Test 1 practice questions

Which of the following should the nurse identify as risk factors for coronary artery disease? Select all that apply. A. African American race B. Male gender C. Potassium intake D. High stress level E. Central obesity

A. African American race B. Male gender D. High stress level E. Central obesity

Which of the following individuals are at high risk for development of deep vein thrombosis? Select all that apply. A. An elderly man who is confined to bed B. A newborn C. A woman with cancer D. A woman who is taking oral contraceptives

A. An elderly man who is confined to bed C. A woman with cancer D. A woman who is taking oral contraceptives

Which data collected during a patient health history would cause the nurse to monitor for sinus tachycardia during the physical examination process? A. Anemia B. Pericarditis C. Digoxin toxicity D. High intake of caffeinated coffee

A. Anemia

Which terminology should the nurse use to document pre-ventricular contractions that occur after every other heart beat? A. Bigeminy B. Trigeminy C. Left-sided heart failure D. Ventricular tachycardia

A. Bigeminy

Which assessment findings should the preoperative nurse report to the surgeon? Select all that apply. A. Blood pressure 179/93 mm Hg B. Daily baby aspirin use C. Sinus rhythm on electrocardiogram D. White blood cell count 8,000 per mcL E. Oral temperature 100.6 degrees Fahrenheit

A. Blood pressure 179/93 mm Hg B. Daily baby aspirin use E. Oral temperature 100.6 degrees Fahrenheit Ch 15

Which organs are at risk for injury as a result of uncontrolled hypertension? Select all that apply. A. Brain B. Uterus C. Retinas D. Kidneys E. Intestines

A. Brain C. Retinas D. Kidneys

Shortly later after admission to the PACU, Mr. Wells becomes restless, and his heart rate goes up to 100 bpm. As the nurse assesses him, the priority assessment should include which interventions? Select all that apply. A. Check his dressing and drains for bleeding B. Check his breathing and oxygen saturation C. Check his pain and comfort level D. Check to see if he has to have a bowel movement E. Check his blood pressure and fluid volume status

A. Check his dressing and drains for bleeding B. Check his breathing and oxygen saturation C. Check his pain and comfort level E. Check his blood pressure and fluid volume status Ch 17

Prior to the start of Ms. Doe's surgical procedure, all members of the surgical team participate in a time-out. Which of the following are components of the time out? Select all that apply A. Correct procedure B. Correct site C. Correct equipment D. Laterality E. Correct OR

A. Correct procedure B. Correct site C. Correct equipment Ch 16

Which symptoms should the nurse anticipate when providing care to a patient who is diagnosed with left ventricular failure? Select all that apply. A. Cyanosis B. Peripheral edema C. S3 and S4 heart sounds D. Jugular vein distention E. Weak peripheral pulses

A. Cyanosis C. S3 and S4 heart sounds E. Weak peripheral pulses

What diagnostic test measures the byproducts produced by the breakdown of a clot? A. D-dimer B. Ultrasonography C. B-type natriuretic peptide D. Complete blood count

A. D-dimer

While caring for the patient in the hospital with a diagnosis of deep vein thrombosis (DVT), the nurse recognizes that the most serious potential complication from a DVT is what? A. Development of a pulmonary embolism B. Development of post-thrombotic syndrome C. Recurrence within five years D. Leg ulcerations

A. Development of a pulmonary embolism

Which medication should the nurse anticipate for a patient diagnosed with heart failure who requires positive inotropic therapy? A. Digoxin B. Enalapril C. Furosemide D. Metoprolol

A. Digoxin

Which drug classification should the nurse anticipate for a patient diagnosed with heart failure to increase urine output? A. Diuretic B. Inotropic C. Angiotensin-converting-enzyme inhibitor D. Beta blocker

A. Diuretic

Which clinical manifestations should the nurse anticipate when providing care to a patient who is diagnosed with left - sided heart failure? Select all that apply. A. Dyspnea B. Dependent edema C. Fatigue D. Jugular vein distention E. Crackles noted on lung auscultation

A. Dyspnea C. Fatigue E. Crackles noted on lung auscultation

Prior to surgery, the nurse is teaching the patient about interventions used to prevent postoperative complications. Which patient teaching topics may the nurse want to discuss with the patient? Select all that apply. A. Early ambulation B. Compression devices C. Incentive spirometer use D. Upper extremity range of motion E. Blood clot prevention

A. Early ambulation B. Compression devices C. Incentive spirometer use E. Blood clot prevention Ch 15

What is the priority role of the operating room nurse during any surgical procedure? A. Ensuring patient safety and preventing injury B. Assuming team leader duties C. Verifying accuracy of patient's medical history D. Documenting the details of the procedure

A. Ensuring patient safety and preventing injury Ch 16

During the initial assessment and admission question, the nurse asks Jane for the time of her last oral intake. The patient replies, "I had dinner last night at 8 PM but I took a few sips of water this morning with my vitamins. The nurse's best response is which of the following? A. Explain to the patient that just a sip of water should not be a problem for anesthesia but that the vitamins may not be a problem. We will pass that information on to the anesthesiologist B. Tell the patient that just a sip of water is not an issue because tit was only a sip C. Inform the patient that her surgery will not be performed today because the risk is too high for a negative outcome D. Inform the patient that taking her vitamins before surgery was a good plan

