Ticket to Test/Prep U-Module 5,6,7

A client recovering from hip surgery is receiving morphine through a patient-controlled analgesia (PCA) infusion pump with a set basal rate. What action is most important for the nurse to implement?

Assess the client's respiratory status

The ABCD method offers one way to assess skin lesions for possible skin cancer. What does the A stand for?

Asymmetry

When the nurse is performing an assessment and finds no physical cause for a patient's pain, what should the nurse do when the patient continues to complain of pain?

Believe a patient when he or she states that pain is present.

A gerontologic nurse is teaching a group of nursing students about integumentary changes that occur in older adults. How should these students best integrate these changes into care planning?

By protecting older adults against shearing injuries

A client comes to the clinic reporting a red rash of small, fluid-filled blisters and is suspected of having herpes zoster. What presentation is most consistent with this diagnosis?

Grouped vesicles in linear patches along a dermatome

The nurse is conducting a health history of a preoperative client. The client shares that she experienced vaginal itching and burning and labial swelling after her partner tried a new brand of condoms. The nurse suspects that the client:

May have a latex allergy.

Which medication should be readily available for patients receiving epidural opioids who are experiencing respiratory depression?

Naloxone

In which zone of the surgical area are street clothes allowed?

Unrestricted

The nurse has administered preanesthetic medication. What action should the nurse take next?

Place the client on bed rest with the side rails up.

The nurse is completing a preoperative assessment. The nurse notices the client is tearful and constantly wringing their hands. The client states, "I'm really nervous about this surgery. Do you think it will be ok?" What is the nurse's best response?

"What are your concerns?"

The nurse is to administer meperidine 75 mg intramuscularly to a client. The medication is supplied in an ampule of 50 mg/mL. How many milliliters should the nurse administer to the client? Enter the correct number ONLY.

1.5

Which of the following assessment tools will be most effective when assessing for pain in a four-year-old client?

A FACES scale

Which is a true statement regarding placebos?

A placebo should never be used to test a client's truthfulness about pain.

A client who had abdominal surgery 4 days ago reports that "something gave way" when he sneezed. The nurse observes a wound evisceration. Which nursing action is the first priority?

Applying a sterile, moist dressing

During the course of a health interview, Mrs. Young tells the nurse that she has been using a new perfume because she wants to smell good. She explains that she has had a rash on her arms and neck since she purchased and used the product. What would be an initial diagnosis for Mrs. Young?

Contact dermatitis

The nurse is assessing a client's skin when the client points out a mole. The nurse brings the mole to the physician's attention when which characteristic is noted?

Diameter exceeding 6 mm

In which instance may a surgeon operate without informed consent?

Emergency situations

Which is the primary preventable cause of skin cancer?

Exposure to UV radiation

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

General

A nurse on the surgical team has been assigned the role of scrub nurse. What action by the scrub nurse is appropriate?

Handing instruments to the surgeon and assistants

A patient with a history of chronic respiratory illness exhibits nail clubbing. The nurse interprets this finding as indicating which of the following?

Hypoxia

A client with a skull fracture after falling from a ladder requires surgery. The nurse should anticipate transporting the client to surgery during what time frame?

Immediately

While waiting to see the physician, a client shows the nurse skin areas that are flat, nonpalpable, and have had a change of color. The nurse recognizes that the client is demonstrating what?

Macules

Which of the following pain assessment tools is most commonly used in adults?

Numeric scale

What term refers to the time the pain began?

Onset

What intervention by the nurse is most effective for reducing hospital-acquired infections?

Proper hand-washing techniques

Scabies are spread by which type of transmission?

Skin-to-skin contact

A client with squamous cell carcinoma has been scheduled for treatment of this malignancy. The nurse should anticipate that treatment for this type of cancer will primarily consist of what intervention?

Surgical excision

Which of the following superficial fungal infections begins in the skin between the toes and spreads to the soles of the feet?

Tinea pedis

A registered nurse who is responsible for coordinating and documenting client care in the operating room is a

circulating nurse.

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.

The nurse on a rehabilitation unit receives report about a new client who has fibromyalgia and has difficulty with her ADLs. The off-going nurse also reports that the client is withdrawn, refusing visitors, and has been vacillating between tears and anger all afternoon. What aspect of chronic pain syndromes could account for this client's behavior?

Chronic pain can cause intense emotional responses.

A presurgical client asks, "Why will I go to the PACU instead of just going straight up to the postsurgical unit?" What is the nurse's best response?

"The PACU allows you to recover from the effects of anesthesia, and you'll stay in the PACU until you're oriented, have stable vital signs, and are without complications."

The client asks the nurse how the spinal anesthesia will be administered. The best response by the nurse is:

"The anesthesiologist will inject the anesthetic into the space around your lower spinal cord."

A nurse is planning the care of a client with herpes zoster. What medication, if given within the first 24 hours of the initial eruption, can arrest herpes zoster?

Acyclovir

The nurse in an ambulatory care center is admitting an older adult client who has bright red moles on the skin. Benign changes in elderly skin that appear as bright red moles are termed what?

Cherry angiomas

How can the nurse determine that a client's pain is characteristic of acute pain?

It is associated with a specific injury.

Which of the following is the most common complaint related to a diagnosis of head lice?

