305 Exam 3 Review :)
What is the removal of devitalized tissue from a wound called? A) Debridement B) Pressure distribution C) Negative-pressure wound therapy D) Sanitization
A) Debridement
A postoperative patient experiences tachypnea during the first hour of recovery. Which nursing intervention is a priority? A) Elevate the head of the patient's bed B) Give ordered oxygen through a mask at 4 L/min C) Ask the patient to use an incentive spirometer D) Position the patient on one side with the face down and the neck slightly extended so that the tongue falls forward
A) Elevate the head of the patient's bed
A nurse cares for a postoperative patient in the PACU. Upon assessment, the nurse finds the surgical dressing is saturated with serosanguineous drainage. Which interventions are a priority? (Select all that apply.) A) Notify surgeon B) Maintain the intravenous fluid infusion C) Provide 2 L/min of oxygen via nasal cannula D) Monitor the patient's vital signs every 5 to 10 minutes E) Reinforce the dressing
A) Notify surgeon E) Reinforce the dressing
A client with diabetes mellitus is admitted to the hospital for eye surgery. Which task does the nurse plan to delegate to the assistive personnel (AP)? A) Orient the client to the hospital surroundings B) Instruct the client on how to apply the eye drops C) Listen to the client express their frustration or loss D) Review hand-washing and hygiene practices with the client
A) Orient the client to the hospital surroundings
The nurse is providing discharge instructions to the client with lung cancer who has had a pneumonectomy and prepares a list of postoperative instructions for the client. Which intervention would the nurse include in the list? A) Report any signs of respiratory infection to the surgeon B) Avoid breathing exercises to allow the diaphragm to strengthen C) Avoid lifting any objects greater than 30 pounds for at least 3 weeks D) Contact the surgeon if any feelings of weakness and fatigue occur
A) Report any signs of respiratory infection to the surgeon
Match the characteristics on the left with the appropriate pain category: acute pain or chronic pain A. Has a protective effect B. Lasts more than 3 to 6 months C. Usually has identifiable cause D. Dramatically affects quality of life E. Viewed as a disease F. Eventually resolves with or without treatment
Acute pain: A, C, F Chronic pain: B, D, E
The nurse is preparing a patient for surgery. Which goal is a priority for assessing the patient before surgery? A. Plan for care after the procedure B. Establish a patient's baseline of normal function C. Educate patient and family about the procedure D. Gather appropriate equipment for the patient's needs.
B. Establish a patient's baseline of normal function
A patient is being discharged home on an around-the-clock (ATC) opioid for postoperative pain. Because of this order, the nurse anticipates an additional order for which class of medication? A) Opioid antagonists B) Antiemetics C) Stool softeners D) Muscle relaxants
C) Stool softeners
The nurse is caring for a patient in the post anesthesia care unit. The patient has developed profuse bleeding from the surgical site, and the surgeon has determined to need to return to the operative area. How will the nurse classify this procedure? A. Major B. Urgent C. Elective D. Emergency
D. Emergency
The nurse is caring for a client who has just returned from the post-anesthesia care unit after radical neck dissection. The nurse would assess for which characteristic of wound drainage expected in the immediate postoperative period? A) Serous B) Grossly bloody C) Serous with sputum D) Serosanguineous
D) Serosanguineous
A nurse is assigned to a new patient admitted to the medical unit. The nurse collects a nursing history and interviews the patient. Place the following steps for making a nursing diagnosis in the correct order. 1. Consider the context of patient's health problem and select a related factor. 2. Review assessment findings, noting objective and subjective clinical cues. 3. Cluster cues that form a pattern. 4. Gather thorough patient data about the patient's health problem. 5. Identify the nursing diagnosis. 6. Consider whether data are expected or unexpected based on the patient's problem.
4, 2, 3, 6, 1, 5
The nurse is preparing a client for surgery scheduled in 2 hours. Which interventions are appropriate in the preoperative period? Select all that apply. A) Assist the client to void before transfer to the operating room B) Check all surgeon's prescriptions to ensure that they have been carried out C) Teach postoperative breathing exercises before the client is premedicated D) Review the client's record for a history and physical report and laboratory reports E) Administer all the daily medications 2 hours before the scheduled time of the surgery
A) Assist the client to void before transfer to the operating room B) Check all surgeon's prescriptions to ensure that they have been carried out D) Review the client's record for a history and physical report and laboratory reports
Which assessment questions should the nurse ask a preoperative patient preparing for surgery? (Select all that apply.) A) "Are you experiencing any pain?" B) "Do you exercise on a daily basis?" C) "When do you regularly take your medications?" D) "Do you have any medication allergies?" E) "Do you use drugs and/or tobacco products?"
A) "Are you experiencing any pain?" D) "Do you have any medication allergies?" E) "Do you use drugs and/or tobacco products?"
The nurse is teaching a client about coughing and deep-breathing techniques to prevent postoperative complications. Which statement is most appropriate for the nurse to make to the client at this time as it relates to these techniques? A) "Use of an incentive spirometer will help prevent pneumonia." B) "Close monitoring of your oxygen saturation will detect hypoxemia." C) "Administration of intravenous fluids will prevent or treat fluid imbalance." D) "Early ambulation and administration of blood thinners will prevent pulmonary embolism."
A) "Use of an incentive spirometer will help prevent pneumonia."