A. Explain to the patient that just a sip of water should not be a problem for anesthesia but that the vitamins may not be a problem. We will pass that information on to the anesthesiologist Ch 15

Which clinical manifestations should the nurse assess for when providing care to a patient who is experiencing chronic uncontrolled hypertension? Select all that apply. A. Fatigue B. Epistaxis C. Dyspnea D. Headache E. Hyperglycemia

A. Fatigue B. Epistaxis C. Dyspnea D. Headache

Immediately after surgery, the post-anesthesia care unit nurse receives a report from a member of the anesthesia care team. What information should this report contain? Select all that apply. A. General patient report B. Pharmacological report C. Procedural report from circulating nurse D. Anesthetic report E. Discharge instructions

A. General patient report B. Pharmacological report C. Procedural report from circulating nurse D. Anesthetic report Ch 17

Initially upon admission to the PACU, Mr. Wells remains sleepy and hard to arouse. The PACU nurse anticipates an order for which laboratory test? A. Glucose test B. Arterial blood gas C. Lactate level D. Liver function test

A. Glucose test Ch 17

The nurse should report the following finding from a patient's history as an increased risk for DVTs postoperatively. Select all that apply. A. History of smoking B. Age C. History of DVTs with previous pregnancy D. Borderline hypertension E. Allergies

A. History of smoking C. History of DVTs with previous pregnancy D. Borderline hypertension Ch 15

Which is a cause of pulseless electrical activity the nurse should include in a teaching session for a patient diagnosed with a cardiac dysrhythmia? A. Hypoxia B. Alkalosis C. Hypervolemia D. Pneumothorax

A. Hypoxia

During the preoperative period, the nurse would notify the healthcare provider of which of the following assessment findings? Select all that apply. A. Increased blood pressure B. Normal sinus rhythm on ECG tracing C. Elevated white blood cell count D. Patient taking aspirin daily for pain E. Fever

A. Increased blood pressure C. Elevated white blood cell count D. Patient taking aspirin daily for pain E. Fever Ch 15

A patient who suffered a myocardial infarction is admitted to the coronary care unit. The family is confused as to why there is also a diagnosis of pericarditis. Which should the nurse include in the response to the patient's family as a cause of pericarditis? A. Inflammation B. Valve malfunction C. Inability to maintain blood flow D. Weak contraction and blood stasis

A. Inflammation

The PACU nurse supports Mr. Wells' family by doing which of the following? Select all that apply A. Informing family when the patient arrives in the PACU B. Allowing visitation immediately prior to transfer to his inpatient C. Allowing visitation as safety and privacy allow D. Providing frequent updates E. Providing visitation policy that allows visitation after discharge from the PACU

A. Informing family when the patient arrives in the PACU C. Allowing visitation as safety and privacy allow D. Providing frequent updates Ch 17

The nurse understands which actions are essential when providing support to the intraoperative patient and family during the OR experience? Select all that apply. A. Introduce the patient and family to the surgical team members B. Give family members updates every 2 hours as possible during the procedure C. Explain what to expect from the operative experience D. Alert the family to mealtimes E. Explain that once the procedure is complete, the surgeon will discuss surgery outcomes

A. Introduce the patient and family to the surgical team members B. Give family members updates every 2 hours as possible during the procedure C. Explain what to expect from the operative experience Ch 16

The nurse in the preoperative area knows that a complete informed consent includes which of the following components? Select all that apply. A. Name of the surgeon performing surgery B. Consent to administer blood products C. Consent for anesthesia D. Exact length of time surgery is to take E. Description of how the surgery will benefit the patient

A. Name of the surgeon performing surgery B. Consent to administer blood products C. Consent for anesthesia E. Description of how the surgery will benefit the patient Ch 15

The nurse is completing the preoperative checklist for a patient scheduled to undergo knee replacement surgery. Which actions must the nurse take? Select all that apply. A. Obtain a full medical history B. Assess patient's current health status C. Give patient a copy of current lab work D. Hang prescribed intravenous antibiotic E. Perform a "time out" at the bedside

A. Obtain a full medical history B. Assess patient's current health status D. Hang prescribed intravenous antibiotic E. Perform a "time out" at the bedside Ch 15

A new staff nurse in the operating room requires further education when stating that which team member may be nonsterile? A. Operating room nurse B. Anesthesia provider C. Circulating registered nurse D. Operating room director

A. Operating room nurse Ch 16

Which of these outcomes would be most appropriate to establish for a patient who is being discharged from an inpatient post-anesthesia care unit? Select all that apply. A. Patient able to tolerate liquids without nausea and vomiting B. No signs of bleeding from surgical site C. Patient monitor displays new onset atrial fibrillation D. Patient stable and able to walk E. Patient's abdominal dressing shows moderate amount of sanguineous drainage

A. Patient able to tolerate liquids without nausea and vomiting B. No signs of bleeding from surgical site D. Patient stable and able to walk Ch 17

Before a patient is discharged home following surgery, which criteria must be met? Select all that apply. A. Patient is awake and alert. B. Patient is voiding normally. C. Patient is eating and drinking normally. D. Surgical wound is clean and dry. E. Patient verbalizes understanding of instructions.