Itching

The nurse is aware that a religious group that refuses blood transfusions for religious reasons is:

Jehovah's Witnesses

The nurse assesses the client and observes reddish-purple to dark blue macules, plaques, and nodules. The nurse recognizes that these manifestations are associated with which condition?

Kaposi sarcoma

The nurse observes an African-American patient with a large hypertrophied area of scar tissue on the left ear lobe. What does the nurse document this finding as?

Keloid

A nurse is providing preoperative teaching to a client who will soon undergo a cardiac bypass. The nurse's teaching plan includes exercises of the extremities. What is the purpose of teaching a client leg exercises prior to surgery?

Leg exercises improve circulation and prevent venous thrombosis.

During assessment of a light-skinned patient, the nurse notices a yellow color present in the sclera of both eyes and the mucous membranes. The nurse knows that this finding could be associated with the presence of:

Liver dysfunction.

A client is admitted to the intensive care unit with what is thought to be toxic epidermal necrolysis (TEN). When assessing the health history of the client, the nurse would be alert to what precipitating factor?

Recent administration of new medications

A client reports having joint pain that has gotten worse over the last year despite gradually increasing doses of an OTC pain reliever. Which type of pain will the nurse document as the chief complaint?

chronic pain

In the immediate postoperative period, vital signs are taken at least every

15 minutes.

The surgical unit nurse is developing a postoperative plan of care. In which client's plan of care would the nurse document interventions of coughing and deep breathing, gastrointestinal assessment, and effective regulation of temperature?

A client with gastrointestinal surgery and general anesthesia

The nurse is monitoring a presurgical patient for electrolyte imbalance. Which classification of medication may cause electrolyte imbalance?

Diuretics

A nurse is providing care for a client who has developed Kaposi sarcoma secondary to HIV infection. The nurse should be aware that this form of malignancy originates in what part of the body?

Endothelial cells lining small blood vessels

The nurse is assisting an older adult client with performing activities of daily living (ADL) and is brushing her hair. What does the nurse document as an abnormal finding?

Pearly white substance that is attached to the hair shaft that is not removed with brushing

A nurse is preparing a patient with a history of allergies for diagnostic testing. Which of the following would the nurse anticipate as being most likely?

Patch testing

A client's blistering disorder has resulted in the formation of multiple lesions in the client's mouth. What intervention should be included in the client's plan of care?

Provide chlorhexidine solution for rinsing the client's mouth.

The home health nurse is caring for a homebound client who is terminally ill and is delivering a patient-controlled analgesia (PCA) pump at today's visit. The family members will be taking care of the client. What would the nurse's priority interventions be for this visit?

Provide client and family teaching regarding the operation of the pump, monitoring the IV site, and knowing the side effects of the medication.

The nurse assesses a patient with silvery-white, thick scales on the scalp, elbows, and hand that bleed when picked off. What does the nurse suspect that this patient may have?

Psoriasis

The nurse administers an opioid analgesic to a patient. What serious side effect should the nurse carefully monitor for?

Respiratory depression

The nurse documents a fissure on the plantar aspect of a patient's foot. Which image best depicts this lesion?

The third picture down. Looks like a crack in the heel.

A client waiting in the presurgical holding area asks the nurse, "Why exactly do they have to put a breathing tube into me? My surgery is on my knee." What is the best rationale for intubation during a surgical procedure that the nurse should describe?

The tube provides an airway for ventilation.

Which of the following is true regarding the use of narcotic analgesics in older adults?

There is an increased potential for falls related to sedation.

The circulating nurse is admitting a client prior to surgery and proceeds to greet the client and discuss what the client can expect in surgery. What aspect of therapeutic communication should the nurse implement?

Use a tone that decreases the client's anxiety.

It is important for the nurse to assist a postsurgical client to sit up and turn the head to one side when vomiting in order to

avoid aspiration

In which phase of perioperative care will the nurse prepare the client's skin, encourage the client to void, and remove the client's dentures?

preoperative

When a client who has been taking opioids becomes less sensitive to the drug's analgesic properties, that client is said to have developed a(n)

tolerance.

The nurse is admitting a client to the medical-surgical unit from the PACU. In order to help the client clear secretions and help prevent pneumonia, the nurse should encourage the client to:

use the incentive spirometer every 2 hours.

The circulating nurse is performing a skin preparation for a client who is unconscious from general anesthesia when the scrub nurse states, "I know her, she sure has gotten fat!" What is the best response by the circulating nurse?

"It is inappropriate to make comments even when clients appear to be unconscious from anesthesia."

Which of the following terms refers to a graft derived from one part of a patient's body and used on another part of that same patient's body?

Autograft

During the admission history the client reports to the nurse of taking the usual dose of warfarin the previous day. What is an appropriate nursing action?

Notify the surgeon that the client took warfarin the day before surgery.

What is the major purpose of withholding food and fluid before surgery?

Prevent aspiration

The nurse is educating a client scheduled for elective surgery. The client currently takes aspirin daily. What education should the nurse provide with regard to this medication?

Stop taking the aspirin 7 days before the surgery, unless otherwise directed by your physician.

An OR nurse is participating in an interdisciplinary audit of infection control practices in the surgical department. The nurse should know that a basic guideline for maintaining surgical asepsis is what?

Sterile surfaces or articles may touch other sterile surfaces.

The perioperative nurse is preparing to discharge a female client home from day surgery performed under general anesthetic. What instruction should the nurse give the client prior to the client leaving the hospital?

The client should not drive herself home.