During pre-operative assessment for a 7:30 AM surgery, the nurse finds the patient drink a cup of coffee this morning. The nurse reports this information to the anesthesia provider. Which action does the nurse anticipate next? A. A delay in or cancellation of surgery B. Questions regarding components of the coffee C. Additional questions about why the patient had coffee D. Instructions to determine what education was provided in the preoperative visit
A. A delay in or cancellation of surgery
The nurse is reviewing the surgical content with the patient during pre-operative education and finds the patient does not understand what procedure will be completed. What is the nurses best next step? A. Notify the healthcare provider about the patient question B. Explain the procedure that will be completed C. Continue with pre-operative education D. Ask the patient to sign the form
A. Notify the healthcare provider about the patient question
The nurse has completed a preoperative assessment for a patient going to surgery and gathers assessment data. Which will be the most important next step for the nurse to take? A. Notify the operating suite that the patient has a latex allergy B. Document that the patient had a bath at home this morning C. Administer the ordered pre-operative intervenous antibiotic D. Ask the nursing assistive personnel to obtain vital signs
A. Notify the operating suite that the patient has a latex allergy
The nurse is participating in a "time-out". In which activities will the nurse be involved? )Select all that apply.) A. Verify the correct site B. Verify the correct patient C. Verify the correct procedure D. Perform timeout after surgery E. Perform the actual marking off the operative site
A. Verify the correct site B. Verify the correct patient C. Verify the correct procedure
The nurse is caring for a postoperative patient on the medical surgical floor. Which activity will the nurse encourage to prevent venous stasis and the formation of thrombus? A. Diaphragmatic breathing B. Incentive Spirometry C. Leg exercises D. Coughing
C. Leg exercises
The nurse is caring for a group of post operative patient on the surgical unit. Which patient assessments indicate the nurse needs to follow up? (Select all that apply.) A. Patient with abdominal surgery has patent airway B. Patient with knee surgery has approximated incision C. Patient with femoral artery surgery has strong pedal pulse D. Patient with lung surgery has 20 mL/hr of urine output be a catheter E. Patient with bladder surgery has bloody urine within the first 12 hours F. Patient with appendix surgery has thready pulse and blood pressure is 90/60
D. Patient with lung surgery has 20 mL/hr of urine output be a catheter F. Patient with appendix surgery has thready pulse and blood pressure is 90/60
A health care provider writes the following order for a patient who is opioid naïve who returned from the operating room after a total hip replacement: "Fentanyl patch 100 mcg; change every 3 days." On the basis of this order, the nurse takes the following action: A) Calls the health care provider and questions the order B) Applies the patch the third postoperative day C) Applies the patch as soon as the patient reports pain D) Places the patch as close to the hip dressing as possible
A) Calls the health care provider and questions the order
The nurse is assessing a client who had abdominal surgery earlier in the day. Which preexisting medical condition would place the client at most risk for postoperative complications? A) Pacemaker B) Osteoporosis C) Alcohol abuse D) Peptic ulcer disease
C) Alcohol abuse
A client is admitted to a surgical unit postoperatively with a wound drain in place. Which actions would the nurse take in the care of the drain? Select all that apply. A) Check the drain for patency B) Observe for bright red bloody drainage C) Clamp the drain for 15 minutes every hour D) Curl the drain tightly, and tape it firmly to the body E) Maintain aseptic technique when emptying the drain
A) Check the drain for patency B) Observe for bright red bloody drainage E) Maintain aseptic technique when emptying the drain
A patient who returned from surgery 3 hours ago following a kidney transplant is reporting pain at a 7 on a scale of 0 to 10. The nurse has tried repositioning with no improvement in the patient's pain report. Unmanaged surgical pain can lead to which of the following problems? (Select all that apply.) A) Delayed ambulation B) Reduced ventilation C) Catheter-associated urinary tract infection D) Retained pulmonary secretions E) Reduced appetite
A) Delayed ambulation B) Reduced ventilation D) Retained pulmonary secretions E) Reduced appetite
Which is the best intervention the nurse should implement to promote bowel function? A) Early ambulation B) Deep-breathing exercises C) Repositioning on the left side D) Lowering the head of the patient's bed
A) Early ambulation
The registered nurse (RN) is planning her client assignments for the day. The RN has a licensed practical nurse and an assistive personnel (AP) on the team. Which task would the RN delegate to the AP? A) Empty a client's urinary catheter bag B) Instruct a client on their new diabetic diet C) Teach a client how to check their blood glucose D) Evaluate a newly admitted client's home medications
A) Empty a client's urinary catheter bag
The nurse is preparing a preoperative client for transfer to the operating room. The nurse would take which action in the care of this client at this time? A) Ensure that the client has voided B) Administer all the daily medications C) Verify that the client has not eaten for the past 24 hours D) Have the client practice postoperative breathing exercises
A) Ensure that the client has voided
A registered nurse is delegating activities to the nursing staff. Which activities are most appropriate for the assistive personnel (AP)? Select all that apply. A) Collecting a urine specimen from a client B) Obtaining frequent oral temperatures on a client C) Accompanying a client being discharged to their transportation to home D) Assisting a postcardiac catheterization client who needs to lie flat to eat lunch E) Monitoring the amounts of fluid remaining in intravenous (IV) solution bags for a client receiving IV fluids
A) Collecting a urine specimen from a client B) Obtaining frequent oral temperatures on a client C) Accompanying a client being discharged to their transportation to home
A client who has had abdominal surgery complains of feeling as though "something gave way" in the incisional site. The nurse removes the dressing and notes the presence of a loop of bowel protruding through the incision. Which interventions would the nurse take? Select all that apply. A) Contact the surgeon B) Instruct the client to remain quiet C) Prepare the client for wound closure D) Document the findings and actions taken E) Place a sterile saline dressing and ice packs over the wound F) Place the client in a supine position without a pillow under the head.