A. Patient is awake and alert. B. Patient is voiding normally. C. Patient is eating and drinking normally. D. Surgical wound is clean and dry. E. Patient verbalizes understanding of instructions. Ch 17

The post-anesthesia unit nurse is participating in handoff with the operating room team. What information should she expect to receive? Select all that apply. A. Patient's medical history B. Medications received C. Significant laboratory results D. Procedure performed E. Patient identification with one identifier

A. Patient's medical history B. Medications received C. Significant laboratory results D. Procedure performed Ch 17

Which post-myocardial infarction complication should the nurse include in the patient's plan of care? Select all that apply. A. Pericarditis B. Pneumonia C. Heart murmur D. Clot formation E. Heart failure

A. Pericarditis C. Heart murmur D. Clot formation E. Heart failure

The nurse understands surgical attire is worn to: Select all that apply. A. Prevent transmission of microorganisms between the patient and the team B. Promote cleanliness C. Prevent passage of blood and body fluids from the surgical site to the surgical team's apparel D. Promote confidentiality

A. Prevent transmission of microorganisms between the patient and the team C. Prevent passage of blood and body fluids from the surgical site to the surgical team's apparel Ch 16

Which finding would indicate a patient's hypertension is due to renal dysfunction? A. Proteinuria B. Increased triglycerides C. Left ventricular hypertrophy D. Decreased low-density lipoproteins

A. Proteinuria

The nurse is admitting the patient to the nursing unit at the hospital. the nurse is concerned that the patient is at risk of deep vein thrombosis because of which of the following risk factors? Select all that apply. A. Pt's advanced age B. Pt's admitting diagnosis of cancer C. Pt's stated drug allergy to aspirin D. Pt's history of of prior venous thrombosis E. Pt's low protein diet

A. Pt's advanced age B. Pt's admitting diagnosis of cancer D. Pt's history of of prior venous thrombosis Pre - assessment DVT

The post-anesthesia care unit nurse should administer pain medications based on which assessment findings in a patient who remains very drowsy? Select all that apply. A. Restlessness B. Relaxed jaw C. Pupil dilation D. Heart rate of 118 beats/minute E. Respiratory rate of 10 breaths /minute

A. Restlessness C. Pupil dilation D. Heart rate of 118 beats/minute Ch 17

Before administering pain medication to Mr. Wells in the PACU, the nurse's assessments include which of the following? Select all that apply. A. Sedation level B. Self report of pain C. Vital signs D. Bowel sounds E. Urine output

A. Sedation level B. Self report of pain C. Vital signs

Potential adverse effects o Ms. doe being placed in the supine position for her surgery include which of the following? Select all that apply A. Skin breakdown in the heels and elbows B. Venous pooling in the legs C. Ulnar nerve injury D. Retinal detachment E. Cerebral edema

A. Skin breakdown in the heels and elbows B. Venous pooling in the legs C. Ulnar nerve injury Ch 16

A patient scheduled for abdominal surgery states he is concerned about post-operative pain. Which patient teaching topics best address the patient's concern? Select all that apply. A. Splinting of the wound B. Need for early ambulation C. Patient-controlled analgesia use D. Use of compression stockings E. Use incentive spirometry every hour

A. Splinting of the wound C. Patient-controlled analgesia use Ch 15

The operating room nurse should intervene when making which observation during a surgical procedure? A. The anesthesiologist hands the surgeon a sterile instrument. B. The chief surgeon dons a pair of sterile gloves. C. The circulating nurse obtains additional sterile supplies. D. Unlicensed assistive personnel close the operating room doors.

A. The anesthesiologist hands the surgeon a sterile instrument. Ch 16

When planning discharge education for a 65 year old male who is having a hi replacement, it is appropriate for the nurse to consider which of the following Select all that apply. A. The patient's resources at home for completing activities of daily living B. The number of stairs in the patient's home C. Transportation to follow - up appointments D. Preexisting medical conditions E. The number of bathrooms in the home

A. The patient's resources at home for completing activities of daily living B. The number of stairs in the patient's home C. Transportation to follow - up appointments D. Preexisting medical conditions Ch 15

While Ms. doe is in the OR, what considerations will be taken to ensure her safety and positive outcome? Select all that apply A. Time - out B. Maintenance of sterile technique C. Continuous patient monitoring D. Instrument count E. Sponge count F. Breaks for personnel

A. Time - out B. Maintenance of sterile technique C. Continuous patient monitoring D. Instrument count E. Sponge count Ch 16

The OR nurse is completing a preoperative assessment for a patient, who is scheduled for exploratory surgery. Which of the following interventions must be competed prior to this patient going into the OR? Select all that apply. A. Verify operative consent has been signed B. Assure allergy and ID bands are in place C. Removal of patient's personal clothing D. Determine evidence of advance directive E. Validate completed patient history and physical examination F. Determine NPO status (last food/ fluid consumed)

A. Verify operative consent has been signed B. Assure allergy and ID bands are in place C. Removal of patient's personal clothing D. Determine evidence of advance directive E. Validate completed patient history and physical examination F. Determine NPO status (last food/ fluid consumed) Ch 16

Which actions should the operating room team perform according to The Joint Commission's universal protocol? Select all that apply. A. Verify the correct procedure. B. Verify the correct patient. C. Verify the correct date. D. Verify the correct site. E. Verify the correct hospital.

