return and decreasing venous pooling at the distal portion of the extremity. Bed rest isn't indicated and could predispose the client to complications of immobility. Heat application would be inappropriate because it promotes vasodilation, which may cause hemorrhage and increase pain. The initial pressure dressing usually remains in place for 48 to 72 hours after surgery.

Informed consent from the surgical client is essential in all of the following categories of surgery except:

Emergent surgery In an emergency, a physician may perform surgery without a client's informed consent in order to save the client's life.

The nurse is caring for a client who just returned from a trip requiring an airline flight. The client commented on how his ears hurt upon descent. The nurse is correct in stating which site as being the pressure equalizer in the ear?

Eustachian tube

Which portion of the middle ear equalizes pressure?

Eustachian tube The eustachian tube drains secretions of the middle ear and equalizes pressure in the middle ear with that of the atmosphere. Ossicles, which are held in place by joints, muscles, and ligaments, assist in the transmission of sound. The auricle collects sound waves and directs vibrations into the external auditory canal. The cochlea is a winding, snail-shaped bony tube that forms a portion of the inner ear and contains the organ of Corti, which is the transducer of hearing.

A nurse assesses a postoperative client as having abdominal organs protruding through the surgical incision. Which term best describes this assessment finding?

Evisceration

A client has been prescribed eye drops for the treatment of glaucoma. At the yearly follow-up appointment, the client tells the nurse that she has stopped using the medication because her vision did not improve. Which action by the nurse is appropriate?

Explain the therapeutic effect and expected outcome of the medication

A client with a fracture develops compartment syndrome that requires surgical intervention. What treatment will the nurse would most likely prepare the client for?

Fasciotomy

A nurse is caring for a client who underwent a skin biopsy and has three stitches in place. This wound is healing by:

First Intention Wounds with a small amount of tissue damage that are the result of procedures that use sterile technique and that are properly closed, such as with stitches, heal by first intention. Granulation tissue is generally not visible and scar formation is minimal. Second intention healing occurs in infected wounds or wounds with edges that aren't approximated. These wounds are usually packed with moist dressings. Third intention healing occurs with deep wounds that aren't sutured together, resulting in a deep, wide scar. There is no fourth intention of wound healing.

A client has been administered ketamine for moderate sedation. What is the priority nursing intervention?

Frequently monitoring vital signs Vital signs must be monitored frequently to assess for respiratory depression and to enable quick intervention. Oxygen may need to be administered if respiratory depression occurs; therefore, monitoring vital signs is a higher priority nursing intervention. Providing a dark quiet room is appropriate after the procedure is completed and the client is recovering. Hallucinations may occur as a side effect of the medication.

Which precautions should the nurse take when a client is at risk of injury secondary to vertigo and probable imbalance?

Grasp the siderails when rising to a standing position

The nurse caring for a client with Ménière's disease makes which primary assessments?

Gross hearing The nurse assesses gross hearing and performs the Weber and Rinne tests. It also is important to determine the extent and effect of the client's disability.

A patient in pelvic traction needs circulatory status assessed. How should the nurse assess for a positive Homans' sign?

Have the patient extend each leg and dorsiflex each foot to determine if pain or tenderness is present in the lower leg The nurse should assess for pain on passive flexion of each foot, which could indicate deep vein thrombosis.

Which type of benign tumor of the eyelids is characterized by superficial, vascular capillary lesions that are strawberry-red in color?

Hemangioma

The client returns to the nursing unit following an open reduction with internal fixation of the right hip. Nursing assessment findings include temperature 100.8 degrees Fahrenheit, heart rate 112 beats per minute, respiratory rate 28 breaths per minute, and blood pressure 86/58. There is no urine in the Foley catheter collection bag. The nurse interprets these findings as indicating which complication?

Hypovolemic shock Indicators of hypovolemic shock include a heart rate greater than 100 beats per minute, a blood pressure less than 90/60 mm Hg, and urine output less than 30 ml per hour.

A client experienced an open fracture to the left femur during a horse-riding accident. For which complication is this client at highest risk?

Infection This client is at the highest risk for infection because of the open fracture that was obtained while horseback riding. Infection that enters the body and affects the bone can lead to osteomyelitis. The treatment may involve long-term antibiotics and may even result in death. The client is still at risk for malunion, but this risk is slight because the bone can be visualized (either through the wound or surgical intervention) and returned to anatomical position. The other options are possible consequences of this type of injury but do not represent the most serious complication.

An obese client is undergoing abdominal surgery. During the procedure a surgical resident states, "The amount of fat we have to cut through is disgusting." What is the best response by the nurse?

Inform the resident that all communication needs to remain professional.

A client complains of vertigo. The nurse anticipates that the client may have a problem with which portion of the ear?

Inner ear

The client with chronic open-angle glaucoma is receiving timolol (Timoptic) eye drops. Which evaluation finding would indicate to the nurse the treatment is working?

Intraocular pressure 15 mm Hg

You are doing discharge teaching with a client after a stapedectomy. Why would it be important for you to advise the client to refrain from blowing the nose?