A) Contact the surgeon B) Instruct the client to remain quiet C) Prepare the client for wound closure D) Document the findings and actions taken
Which of the following signs or symptoms in a patient who is opioid naïve is of greatest concern to the nurse when assessing the patient 1 hour after administering an opioid? A) Oxygen saturation of 95% B) Difficulty arousing the patient C) Respiratory rate of 12 breaths/min D) Pain intensity rating of 5 on a scale of 0 to 10
B) Difficulty arousing the patient
The nurse is teaching a client about coughing and deep-breathing techniques to prevent postoperative complications. Which statement is most appropriate for the nurse to make to the client relating to these techniques? A) "Use of an incentive spirometer will help prevent pneumonia." B) "Close monitoring of your oxygen saturation will detect hypoxemia." C) "Administration of intravenous fluids will prevent or treat fluid imbalance." D) "Early ambulation and the administration of blood thinners will prevent pulmonary embolism."
A) "Use of an incentive spirometer will help prevent pneumonia."
A client is recovering well 24 hours after cranial surgery but is fatigued. The surgeon advances the client from nothing-by-mouth status to clear liquids. The nurse knows that which information is least reliable in determining the client's readiness to take in fluids? A) Appetite B) Absence of nausea C) Presence of bowel sounds D) Presence of a swallow reflex
A) Appetite
When using ice massage for pain relief, which of the following is correct? (Select all that apply.) A) Apply ice using firm pressure over the skin B) Apply ice for 5 minutes or until numbness occurs C) Apply ice no more than 3 times a day D) Limit application of ice to no longer than 10 minutes E) Use a slow, circular steady massage
A) Apply ice using firm pressure over the skin B) Apply ice for 5 minutes or until numbness occurs E) Use a slow, circular steady massage
In preparation for ambulation, the nurse is planning to assist a postoperative client to progress from a lying position to a sitting position. Which nursing action is appropriate to maintain the safety of the client? A) Assess the client for signs of dizziness and hypotension B) Allow the client to rise from the bed to a standing position unassisted C) Elevate the head of the bed quickly to assist the client to a sitting position D) Assist the client to move quickly from the lying position to the sitting position.
A) Assess the client for signs of dizziness and hypotension
The nurse receives a telephone call from the postanesthesia care unit stating that a client who had abdominal surgery is being transferred to the surgical unit. The nurse plans to take which action first on arrival of the client? A) Assess the patency of the airway B) Check tubes or drains for patency C) Check the dressing to assess for bleeding D) Assess the vital signs to compare with preoperative measurements
A) Assess the patency of the airway
The nurse is caring for a postoperative client who has just returned from the post-anesthesia care unit after having nasal surgery. What priority action is essential for the nurse to perform? A) Assessing how often the client swallows B) Checking vital signs per agency protocol C) Viewing the external packing for bleeding D) Ensure intravenous fluids are administered and infusing at the prescribed rate
A) Assessing how often the client swallows
Which of the following statements correctly describes the evaluation process? (Select all that apply.) A) Evaluation involves reflection on the approach to care B) Evaluation involves determination of the completion of a nursing intervention C) Evaluation involves making clinical decisions D) Evaluation requires the use of assessment skills E) Evaluation is performed only when a patient's condition changes
A) Evaluation involves reflection on the approach to care C) Evaluation involves making clinical decisions D) Evaluation requires the use of assessment skills
Which skin-care measures are used to manage a patient who is experiencing fecal and/or urinary incontinence? (Select all that apply.) A) Frequent position changes B) Keeping the buttocks exposed to air at all times C) Using a large absorbent diaper, changing when saturated D) Using an incontinence cleaner E) Applying a moisture barrier ointment
A) Frequent position changes D) Using an incontinence cleaner E) Applying a moisture barrier ointment
Which nursing assessment will indicate the patient is performing diaphragmatic breathing correctly? A. Hands placed on the border of the rib cage with fingers extended will touch as the chest wall contracts B. Hands placed on the chest wall with fingers extended will separate as the chest wall contracts C. Patient of feel upward movement of the diaphragm during inspiration D. Patient will feel downward movement of the diaphragm during expiration
A. Hands placed on the border of the rib cage with fingers extended will touch as the chest wall contracts
The nurse is caring for a patient in the post anesthesia care unit who has undergone a left total knee arthroplasty. The anesthesia provider has indicated that the patient received a left femoral peripheral nerve block. Which assessment will be an expected finding for this patient? A. Sensation decreased in the left leg B. Patient report of pain in the left foot C. Pulse decrease at the left posterior tubular D. Left toes cool to touch and slightly cyanotic
A. Sensation decreased in the left leg
An 85-year-old client is hospitalized for a fractured right hip. During the postoperative period, the client's appetite is poor and the client refuses to get out of bed. Which nursing statement would be most appropriate to make to the client? A) "We need to give you iodine to help in hemoglobin synthesis." B) "It is important for you to get out of bed so that calcium will go back into the bone." C) "We need to increase your calcium intake because you are spending too much time in bed." D) "You need to remember to turn yourself in bed every 2 hours to keep from getting so stiff."
B) "It is important for you to get out of bed so that calcium will go back into the bone."
The nurse is performing discharge teaching for a patient with chronic obstructive pulmonary disease (COPD). What statement, made by the patient, indicates the need for further teaching? A) "Pursed-lip breathing is like exercise for my lungs and will help me strengthen my breathing muscles." B) "When I am sick, I should limit the amount of fluids I drink so that I don't produce excess mucus." C) "I will ensure that I receive an influenza vaccine every year, preferably in the fall." D) "I will look for a smoking-cessation support group in my neighborhood."