A. Verify the correct procedure. B. Verify the correct patient. D. Verify the correct site. Ch 16

The nurse is closely monitoring the intake and output of an infant wit heart failure who is receiving diuretic therapy. The nurse should use which most appropriate method to assess the urine output? A. Weighting the diapers B. Inserting a urinary catheter C. Comparing intake with output D. Measuring the amount of water added to formula

A. Weighting the diapers

The patient undergoing a surgical procedure with general anesthesia needs to be repositioned by staff members. Which are the most important actions by the operating room nurse? Select all that apply. A.Notify the anesthesia provider B.Pressure points are padded and protected C.Note the time when moving the patient D.Gently cross the patient's legs calf over calf E.Arms should be supported by nearby Mayo stand

A.Notify the anesthesia provider B.Pressure points are padded and protected Ch 16

When teaching a patient about cholesterol, which statement by the nurse is appropriate? A. "LDL should be less than 200 mg/dL." B. "HDL should be greater than 40 mg/dL." C. "Total cholesterol should be less than 130 mg/dL." D. "Triglyceride levels should be greater than 200 mg/dL."

B. "HDL should be greater than 40 mg/dL."

The nurse has provided home care instructions to the parents of a child who is being discharged after cardiac surgery. Which statement made by the parents indicates a need for further instruction? A. "A balance of rest and exercise is important." B. "I can apply lotion or powder to the incision if it is itchy." C. "Activities in which my child could fall need to be avoided for 2 to 4 weeks." D. "Large crowds of people need to be avoided for at least 2 weeks after surgery."

B. "I can apply lotion or powder to the incision if it is itchy."

Jane's surgeon has asked that thromboembolic stockings (TEDs) be placed on the patient before surgery as well as sequential compression devices on both legs to the knees. Jane asks the nurse what they will do for her. Which response by the nurse is most appropriate? A. "They work together to make sure that you do not have a decrease in arterial blood flow in your legs during the surgery." B. "They complement each other to prevent blood from backing up in your legs and causing a deep vein thrombosis due to you not moving during the surgery" C. "They prevent deep tissue clotting during the surgery." D. "The two devices do other same thing, but one is better during the surgery and the other is better postoperatively."

B. "They complement each other to prevent blood from backing up in your legs and causing a deep vein thrombosis due to you not moving during the surgery" Ch 15

How much exercise each day should the nurse recommend for a patient who is diagnosed with hyperlipidemia? A. 15 minutes B. 30 minutes C. 45 minutes D. 60 minutes

B. 30 minutes

John is a 6 year old child scheduled for a cardiac catheterization. Preoperative teaching should be with of the following? A. Directed at his parent because he is too young to understand B. Adapted to his level of development o that he can understand C. done several days before the procedure so he will be prepared D. Provide details about the actual procedure so he will know what to expect

B. Adapted to his level of development o that he can understand

Which statement is true about the complicated nature of managing pain medication in the immediate postanesthesia patient? A. All patients respond to pain in the same way but have different medications ordered B. All patients respond to pain in different ways, potentially requiring different medications C. The synergy of all multimodal pain management is unpredictable D. Nonpharmacological methods of pain control do not work in the PACU setting

B. All patients respond to pain in different ways, potentially requiring different medications Ch 17

Which clinical manifestations should the nurse identify as an indication of cardiac instability? Select all that apply. A. Dysuria B. Anxiety C. Shortness of breath D. Diaphoresis E. Dizziness

B. Anxiety C. Shortness of breath D. Diaphoresis E. Dizziness

Which action should the nurse take in the post-anesthesia care unit to prevent the complication of venous thromboembolism? A. Ambulate the patient around the unit. B. Apply compression stockings. C. Administer enoxaparin subcutaneously. D. Turn and reposition the patient often.

B. Apply compression stockings. Ch 17

Jane expresses her anxiety about the procedure and anesthesia to her nurse. The most appropriate response is: A. Tell her that It's okay we do this every day B. Assure her that her fears are normal and encourage her to use her consultation time with the surgeon and anesthesiologist to address her concerns C. Share a story about your friend who had similar fears prior to her surgery D. Document her concerns in the chart so that the PACU nurse will expect her to be anxious during recovery

B. Assure her that her fears are normal and encourage her to use her consultation time with the surgeon and anesthesiologist to address her concerns Ch 15

The PACU nurse understands the first priority for Mr. Wells upon admission to the PACU is which of the following? A. Informing the family of his status B. Checking vital signs and neurological status C. Providing pain medication D. Assessing the nasogastric tube

B. Checking vital signs and neurological status Ch 17

The nurse is explaining to the nursing student the concept of Virchow's triad, the three mechanisms that can create a venous thrombosis. The nurse explains that which of the following is not a mechanism included in Virchow's triad? A. Increased tendency of the blood to clot B. Decreased number of platelets C. Decreased blood flow rate D. Damage to the blood vessel wall