It may dislodge the prosthesis The nurse should advise a client who has undergone a stapedectomy to refrain from blowing the nose because it may dislodge the prosthesis. It does not lead to sudden headaches, vertigo, or excessive drainage.

A client undergoes open reduction with internal fixation to treat an intertrochanteric fracture of the right hip. The nurse should include which intervention in the postoperative care plan?

Keeping a pillow between the client's legs at all times

As a circulating nurse, what task are you solely responsible for?

Keeping records

Which surgical procedure involves flattening the anterior curvature of the cornea by removing a stromal lamella?

Laser-assisted in situ keratomileusis (LASIK)

A patient is participating in aural rehabilitation. The nurse understands that this type of training emphasizes which of the following?

Listening skills

The patient is having a repair of a vaginal prolapse. What position does the nurse place the patient in?

Lithotomy position

The nurse teaches the client which intervention to avoid hip dislocation after replacement surgery?

Never cross the affected leg when seated Crossing the affected leg may result in dislocation of the hip joint after total hip replacement. The client should be taught to keep the knees apart at all times, to put a pillow between the legs when sleeping, and to avoid bending forward when seated in a chair.

An unresponsive client had a plaster cast applied to the right lower leg 8 hours ago. When moving the client, the nurse notices an indentation on the posterior lower portion of the cast. What is the best action by the nurse?

Notify the physician Indentations in the cast can cause skin irritation and breakdown. The physician needs to be notified to assess the need for a new cast or manipulation of the current cast to prevent the skin breakdown. The nurse will need to document the findings and actions taken to resolve the issue but cannot document actions without completing an action, such as notifying the physician. The cast does not need to be removed immediately. Pedal pulse will indicate whether a circulatory issue is present, but with the client being unresponsive, mobility of the toes cannot be assessed.

The nurse is caring for a client with an external fixator that requires pin care twice a day. The nurse observes that there is a new purulent drainage around one of the pins. What intervention should the nurse anticipate doing?

Obtaining a culture

An OR nurse needs to assist a patient to the Trendelenburg position. Which of the following is the correct position?

On his back, with his head lowered, so that the plane of his body meets the horizontal on an angle

A client's fracture was reduced by surgically exposing the bone and realigning it. What type of treatment does the nurse identity this as?

Open reduction

The nurse is developing a plan of care for a patient with severe vertigo. What expected outcome statement would be a priority for this patient?

Patient will experience no falls due to balance disorder

You are physically preparing a client for surgery and instruct the person to remove any jewelry. The client refuses to remove a wedding band. What should you do in this situation with approval from your facility?

Place gauze under and over the ring and apply adhesive tape over it.

The nurse is caring for the postoperative client in the postanesthesia care unit. Which of the following is the priority nursing action?

Position the client to maintain a patent airway

Which terms refers to the progressive hearing loss associated with aging?

Presbycusis Age-related changes of both the middle and inner ear result in hearing loss. Exostoses refer to small, hard, bony protrusions in the lower posterior bony portion of the ear canal. Otalgia refers to a sensation of fullness or pain in the ear. Sensorineural hearing loss is loss of hearing related to damage of the end organ for hearing and/or cranial nerve VIII.

A nurse is caring for a client who underwent a total hip replacement. What should the nurse and other caregivers do to prevent dislocation of the new prosthesis?

Prevent internal rotation of the affected leg.

The nurse is reviewing the medical record of a client with glaucoma. Which of the following would alert the nurse to suspect that the client was at increased risk for this disorder?

Prolonged use of corticosteroids

Which of the following musculoskeletal injuries is manifested by acromioclavicular joint pain?

Rotator cuff tears Key assessment findings related to rotator cuff tears include acromioclavicular joint pain, limited range of motion, and muscle weakness. Epicondylitis (tennis elbow) is manifested by pain that usually radiates down the extensor surface of the forearm and generally is relieved with rest and avoidance of the aggravating activity. Heterotopic ossification is the abnormal formation of bone, near bones or in muscle, in response to soft tissue trauma after blunt trauma, fracture, or total joint replacement. Acute compartment syndrome involves a sudden and severe decrease in blood flow to the tissues distal to an area of injury that results in ischemic necrosis if prompt, decisive intervention does not occur.

A client is placed on the operating room table for the surgical procedure. Which surgical team member is responsible for handing sterile instruments to the surgeon and assistants?

Scrub Nurse

hypovolemic shock

Shock caused by fluid or blood loss.

A client sustains an injury to the ligaments surrounding a joint. What will the nurse identify this injury as?

Sprain A sprain is an injury to the ligaments surrounding a joint. A strain is an injury to a muscle when it is stretched or pulled beyond its capacity. A contusion is a soft tissue injury resulting from a blow or blunt trauma. A fracture is a break in the continuity of a bone.

A client's left leg is in skeletal traction with a Thomas leg splint and Pearson attachment. Which intervention should the nurse include in this client's care plan?