B) "When I am sick, I should limit the amount of fluids I drink so that I don't produce excess mucus."
The nurse cares for a client prior to surgery. The client asks the nurse, "What is the advantage of spinal anesthesia over general anesthesia for controlling my pain?" Which is the best response by the nurse? A) "There is less risk of developing a low blood pressure." B) "Your pain can be managed without making you as sleepy." C) "Itching, a side effect of the morphine, will be minimized." D) "You will be able to maintain control of your bladder function."
B) "Your pain can be managed without making you as sleepy."
The nurse is planning the client assignments for the shift. Which client would the nurse assign to the assistive personnel (AP)? A) A client requiring dressing changes B) A client requiring frequent temperature measurements C) A client on a bowel management program requiring rectal suppositories and a daily enema D) A client with diabetes mellitus requiring daily insulin and reinforcement of dietary measures
B) A client requiring frequent temperature measurements
The nurse is caring for a pre-operative patient. The nurse teaches the principles and demonstrates leg exercises for the patient. The patient is unable to perform leg exercises correctly. What is the nurses best next step? A. Encourage the patient to practice at a later date B. Assess for the presence of anxiety , pain, or fatigue C. Ask the patient why exercises are not being done D. Evaluate the educational methods of use to educate patient
B. Assess for the presence of anxiety , pain, or fatigue
The nurse explains the pain relief measures available after surgery during pre-operative teaching for a surgical patient. Which comment from the patient indicates the need for additional education on this topic? A. I will be asked to rate my pain on a pain scale B. I will have minimal pain because of the anesthesia C. I will take the pain medication as a provider prescribed it D. I will take my pain medications before doing post operative exercises
B. I will have minimal pain because of the anesthesia
The nurse has administered a pre-operative medication to the patient going to surgery. Which action will the nurse take next? A. Notify the operating suite that the medication has been given B. Instruct the patient to call for help to go to the restroom C. Waste any unused medication according to policy D. I asked the patient to sign the consent for surgery.
B. Instruct the patient to call for help to go to the restroom
The nurse is caring for a patient who is scheduled to undergo a surgical procedure. The nurse is completing an assessment and reviews the patient's laboratory test and allergies and prepares the patient for surgery. In which Perioperative nursing phase is the nurse working? A. Perioperative B. Pre-operative C. Intraoperative D. Post operative
B. Pre-operative
The nurse is encouraging the postoperative patient to utilize diaphragmatic breathing. Which priority goal is the nurse trying to achieve? A. Manage pain B. Prevent atelectasis C. Reduce healing time D. Decrease thrombus formation
B. Prevent atelectasis
The patient has presented to the ambulatory surgery center to have a colonoscopy. The patient is scheduled to receive moderate sedation (conscious sedation) during the procedure. How would the nurse interpret this information? A. The procedure results in loss of sensation in an area of the body B. The procedure requires a depressed level of consciousness C. The procedure will be performed on an outpatient basis D. The procedure necessitates the patient to be immobile
B. The procedure requires a depressed level of consciousness
A preoperative client expresses anxiety to the nurse about upcoming surgery. Which response by the nurse is most likely to stimulate further discussion between the client and the nurse? A) "If it's any help, everyone is nervous before surgery." B) "I will be happy to explain the entire surgical procedure to you." C) "Can you share with me what you've been told about your surgery?" D) "Let me tell you about the care you'll receive after surgery and the amount of pain you can anticipate."
C) "Can you share with me what you've been told about your surgery?"
The nurse has conducted preoperative teaching for a client scheduled for surgery in 1 week. The client has a history of rheumatoid arthritis and has been taking acetylsalicylic acid. The nurse determines that the client needs additional teaching if the client makes which statement? A) "Aspirin can cause bleeding after surgery." B) "Aspirin can cause my ability to clot blood to be abnormal." C) "I need to continue to take the aspirin until the day of surgery." D) "I need to check with my surgeon about the need to stop the aspirin before the scheduled surgery."
C) "I need to continue to take the aspirin until the day of surgery."
The nurse is caring for a client who is mechanically ventilated and is monitoring for complications of mechanical ventilation. Which assessment finding, if noted by the nurse, indicates the need for follow-up? A) Muscle weakness in the arms and legs B) A temperature of 98.6° F (37° C), decreased from 99.0° F (37.2° C) C) A blood pressure of 90/60 mm Hg, decreased from 112/78 mm Hg D) A heart rate of 80 beats/minute, decreased from 85 beats/minute
C) A blood pressure of 90/60 mm Hg, decreased from 112/78 mm Hg
A client is admitted to the ambulatory surgery center for elective surgery. The nurse asks the client whether any food, fluid, or medication was taken today. Which medication, if taken by the client, would indicate to the nurse the need to contact the surgeon? A) A beta-blocker B) An antibiotic C) An anticoagulant D) A calcium-channel blocker
C) An anticoagulant
The nurse is making a pre-operative education appointment with a patient. The patient asked if a family member should come to the appointment. Which is the best response by the nurse? A. "There is no need for an additional person at the appointment." B. "Your family can come and wait with you in the waiting room." C. "We recommend including family members at this appointment." D. "It is required that you have a family member at this appointment."
C. "We recommend including family members at this appointment."
The nurse is caring for a surgical patient when the family member asked what perioperative nursing means. How should the nurse respond? A. Perioperative nursing occurs in preadmission testing B. Perioperative nursing occurs primarily in the post anesthesia care unit C. Perioperative nursing includes activities before, during, and after surgery D. Perioperative nursing includes activities only during the surgical procedure.