B. Decreased number of platelets

Which clinical manifestation should the nurse anticipate when providing care to a patient who is diagnosed with right - sided heart failure? Select all that apply. A. Dyspnea B. Dependent edema C. Delayed capillary refill D. Jugular vein distention E. Crackles noted on lung auscultation

B. Dependent edema D. Jugular vein distention

To identify whether a client is developing malignant hyperthermia, which assessment finding should the nurse identify first? A. Severe muscle rigidity B. Elevated heart rate C. Elevated end tidal carbon dioxide D. Brown urine output

B. Elevated heart rate Ch 16

What role does the preoperative nurse have in obtaining consent for anesthesia? Select all that apply. A. Inform patient about type of anesthesia and medications to be used B. Ensure patient understands information being presented C. Inform patient about the risks associated with type of anesthesia planned D. Inform patient about how the anesthesia is administered E. Request a time-out prior to obtaining consent

B. Ensure patient understands information being presented Ch 15

What is the nurse's highest priority of care during the preoperative phase of care? A. Teaching to prevent complications B. Ensuring the patient's physiological safety C. Explaining the 0-10 pain assessment scale D. Asking the patient about support system

B. Ensuring the patient's physiological safety Ch 15

The nurse should intervene immediately if pt with DVT is noted to A. Have redness and warmth in lower calf of right leg B. Experience new shortness of breath and a decrease in o2 sat C. Have pain and tenderness in right thigh D. Begin having nausea and diarrhea

B. Experience new shortness of breath and a decrease in o2 sat

The nurse understands which of the following is true about family support in the PACU setting? A. Families are allowed to visit as freely as they wish B. Families are allowed to visit as safety and privacy in the PACU allow C. Family visitation in the PACU setting is discouraged until the patient is ready for transfer D. Family visitation is allowed in the phase 3 level of care

B. Families are allowed to visit as safety and privacy in the PACU allow Ch 17

Which actions should the operating room nurse perform to ensure the safety of the patient? Select all that apply. A. Apply safety strap across patient's ankles once patient is on the OR table. B. Frequently monitor patient's respiratory rate. C. Ensure the side rails are in the up position. D. Carefully position patient's arms on the instrument table. E. Cross the patient's legs over the calf area instead of the ankles.

B. Frequently monitor patient's respiratory rate. C. Ensure the side rails are in the up position. Ch 16

The RN is caring for a client with lower extremity peripheral arterial disease. Which Statements by the client regarding self management requires further health teaching? Select all that appply A. I need to quit smoking as soon as I can B. I will elevate my legs above the level of my heart C. I will use a heating pad to promote circulation D. I will avoid crossing my legs all the time E. I will inspect my feet daily

B. I will elevate my legs above the level of my heart C. I will use a heating pad to promote circulation

Which is a cause for diastolic dysfunction for a patient diagnosed with heart failure? A. Contraction difficulty B. Left ventricle hypertrophy C. Elevated demands on the heart D. Impaired venous return to the heart

B. Left ventricle hypertrophy

Which of the following is an example of a local anesthetic? A. Diazepam B. Lidocaine C. Pavulon D. Morphine

B. Lidocaine Ch 16

Jane is allergic to latex. What is the appropriate action to prevent an allergic reaction in the patient who is having surgery? A. Terminally clean the OR before her case and remove all the latex products B. Maria should be the first case of the day, and only nonlatex items should be used C. All surgical suites are latex free, o this is not a concern d. Anesthesia should be prepared to intubate and treat her if a reaction occurs because there is no way to assure a latex free environment

B. Maria should be the first case of the day, and only nonlatex items should be used Ch 15

The nurse has just received report on assigned pts. Prioritize which pt should be seen first. A. Mr. Casey is a 72 female admitted with hypertensive urgency. She has been started on several antihypertensive medications and lasix B. Mr. Stanley is a 63 male postoperative day one after a carotid endarterectomy. C. His pressure is now 118/70 he is complaining of a headache

B. Mr. Stanley is a 63 male postoperative day one after a carotid endarterectomy.

Which findings would a nurse most likely observe during phase II of the postoperative period? Select all that apply. A. Patient responds to painful stimuli B. Normal oxygen saturation rate C. Blood pressure stabilization D. Patient verbalizes pain 9/10 on 0-10 scale E. Patient denies nausea and has no vomiting

B. Normal oxygen saturation rate C. Blood pressure stabilization E. Patient denies nausea and has no vomiting Ch 17

Which data collected during a patient health history would cause the nurse to monitor for atrial fibrillation during the physical examination process? A. Anemia B. Pericarditis C. Digoxin toxicity D. High intake of caffeinated coffee

B. Pericarditis

The nurse is providing teaching for a patient being discharged from the hospital. The nurse explains which of the following are common signs and symptoms of a deep vein thrombosis? Select all that apply. A. Temperature greater than 100.4 F B. Swelling at site C. Tenderness at site D. Swollen lymph nodes E. Pain at site

B. Swelling at site C. Tenderness at site E. Pain at site Pre - assessment DVT

The preoperative nurse needs further instruction from the nurse manager when which action is observed? A. The nurse places compression stockings on the patient's legs before the procedure. B. The nurse asks the patient's spouse to witness the surgical consent. C. The nurse prints current lab results and places a copy on the chart. D. The nurse tells the patient that early ambulation after surgery is best.