Teach the client how to prevent problems caused by immobility. By teaching the client about prevention measures, the nurse can help prevent problems caused by immobility, such as hypostatic pneumonia, muscle contracture, and atrophy. The nurse applies traction straps for skin traction — not skeletal traction. For a client in skeletal traction, the nurse should assess the affected limb, rather than assess the level of consciousness. Removing skeletal traction is the physician's responsibility — not the nurse's.

The nurse is caring for a client during an intra operative procedure. When assessing vital signs, which result indicates a need to alert the anesthesiologist immediately?

Temperature of 102.5°F (39°C)

Which statement is accurate regarding care of a plaster cast?

The cast can be dented while it is damp.

A perioperative nurse is conducting an in-service education program about maintaining surgical asepsis during the intraoperative period. Which of the following would the nurse emphasize?

The edges of a sterile package, once opened, are considered unsterile.

Which is not a guideline for avoiding hip dislocation after replacement surgery.

The hip may be flexed to put on clothing such as pants, stockings, socks, or shoes

Clients who have received corticosteroids preoperatively are at risk for which type of insufficiency?

adrenal Clients who have received corticosteroids are at risk of adrenal insufficiency. Insufficiency related to corticosteroids does not occur in the pituitary, thyroid, or parathyroid glands.

Which medication is used to treat glaucoma by pulling the iris away from the drainage channels so that aqueous fluid can escape?

carbachol

A 17-year-old client is having same-day surgery. Solely during the intraoperative phase of perioperative care, the nurse:

continuously monitors the sedated client. Intraoperative care includes the entire surgical procedure. During sedation, the nurse continuously evaluates the client. Assessment of heart rate, respiratory rate, BP, oxygen saturation, and level of consciousness occurs during all phases of perioperative care. Obtaining consent would occur during the preoperative phase of perioperative care. During the postoperative phase the nurse would assess how the client is recovering from anesthesia.

The nurse recognizes that the older adult is at risk for surgical complications due to:

decreased renal function Renal function declines with age, resulting in slowed excretion of waste products and anesthetic agents.

A term used to describe a partial or complete separation of wound edges is

dehiscence.A nurse assesses a postoperative client as having abdominal organs protruding through the surgical incision.

A client has just been diagnosed with early glaucoma. During a teaching session, the nurse should:

demonstrate eyedrop instillation

Which term refers to a fracture in which one side of a bone is broken and the other side is bent?

greenstick A greenstick fracture is a fracture in which one side of a bone is broken and the other side is bent. A spiral fracture is a fracture twisting around the shaft of the bone. An avulsion is when a fragment of bone has been pulled away by a ligament or tendon and its attachment. An oblique is a fracture occurring at an angle across the bone.

A client is to receive general anesthesia with sevoflurane. What does the nurse anticipate would be given with the inhaled anesthesia?

oxygen

A client has been diagnosed with a muscle strain. What does the physician mean with the term "strain"?

stretched or pulled beyond its capacity A strain is an injury to a muscle when it is stretched or pulled beyond its capacity.

Which of the following is the treatment of choice for acoustic neuromas?

surgery Surgical removal of acoustic tumors is the treatment of choice because these tumors do not respond well to radiation or chemotherapy. There would be no need for palliation.

A client is treated in the emergency department for acute muscle strain in the left leg caused by trying a new exercise. During discharge preparation, the nurse should provide which instruction?

Apply ice packs for the first 24 to 48 hours, then apply heat packs. The nurse should instruct the client to apply ice packs to the injured area for the first 24 to 48 hours to reduce swelling and then apply heat to increase comfort, promote reabsorption of blood and fluid, and speed healing. Applying ice for only 12 to 18 hours may not keep swelling from recurring. Applying heat for the first 24 to 48 hours would worsen, not ease, swelling. Applying ice 48 hours after the injury would be less effective because swelling already has occurred by that time.

A client with a long arm cast continues to complain of unrelieved throbbing pain even after receiving opioid pain medication. Which is the priority action by the nurse?

Assess for complications Unrelieved pain can be an indicator of a complication, such as compartment syndrome. Previous opioid drug use should not influence a complete and thorough assessment. Repositioning the client for comfort may be appropriate once all indications of a complication are ruled out. It is appropriate to teach relaxation techniques to help ease the pain, but assessing for a complication remains the highest priority.

The nurse is obtaining a history on a client stating the inability to read the newspaper and even seeing detail when looking at an image. Which assessment test would add additional data for a diagnosis?

Assess peripheral vision. The client states symptoms of the inability to discriminate letters, words, and details of an image, indicating the degeneration of the macula. If the macula is damaged, the client will only have the ability to see movement and gross objects in the peripheral fields. Assessing the peripheral vision will add essential information. The other visual tests are not as important at this time.

Which is an inaccurate principle of traction?

Skeletal traction is interrupted to turn and reposition the client. Skeletal traction is never interrupted. The weights are not removed unless intermittent treatment is prescribed. The weights must hang freely, with the client in good alignment in the center of the bed.

scrub nurse

surgical assistant who hands instruments to the surgeon