C. Perioperative nursing includes activities before, during, and after surgery
When creating an assignment for a team consisting of a registered nurse (RN), a licensed practical nurse (LPN), and two assistive personnel (APs), which is the best client for the LPN? A) A client requiring frequent temperature checks B) A client requiring assistance with ambulation every 4 hours C) A client on a mechanical ventilator requiring frequent assessment and suctioning D) A client with a spinal cord injury requiring urinary catheterization every 6 hours
D) A client with a spinal cord injury requiring urinary catheterization every 6 hours
The registered nurse is creating the plan for client assignments for the day. Which is the most appropriate assignment for the assistive personnel (AP)? A) A client scheduled to receive a blood transfusion B) A client with bladder cancer who will be receiving chemotherapy C) A client newly diagnosed with diabetes mellitus scheduled for discharge D) A client on bed rest who requires range-of-motion (ROM) exercises every 4 hours
D) A client on bed rest who requires range-of-motion (ROM) exercises every 4 hours
The nurse provides instructions to a preoperative client about the use of an incentive spirometer. The nurse determines that the client needs further instruction if the client indicates will take which action? A) Sit upright when using the device B) Inhale slowly, maintaining a constant flow C) Place the lips completely over the mouthpiece D) After maximal inspiration, hold the breath for 10 seconds and then exhale
D) After maximal inspiration, hold the breath for 10 seconds and then exhale
The nurse is monitoring the status of a postoperative client in the immediate postoperative period. The nurse would become most concerned with which sign that could indicate an evolving complication? A) Increasing restlessness B) A pulse of 86 beats/min C) Blood pressure of 110/70 mm Hg D) Hypoactive bowel sounds in all four quadrants
A) Increasing restlessness
Which assessment findings indicate that the patient is experiencing an acute disturbance in oxygenation and requires immediate intervention? (Select all that apply.) A) SpO2 value of 95% B) Chest retractions C) Respiratory rate of 28 breaths per minute D) Nasal flaring E) Clubbing of fingers
B) Chest retractions C) Respiratory rate of 28 breaths per minute D) Nasal flaring
The nurse is caring for a patient with pneumonia. On entering the room, the nurse finds the patient lying in bed, coughing, and unable to clear secretions. What should the nurse do first? A) Start oxygen at 2 L/min via nasal cannula B) Elevate the head of the bed to 45 degrees C) Encourage the patient to use the incentive spirometer D) Notify the health care provider
B) Elevate the head of the bed to 45 degrees
Which finding in a postoperative client would be of concern to the nurse? A) Urinary output of 40 mL/hr B) Temperature of 37.6° C (99.6° F) C) Blood pressure of 88/52 mm Hg D) Moderate drainage on the surgical dressing
C) Blood pressure of 88/52 mm Hg
The nurse is assessing the perineal wound in a client who has returned from the operating room following an abdominal perineal resection and notes serosanguineous drainage from the wound. Which nursing intervention is most appropriate? A) Notify the surgeon B) Clamp the surgical drain C) Change the dressing as prescribed D) Remove and replace the perineal packing
C) Change the dressing as prescribed
The nurse is creating a plan of care for a client scheduled for surgery. The nurse would include which activity in the nursing care plan for the client on the day of surgery? A) Avoid oral hygiene and rinsing with mouthwash B) Verify that the client has not eaten for the last 24 hours C) Have the client void immediately before going into surgery D) Report immediately any slight increase in blood pressure or pulse
C) Have the client void immediately before going into surgery
The nurse is reviewing the ventilator settings on a client with an endotracheal tube attached to mechanical ventilation. The nurse notes that the tidal volume is set at 500 mL. How does the nurse interpret this setting? A) It is the amount of air delivered with each set breath B) It is a breath that has a greater volume than the preset tidal volume C) It is the number of breaths that the client will receive per minute by the ventilator D) It is the fraction of inspired oxygen (FiO2) that is delivered to the client through the ventilator.