B. The nurse asks the patient's spouse to witness the surgical consent. Ch 15

The operating room director must intervene when which action has been reported by the operating room nurse? A. "Time-out" procedures are performed before every surgical procedure. B. The surgical assistant reaches his hands below the waist to pick up an item. C. The patient's body has been padded while on the operating room table. D. Two or more people move patients from the stretcher to the operating room table.

B. The surgical assistant reaches his hands below the waist to pick up an item. Ch 16

The nurse knows the patient understands the teaching plan focused on decreasing the reoccurrence of deep vein thrombosis when the patient states which of the following? A. "It is fine for me to ride in the car for 6 hours without having to stop and walk." B. "Sitting in the chair all day is the most activity I should plan on for the next week." C. "It is important that I stay as active as a safely am able." D. "As long as I feel comfortable, I can stand as long as I want."

C. "It is important that I stay as active as a safely am able." Pre - assessment DVT

Which of the following patients presents the greatest risk for a negative response to anesthesia? A. A 40 year old male with high blood pressure B. A 20 year old female with no prior surgical history C. A 29 year old female with a history of stage 2 acute renal failure D. An 85 year old male who drinks one glass of scotch every night

C. A 29 year old female with a history of stage 2 acute renal failure Ch 15

Which patient should be classified, according to the American Heart Association and American College of Cardiology, as stage C? A. A male patient with risk factors but not left ventricular impairment B. A female patient with impaired left ventricular function C. A male patient with current symptoms of heart failure D. A female patient with requiring inotropic support

C. A male patient with current symptoms of heart failure

A nurse is performing the immediate postoperative assessment of a pt who just underwent CEA. What is the most important assessment to be reported immediately? A. A complaint of 7/10 pain B. Falling back to sleep after assessment C. An asymmetric smile D. Complaint of a sore throat

C. An asymmetric smile

Which drug classification should the nurse anticipate for a patient diagnosed with heart failure to reduce fluid volume and afterload? A. Diuretic B. Inotropic C. Angiotensin-converting-enzyme inhibitor D. Beta blocker

C. Angiotensin-converting-enzyme inhibitor

The preoperative nurse is admitting a patient for same-day surgery. What is the nurse's priority action? A. Teach the patient how to use an incentive spirometer B. Assess the patient's vital signs C. Complete the preoperative checklist D. Start a large bore intravenous line

C. Complete the preoperative checklist Ch 15

On assessment of a child admitted with a diagnosis of acute - stage Kawasaki disease, the nurse expects to note which clinical manifestation of the acute stage of the disease? A. Cracked lips B. Normal appearance C. Conjunctival hyperemia D. Desquamation of the skin

C. Conjunctival hyperemia

Upon patient admission to the PACU, the nurse understands the priority intervention is which of the following? A. Administerantiemetics B. Administer pain medication C. Connect patient to the monitor D. Start IV fluid

C. Connect patient to the monitor Ch 17

You are caring for an elderly patient who is on prolonged bed rest and suspect that he may have deep vein thrombosis. What is your appropriate nursing action? A. Apply a sequential compression device. B. Tell the patient to massage his leg. C. Contact the healthcare provider. D. Assist the patient with range-of-motion exercises.

C. Contact the healthcare provider.

The RN assesses a client who had a CABG yesterday. Which finding will the RN report to the surgeon immediately A. Incisional pain B. BP of 136/76 C. Decreased level of consciousness D. Apical pulse of 88

C. Decreased level of consciousness

The nurse knows the most common area of the body for deep vein thrombosis to develop is what location? A. Proximal deep veins of the upper arms B. Proximal deep veins of the lower extremity C. Deep veins of the calf muscles D. Deep veins of the lower arm

C. Deep veins of the calf muscles Pre - assessment DVT

Which is the priority concern when providing care to a patient who has experienced a myocardial infarction? A. Anxiety and fear B. Medication management C. Direct damage to heart tissue D. Indirect damage to lung tissue

C. Direct damage to heart tissue

Which is a cause for high-output failure for a patient diagnosed with heart failure? A. Relaxation difficulty B. Contraction difficulty C. Elevated demands on the heart D. Impaired venous return to the heart

C. Elevated demands on the heart

The clinic nurse reviews he record of a child just seen by health care provider and diagnosed with suspected aortic stenosis. The nurse expects to note documentation of which clinical manifestation specifically found in this disorder? A. Pallor B. Hyperactivity C. Exercise intelorance D. Gastrointestinal disturbances

C. Exercise intelorance

Which medication should the nurse anticipate for a patient diagnosed with heart failure with pulmonary edema? A. Digoxin B. Enalapril C. Furosemide D. Metoprolol

C. Furosemide

Which factors place a patient at risk for experiencing a cardiac dysrhythmia? Select all that apply. A. Infections B. Kidney stones C. Hypertension D. Diabetes mellitus E. Myocardial infarction

C. Hypertension D. Diabetes mellitus E. Myocardial infarction

Which of the following is an airway used to support airway management? Select all that apply. A. MAC B. MH C. LMA D. ETT E. PCP