A) It is the amount of air delivered with each set breath
After surgery the patient with a closed abdominal wound reports a sudden "pop" after coughing. When the nurse examines the surgical wound site, the sutures are open, and small bowel sections are observed at the bottom of the now-opened wound. Which are the priority nursing interventions? (Select all that apply.) A) Notify the health care provider B) Allow the area to be exposed to air until all drainage has stopped C) Place several cold packs over the area, protecting the skin around the wound D) Cover the area with sterile, saline-soaked towels immediately E) Cover the area with sterile gauze and apply an abdominal binder
A) Notify the health care provider D) Cover the area with sterile, saline-soaked towels immediately
The nurse prepares a patient with type 2 diabetes for a surgical procedure. The patient weighs 112.7 kg (248 lb) and is 157.4 cm (5 feet, 2 inches) in height. Which factors increase this patient's risk for surgical complications? (Select all that apply.) A) Obesity B) Prolonged bleeding time C) Delayed wound healing D) Ineffective vital capacity E) Immobility secondary to height
A) Obesity C) Delayed wound healing
The nurse is caring for a client who underwent an open reduction internal fixation to the right hip. When administering opioid analgesics for pain, the nurse would instruct the client that which are side and adverse effects of opioid analgesics? Select all that apply. A) Sedation B) Diarrhea C) Constipation D) Increased pain level E) Respiratory depression
A) Sedation C) Constipation E) Respiratory depression
An 85-year-old patient returns to the inpatient surgical unit after leaving the PACU. Which of the following place the patient at risk during surgery? (Select all that apply.) A) Stiffened lung tissue B) Reduced diaphragmatic excursion C) Increased laryngeal reflexes D) Reduced blood flow to kidneys E) Increased cholinergic transmission
A) Stiffened lung tissue B) Reduced diaphragmatic excursion D) Reduced blood flow to kidneys
The nurse has just reassessed the condition of a postoperative client who was admitted 1 hour ago to the surgical unit. The nurse plans to monitor which parameter most carefully during the next hour? A) Urinary output of 20 mL/hr B) Temperature of 37.6° C (99.6° F) C) Blood pressure of 100/70 mm Hg D) Serous drainage on the surgical dressing
A) Urinary output of 20 mL/hr
Which of the following are measures to reduce tissue damage from shear? (Select all that apply.) A) Use a transfer device (e.g., transfer board) B) Have head of bed elevated when transferring patient C) Have head of bed flat when repositioning patient D) Raise head of bed 60 degrees when patient is positioned supine E) Raise head of bed 30 degrees when patient is positioned supine
A) Use a transfer device (e.g., transfer board) C) Have head of bed flat when repositioning patient E) Raise head of bed 30 degrees when patient is positioned supine
The nurse is caring for a client who is mechanically ventilated, and the high-pressure ventilator alarm is sounding. The nurse understands that which complications may cause this alarm? Select all that apply. A) Water or a kink in the tubing B) Biting on the endotracheal tube C) Increased secretions in the airway D) Disconnection or leak in the system E) The client ceasing spontaneous breathing
A) Water or a kink in the tubing B) Biting on the endotracheal tube C) Increased secretions in the airway
The nurse in a surgical unit receives a postoperative client from the post-anesthesia care unit. After the initial assessment of the client, the nurse would plan to continue with postoperative assessment activities how often? A) Every hour for 2 hours and then every 4 hours as needed B) Every 30 minutes for the first hour, every hour for 2 hours, and then every 4 hours as needed C) Every 15 minutes for the first hour, every 30 minutes for 2 hours, every hour for 4 hours, and then every 4 hours as needed D) Every 5 minutes for the first half-hour, every 15 minutes for 2 hours, every 30 minutes for 4 hours, and then every hour as needed
C) Every 15 minutes for the first hour, every 30 minutes for 2 hours, every hour for 4 hours, and then every 4 hours as needed
The registered nurse is planning the client assignments for the day. Which is the most appropriate assignment for the assistive personnel (AP)? A) A client scheduled to receive parenteral nutrition B) A client who requires assistance with ambulation every 4 hours C) A client scheduled for discharge who needs teaching about medications D) A client with bladder cancer who is scheduled for a cardiac catheterization
B) A client who requires assistance with ambulation every 4 hours
A nurse's assessment reveals a patient having frequent voiding and pain when she urinates. Her body temperature is 38°C (100.4°F). The nurse asks whether she has to go to the bathroom at night, and the patient responds, "Yes." When asked how often, the patient replies, "About three times a night." The nurse asks if having to urinate at night is recent or normal for the patient. The patient explains, "I usually go once a night but that is all." The nurse then asks, "When you feel the need to go, can you reach the toilet in time?" The patient says, "Oh, yes, I can." The nurse asks, "And have you had any leaking of urine?" The patient denies leaking. When asked if she is having any back or abdominal pain, the patient denies discomfort. The nurse then gathers a urine specimen from the patient and inspects its character, noting it is cloudy and foul smelling. Which of the following nursing diagnoses are indicated by cues in this patient's assessment? A) Impaired Kidney Function B) Impaired Urination C) Urge Incontinence of Urine D) Total Urinary Incontinence
B) Impaired Urination
When a client is transferred from the post-anesthesia care unit and arrives on the surgical unit, which would be the first action taken by the nurse? A) Assess the client's pain B) Obtain the client's vital signs C) Administer oxygen to the client D) Check the rate of the intravenous infusion
B) Obtain the client's vital signs
A nurse conducts an assessment of a 42-year-old woman at a health clinic. The woman is married and lives in an apartment with her husband. She reports having frequent voiding and pain when she passes urine. The nurse asks whether she has to go to the bathroom at night, and the patient responds, "Yes." The patient had an episode of diarrhea 1 week ago. She weighs 136 kg (300 lb). The nurse documents the assessment findings listed below. Which of the assessment findings require priority follow-up by the nurse? (Select all that apply.) A) The patient has no history of chronic disease B) Patient urinates at night C) Patient reports having difficulty cleansing herself after voiding or passing stool D) Body temperature 38°C (100.4°F) E) Recent history of weight gain F) Knowledge of perineal care G) Last normal bowel movement 2 days ago H) Frequency of diarrhea
B) Patient urinates at night C) Patient reports having difficulty cleansing herself after voiding or passing stool D) Body temperature 38°C (100.4°F) E) Recent history of weight gain F) Knowledge of perineal care H) Frequency of diarrhea
The nurse is responsible for the care of a client with schizophrenia who has begun to experience hallucinations more frequently. Which activity in the care of the client can be most appropriately delegated to an assistive personnel (AP)? A) Determining whether the client has consistently been medication compliant B) Providing distraction for the client by engaging the client in a board game C) Discussing the frequency and duration of the hallucinations with the client D) Assisting the client in identifying any new stressors he or she may be experiencing
B) Providing distraction for the client by engaging the client in a board game
A client with a tracheostomy tube who is on a ventilator is at risk for reduced gas exchange. The nurse would assess for which finding as the best indicator of adequate ongoing respiratory status? A) Oxygen saturation of 89% B) Respiratory rate of 16 breaths/minute C) Moderate amounts of tracheobronchial secretions D) Small to moderate amounts of frank blood suctioned from the tube
B) Respiratory rate of 16 breaths/minute
Review the following nursing diagnoses and identify the diagnoses that are stated correctly. (Select all that apply.) A) Offer frequent skin care because of Impaired Skin Integrity B) Risk for Infection C) Chronic Pain related to osteoarthritis evidenced by reduced hip range of motion D) Activity Intolerance related to physical deconditioning evidenced by exertional dyspnea E) Lack of Knowledge related to laser surgery
B) Risk for Infection D) Activity Intolerance related to physical deconditioning evidenced by exertional dyspnea
The nurse assesses a client's surgical incision for signs of infection. Which finding by the nurse would be interpreted as a normal finding at the surgical site? A) Red, hard skin B) Serous drainage C) Purulent drainage D) Warm, tender skin
B) Serous drainage
The nurse is providing preoperative teaching to a client scheduled for a laparoscopic cholecystectomy. Which intervention would be of highest priority in the preoperative teaching plan? A) Teaching leg exercises B) Teaching coughing and deep-breathing exercises C) Providing instructions regarding food and fluid restrictions D) Assessing the client's understanding of the surgical procedure
B) Teaching coughing and deep-breathing exercises
A nurse is assigned to five patients, including one who was recently admitted and one returning from a diagnostic procedure. It is currently mealtime. The other three patients are stable, but one has just requested a pain medication. The nurse is working with an assistive personnel. Which of the following are appropriate delegation actions on the part of the nurse? (Select all that apply.) A) The nurse directs the assistive personnel to obtain a set of vital signs on the patient returning from the diagnostic procedure B) The nurse directs the assistive personnel to go to the patient in pain and to reposition and offer comfort measures until the nurse can bring an ordered analgesic to the patient C) The nurse directs the assistive personnel to set up meal trays for patients D) The nurse directs the assistive personnel to gather a history from the newly admitted patient about his medications E) The nurse directs the assistive personnel to assist one of the stable patients to sit up in a chair for his meal
B) The nurse directs the assistive personnel to go to the patient in pain and to reposition and offer comfort measures until the nurse can bring an ordered analgesic to the patient C) The nurse directs the assistive personnel to set up meal trays for patients E) The nurse directs the assistive personnel to assist one of the stable patients to sit up in a chair for his meal
An oxygen delivery system is prescribed for a client with chronic obstructive pulmonary disease to deliver a precise oxygen concentration. Which oxygen delivery system would the nurse prepare for the client? A) Face tent B) Venturi mask C) Aerosol mask D) Tracheostomy collar
B) Venturi mask
A client has a prescription for continuous monitoring of oxygen saturation by pulse oximetry for a preoperative client. The nurse would perform which best action to ensure accurate readings on the oximeter? A) Apply the sensor to a finger that is cool to the touch B) Apply the sensor to a finger with very dark nail polish C) Ask the client to limit motion in the hand attached to the pulse oximeter D) Place the sensor distal to an intravenous (IV) site with a continuous IV infusion.
C) Ask the client to limit motion in the hand attached to the pulse oximeter
A client who is mouth breathing is receiving oxygen by face mask. The assistive personnel (AP) asks the registered nurse (RN) why a water bottle is attached to the oxygen tubing near the wall oxygen outlet. The RN responds that this feature facilitates which purpose? A) Prevents the client from getting a nosebleed B) Gives the client added fluid via the respiratory tree C) Humidifies the oxygen that is bypassing the client's nose D) Prevents fluid loss from the lungs during mouth breathing
C) Humidifies the oxygen that is bypassing the client's nose
The nurse has instructed a preoperative client using an incentive spirometer to sustain the inhaled breath for 3 seconds. When the client asks about the rationale for this action, the nurse explains that this action achieves which function? A) Dilates the major bronchi B) Increases surfactant production C) Maintains inflation of the alveoli D) Enhances ciliary action in the tracheobronchial tree
C) Maintains inflation of the alveoli
An operating room nurse is positioning a client on the operating room table to prevent the client's extremities from dangling over the sides of the table. A nursing student who is observing for the day asks the nurse why this is so important. The nurse responds that this is done primarily to prevent which condition? A) An increase in pulse rate B) A drop in blood pressure C) Nerve and muscle damage D) Muscle fatigue in the extremities
C) Nerve and muscle damage
A nurse working the evening shift has five patients and is teamed up with an assistive personnel. One of the assigned patients has just returned from surgery, one is newly admitted, and one has requested a pain medication. The patient who has returned from surgery just minutes ago has a large abdominal dressing, is still on oxygen by nasal cannula, and has an intravenous line. One of the other patients has just called out for assistance in setting up a meal tray. Another patient is stable and resting comfortably. Which patient is the nurse's current greatest priority? A) Patient in pain B) Patient newly admitted C) Patient who returned from surgery D) Patient requesting assistance with meal tray
C) Patient who returned from surgery