C. LMA - laryngeal mask airway D. ETT - endotracheal tube Ch 16

The nurse understands PACUs are designed for which of the following? A. Managing the transition from anesthesia to long term care B. Managing the transition from anesthesia through stage 3 of recovery C. Managing the transition from anesthesia through phase 2 of recovery D. Managing the transition from anesthesia through rehabilitation

C. Managing the transition from anesthesia through phase 2 of recovery Ch 17

The nurse understands the immediate postoperative assessment upon admission to the PACU includes which of the following? Select all that apply A. Medical history B. Full system review C. Neurological assessment D. Blood pressure E. Surgical site drainage

C. Neurological assessment D. Blood pressure E. Surgical site drainage Ch 17

The operating room nurse needs further teaching when which finding is observed? A. Two people are assisting the patient to the operating room table B. Irrigation fluid is being warmed before administration C. Operating room doors are left open during surgical procedure D. Mask, head cover, gown, and shoe covers worn in sterile area

C. Operating room doors are left open during surgical procedure Ch 16

Assessment findings of an infant admitted to the hospital reveal a machinery-like murmur on auscultation of the heart and signs of heart failure. The nurse reviews congenital cardiac anomalies and identifies the infant's condition as which disorder? (Figure in teal book page 488. A. Aortic stenosis B. Atrial septal defect C. Patent ductus arteriosus D. Ventricular septal defect

C. Patent ductus arteriosus

A patient diagnosed with hyperlipidemia is prescribed a statin drug. Which information should the nurse include in the medication teaching session with the patient? A. Reduces absorption of cholesterol B. Reduces absorption of saturated fats C. Reduces the synthesis of cholesterol in the liver D. Reduces bile, and therefore cholesterol, by blocking reabsorption in the intestines

C. Reduces the synthesis of cholesterol in the liver

During phase I of the postoperative period, the nurse notices that the patient's surgical dressing contains an area of bright, red bleeding. Which action should the nurse take? A. Assess the patient's temperature. B. Notify the anesthesiologist. C. Reinforce the surgical dressing. D. Measure urinary output for past hour.

C. Reinforce the surgical dressing. Ch 17

Because of Jane's smoking history the nurse understands she is at great risk for which of the following? Select all that apply A. Increased postoperative pain B. Difficulty with anesthesia C. Respiratory depression during the procedure D. Increased healing time after the procedure E. Deep vein thrombosis after the procedure

C. Respiratory depression during the procedure D. Increased healing time after the procedure E. Deep vein thrombosis after the procedure Ch 15

The nurse recognizes teaching has been effective by which of the following statements? A. My neighbor was able to eat right up to the time of her procedure B. I know there is nothing you can do about nausea after the procedure C. So that IV line will stay in throughout the procedure? D. I know I will need blood during this procedure

C. So that IV line will stay in throughout the procedure? Ch 15

A patient's average blood pressure is 140/90 mm Hg. Which term should the nurse use to document this finding in the medical record? A. Prehypertension B. Hypertensive crisis C. Stage 1 hypertension D. Stage 2 hypertension

C. Stage 1 hypertension

If Ms. Doe indicates there is a family history of problems with anesthesia, it is important to discuss this with the anesthesia provider in order to avoid the use of which MH - triggering agent? A. Nitrous oxide B. Morphine C. Succinylcholine d. Katamine

C. Succinylcholine Ch 16

The nurse is monitoring an infant with congenital heart disease closely for signs of heart failure (HF). The nurse should assess the infant for which early sign of HF? A. Pallor B. Cough C. Tachycardia D. Slow and shallow breathing

C. Tachycardia

The nurse has just received report on assigned pts in the cardiac step down unit. Which of the following pts should be assessed first? A. The pt 2 days post cabg surgery complaining of 7/10 pain B. The pt scheduled for surgical procedure immediately after report C. The pt complaining of new onset chest pain D. The pt on falls precautions setting off the bed alarm

C. The pt complaining of new onset chest pain

Which topics should the nurse include in a teaching session for a patient who is prescribed a lipid profile by the healthcare provider? Select all that apply. A. CK-MB B. Troponin C. Triglycerides D. Total cholesterol E. Ratio of low-density lipoprotein to high-density lipoprotein

C. Triglycerides D. Total cholesterol E. Ratio of low-density lipoprotein to high-density lipoprotein

During Phase I of the postoperative period, the nurse will perform which of the following priority assessments? Select all that apply. A. Capillary refill B. Auscultation of bowel sounds C. Vital signs D. Level of consciousness E. Airway patency

C. Vital signs D. Level of consciousness E. Airway patency Ch 17

A patient has undergone general anesthesia during hip replacement surgery. The nurse should perform which priority assessment when the patient first arrives to the post-anesthesia care unit? A. Ability to ambulate safely B. Understanding of post-operative care C. Vital signs evaluation D. Check surgical wound

C. Vital signs evaluation Ch 17

A client with CAD is schedules to have a diagnostic exercise stress test. Which instruction should the nurse plan to provide to the client about the procedure A. Eat breakfast just before the procedure B. Wear firm rigid shoes such as work boots C. Wear loose clothing with a shirt that buttons In the front D. Avoid cigarettes for 30 min before procedure

C. Wear loose clothing with a shirt that buttons In the front

A child with rheumatic fever will be arriving to the nursing unit for admission. On admission assessment, the nurse should ask the parents which question to elicit assessment information specific to the development of rheumatic fever? A. "Has the child complained of back pain?" B. "Has the child complained of headaches?" C. "Has the child had any nausea or vomiting?" D. "Did the child have a sore throat or fever within the last 2 months?"