A nurse interviews and conducts a physical examination of a patient that includes the following findings: reduced range of motion of lower hip, reduced strength in left leg, and difficulty turning in bed without assistance. This data set is an example of: A) Collaborative data set B) Diagnostic label C) Related factors D) Data cluster E) Validated data set
C) Related factors
A client arrives at the surgical unit after undergoing rhinoplasty and has a nose splint and gauze drip (moustache dressing) in place. The nurse reviews the primary health care provider's prescriptions and anticipates that which client position will be prescribed? A) Prone B) Supine C) Semi-Fowler's D) Lateral side-lying
C) Semi-Fowler's
The nurse is delegating the morning hygienic care to the assistive personnel (AP). In reviewing the assigned tasks, the nurse would instruct the AP to use an electric razor for which client? A) The client with severe pain related to osteoporosis B) The client with hypokalemia related to diuretic therapy C) The client with thrombocytopenia related to chemotherapy D) The client with an elevated white blood cell count related to infection
C) The client with thrombocytopenia related to chemotherapy
Which postoperative intervention best prevents atelectasis? A) Use of intermittent compression stockings B) Heel-toe flexion C) Use of the incentive spirometer D) Abdominal splinting when coughing
C) Use of the incentive spirometer
Which skills can the nurse delegate to assistive personnel (AP)? (Select all that apply.) A) Initiate oxygen therapy via nasal cannula B) Perform nasotracheal suctioning of a patient C) Educate the patient about the use of an incentive spirometer D) Assist with care of an established tracheostomy tube E) Reposition a patient with a chest tube
D) Assist with care of an established tracheostomy tube E) Reposition a patient with a chest tube
A gastrectomy is performed on a client with gastric cancer. In the immediate postoperative period, the nurse notes bloody drainage from the nasogastric tube. The nurse would take which most appropriate action? A) Notify the surgeon B) Measure abdominal girth C) Irrigate the nasogastric tube D) Continue to monitor the drainage
D) Continue to monitor the drainage
The nurse prepares a client 1 hour prior to surgery. Which assessment finding does the nurse need to communicate to the surgeon at this time? A) Allergy to peanuts B) Potassium is 3.6 mEq/L (3.6 mmol/L) C) History of obstructive sleep apnea D) Daily garlic capsules, last dose yesterday morning
D) Daily garlic capsules, last dose yesterday morning
To prevent postoperative atelectasis in a client recovering from an open cholecystectomy, what would the nurse do first? A) Request a cardiopulmonary consult B) Teach the client to splint the incision C) Teach the proper technique for huff coughing D) Ensure that the client is experiencing adequate pain control
D) Ensure that the client is experiencing adequate pain control
A nurse assesses a 78-year-old patient who weighs 108.9 kg (240 lb) and is partially immobilized because of a stroke. The nurse turns the patient and finds that the skin over the sacrum is very red and the patient does not feel sensation in the area. The patient has had fecal incontinence on and off for the last two days. The nurse identifies the nursing diagnosis of Risk for Impaired Skin Integrity. Which of the following outcomes is appropriate for the patient? A) Patient will be turned every two hours within 24 hours B) Patient will have normal formed stool within 48 hours C) Patient's ability to turn self in bed improves D) Erythema of skin will be mild to none within 48 hours
D) Erythema of skin will be mild to none within 48 hours
The nurse is giving a report to an assistive personnel (AP) who will be caring for a client who has hand restraints (safety devices). The nurse instructs the AP to check the skin integrity of the restrained hands how frequently? A) Every 2 hours B) Every 3 hours C) Every 4 hours D) Every 30 minutes
D) Every 30 minutes
A client who has undergone radical neck dissection is experiencing problems with verbal communication related to postoperative hoarseness. The nurse would formulate which outcome as the most appropriate goal for this client problem? A) Uses nonverbal communication only B) Describes that hoarseness will be permanent C) Initiates communication only when necessary D) Incorporates nonverbal forms of communication as needed
D) Incorporates nonverbal forms of communication as needed
A client with a gastric ulcer is scheduled for surgery. The client cannot sign the operative consent form because of sedation from opioid analgesics that have been administered. The nurse would take which most appropriate action in the care of this client? A) Obtain a court order for the surgery B) Have the charge nurse sign the informed consent immediately C) Send the client to surgery without the consent form being signed D) Obtain a telephone consent from a family member, following agency policy
D) Obtain a telephone consent from a family member, following agency policy
The nurse is caring for a client who recently returned from the operating room. On data collection, the nurse notes that the client's vital signs are blood pressure (BP), 118/70 mm Hg; pulse, 81 beats/min; and respirations, 16 breaths/min. Preoperative vital signs were BP, 132/88 mm Hg; pulse, 74 beats/min; and respirations, 20 breaths/min. Which action would the nurse plan to take first? A) Call the surgeon immediately B) Shake the client gently to arouse C) Cover the client with a warm blanket D) Recheck the vital signs in 15 minutes
D) Recheck the vital signs in 15 minutes
The nurse is caring for a patient with an abdominal obstruction. The nurse irrigates the patient's nasogastric tube and reports the amount of fluid aspirated from the patient's stomach to the health care provider. The patient has an IV infusing; the nurse changes the transparent dressing over the IV site and instructs the patient to report any tenderness at the site. Which of these interventions is an indirect care measure? A) Irrigation of nasogastric tube B) Changing of transparent dressing C) Instructing patient to report tenderness at IV site D) Report of the amount of fluid aspirated
D) Report of the amount of fluid aspirated
A client has just returned to a nursing unit after an above-knee amputation of the right leg. The nurse would place the client in which position? A) Prone B) Reverse Trendelenburg's C) Supine, with the residual limb flat on the bed D) Supine, with the residual limb supported with pillows
D) Supine, with the residual limb supported with pillows
The nurse is conducting preoperative teaching with a client about the use of an incentive spirometer. The nurse would include which piece of information in discussions with the client? A) Inhale as rapidly as possible B) Keep a loose seal between the lips and the mouthpiece C) After maximum inspiration, hold the breath for 15 seconds and exhale D) The best results are achieved when sitting up or with the head of the bed elevated to 45 to 90 degrees
D) The best results are achieved when sitting up or with the head of the bed elevated to 45 to 90 degrees