D. "Did the child have a sore throat or fever within the last 2 months?"

Which patient statement indicates correct understanding of cholesterol? A. "LDL is the good cholesterol." B. "HDL is the bad cholesterol." C. "Elevated levels of potassium decrease my risk for coronary artery disease." D. "Elevated levels of total cholesterol increase my risk for coronary artery disease."

D. "Elevated levels of total cholesterol increase my risk for coronary artery disease."

The nurse provides home care instructions to the parents of a child with heart failure regarding the procedure for administration of digoxin. Which statement made by the parent indicates the need for further instruction? A. "I will not mix the medications with food." B. "I will take my child's pulse before administering the medication." C. "If more than 1 dose is missed, I will call the health care provider." D. "If my child vomits after medication administration, I will repeat the dose."

D. "If my child vomits after medication administration, I will repeat the dose."

The nurse reviews the laboratory results for a child with a suspected diagnosis of rheumatic fever, knowing that which laboratory study would assist in confirming the diagnosis? A. Immunoglobulin B. Red blood cell count C. White blood cell count D. Anti-streptolysin O titer

D. Anti-streptolysin O titer

You are preparing a patient for surgery and have asked her to verify her information on her patient identification band. She tells you that the birth date is incorrect her identification band. The most appropriate action by the nurse at this time is which of the following? A. Cross out the birth date and put the correct one in tis place with the nurse's initials B. Ask the family members to validate the patient's birth date C. Call the surgeon's office to validate the birth date D. Ask the admissions office to please send a corrected identification band

D. Ask the admissions office to please send a corrected identification band Ch 15

Appropriate pharmacologic treatment for kawasaki disease includes which of the following? A. Aspirin 3-5 mg/kg/day for antiinflammatory effects B. Acetaminophen for analgesia and fever C. Ibuprofen and acetaminophen alternated to prevent fever D. Aspirin 80 - 100 mg/kg/day for antiinflammatory effects

D. Aspirin 80 - 100 mg/kg/day for antiinflammatory effects

A patient who recently suffered a myocardial infarction is diagnosed with a blood clot. What should the nurse attribute this to? A. Inflammation B. Valve malfunction C. Increased blood flow D. Atrial fibrillation

D. Atrial fibrillation

The nurse is reviewing admission lab work for a patient admitted with deep vein thrombosis. The nurse knowns which of the following serum laboratory tests is used to diagnosis deep vein thrombosis. A.Prothrombin time/ international normalized ratio B. Partial thromboplastin time C. Platelet count D. D - dimer

D. D - dimer Pre - assessment DVT

What is an important responsibility of Jane's nurse before the procedure? A. Explain the procedure and have Jane sign the consent form B. Revive the risks of anesthesia preop C. Mark the surgical site with the patient D. Ensure completion of the preoperative assessment

D. Ensure completion of the preoperative assessment Ch 15

The nurse understands that a patient undergoing right upper lobe lobectomy requiring general anesthesia will be recovered in which of the following settings? A. Outpatient PACU B. Procedure area PACU C. Surgical enter PACU D. Inpatient PACU

D. Inpatient PACU Ch 17

Which of these outcomes would be most appropriate to establish for a patient who is receiving warmed intravenous fluids during surgery? A.Patient's oxygen saturation level remains above 94% on continuous pulse oximetry. B.Patient remains slightly hypertensive throughout the entire surgical procedure. C.Patient does not develop a deep vein thrombosis in either lower extremity. D. Patient maintains body temperature between 97.0 - 99.0 degrees Fahrenheit.

D. Patient maintains body temperature between 97.0 - 99.0 degrees Fahrenheit. Ch 16

The nurse caring for a patient in the supine position on the OR table incorporates which nursing diagnosis into the plan of care? A. Risk for fluid volume deficit B. Risk for knowledge deficit C. Risk for aspiration D. Risk for potential alteration in skin integrity

D. Risk for potential alteration in skin integrity Ch 16

Which of the following is the identified leader fo the surgical team? A. the circulator B. The anesthesia care provider (the anesthesiologist/ anesthetist) C. The PA D. The surgeon

D. The surgeon Ch 16

A health care provider has prescribed oxygen as needed for an infant with heart failure. In which situation should the nurse administer the oxygen to the infant? A. During sleep B. When changing the infant's diapers C. When the mother is holding the infant D. When drawing blood for electrolyte level testing

D. When drawing blood for electrolyte level testing

Which of the following is an accurate description of the physiologic defect caused by anemia? A. increased blood viscosity B. depressed hematopoietic system C. presence of abnormal hemoglobin D. decreased oxygen carrying capacity of blood

D. decreased oxygen carrying capacity of blood