Adult Final Review Questions

A 49-yr-old patient tells the nurse that she is 3 years postmenopausal but has recently had occasional spotting. Which initial response would the nurse provide?

"Are you using hormone replacement therapy?" In postmenopausal women, a common cause of spotting is hormone replacement therapy. Because breakthrough bleeding may be a sign of problems such as cancer or infection, the nurse would not imply that this is normal. The length of time since the last menstrual period is not relevant to the patient's symptoms. Although endometrial cancer may cause spotting, this information is not appropriate as an initial response.

A patient with a venous thromboembolism (VTE) has new prescriptions for enoxaparin (Lovenox) and warfarin (Coumadin). The patient asks the nurse why two medications are necessary. Which response by the nurse is accurate? "Enoxaparin works right away, but warfarin takes several days to prevent clots." OR "Enoxaparin will start to dissolve the clot, and warfarin will prevent any more clots from forming."

"Enoxaparin works right away, but warfarin takes several days to prevent clots." Low-molecular-weight heparin (LMWH) is used because of the immediate effect on coagulation and discontinued once the international normalized ratio (INR) value indicates that the warfarin has reached a therapeutic level, usually about 5 days. LMWH and warfarin have no thrombolytic properties and they do not dissolve clots. The use of two anticoagulants is not related to the risk for pulmonary embolism.

The nurse has started discharge teaching for a patient who is to continue warfarin (Coumadin) after hospitalization for venous thromboembolism (VTE). Which patient statement indicates a need for additional teaching?

"I should reduce the amount of green, leafy vegetables that I eat." Teach patients taking warfarin to follow a consistent diet regarding foods that are high in vitamin K, such as green, leafy vegetables. There is no need to reduce the intake of these vegetables. The other patient statements are accurate.

The nurse assesses a patient on thesecond postoperative day after abdominal surgery to repair a perforated duodenal ulcer. Which finding is most important for thenurse to report to thesurgeon?

200 mL sanguineous fluid in the wound drain Wound drainage should decrease and change in color from sanguineous to serosanguineous by thesecond postoperative day. thecolor and amount of drainage for this patient are abnormal and should be reported. Redness and swelling along thesuture line and a slightly elevated temperature are normal signs of postoperative inflammation. Atelectasis is common after surgery. thenurse should have thepatient cough and deep breathe, but there is no urgent need to notify thesurgeon.

Which patient in the women's health clinic will the nurse expect to teach about an endometrial biopsy? A 35-yr-old patient who has used oral contraceptives for 15 years OR A 25-yr-old patient who has a family history of hereditary nonpolyposis colorectal cancer

A 25-yr-old patient who has a family history of hereditary nonpolyposis colorectal cancer.

A patient with a complex pelvic fracture from a motor vehicle crash is on bed rest. Which assessment finding indicates a potential complication of the fracture?

Abdomen is distended and bowel sounds are absent. The abdominal distention and absent bowel sounds may be due to complications of pelvic fractures such as paralytic ileus or hemorrhage or trauma to the bladder, urethra, or colon. Pelvic instability, abdominal pain with palpation, and abdominal bruising would be expected with this type of injury.

A patient with acute pancreatitis is NPO and has a nasogastric (NG) tube to suction. Which information obtained by the nurse indicates that these therapies have been effective?

Abdominal pain is decreased.

A patient who had knee surgery received IV ketorolac 30 minutes ago and continues to report pain at a level of 7 (0 to 10 scale). Which action would thenurse take?

Administer the prescribed PRN IV morphine sulfate. The priority at this time is pain relief. Concomitant use of opioids and nonsteroidal antiinflammatory drugs improves pain control in postoperative patients. Patient teaching and reassurance are appropriate but should be done after the patient's pain is relieved. If the patient continues to have pain after the morphine is administered, notify the health care provider.

Which finding would indicate to thenurse that a postoperative patient is at increased risk for poor wound healing?

Albumin level 2.2 g/dL Because adequate nutrition including proteins are needed for an appropriate inflammatory response and wound healing, the low serum albumin level (normal level, 3.5 to 5.0 g/dL) indicates a risk for poor wound healing. the potassium level is normal. Because a small amount of blood loss is expected with surgery, the hemoglobin level is not indicative of an increased risk for wound healing. WBC count is expected to increase after surgery as a part of the normal inflammatory response.

A 36-yr-old patient who has a diagnosis of fibrocystic breast changes calls the nurse in the clinic reporting symptoms. Which information is likely to change the treatment plan?

An area on the breast is hot, pink, and tender to the touch. An area that is hot or pink suggests an infectious process such as mastitis, which would require further assessment and treatment. Manifestations of fibrocystic breast changes include one or more palpable lumps that are often round, well delineated, and freely movable within the breast. Discomfort ranging from tenderness to pain may also occur. The lump may increase in size and tenderness before menstruation. Nipple discharge associated with fibrocystic breasts is often milky, watery-milky, yellow, or green.

A patient who has nephrotic syndrome develops flank pain. Which treatment will the nurse plan to explain to this patient?

Anticoagulants

Which information will the nurse teach a patient who has been newly diagnosed with Graves' disease?

Antithyroid medications may take months for full effect. Medications used to block the synthesis of thyroid hormones may take 2 months before the full effect is seen.

A patient has a ruptured cerebral aneurysm and subarachnoid hemorrhage. Which intervention will the nurse include in the plan of care?

Apply intermittent pneumatic compression stockings. The patient with a subarachnoid hemorrhage usually has minimal activity to prevent cerebral vasospasm or further bleeding and is at risk for venous thromboembolism. Activities such as coughing and sitting up that might increase intracranial pressure or decrease cerebral blood flow are avoided. Because there is no indication that the patient is unconscious, an oropharyngeal airway is inappropriate.

The nurse is admitting a patient scheduled this morning for lumpectomy and axillary lymph node dissection. Which action would the nurse take first?

Ask the patient to describe what she knows about the surgery. Before teaching, the nurse should assess the patient's current knowledge level. The other teaching also may be appropriate, depending on the assessment findings.

A patient who has begun to awaken after 30 minutes in the postanesthesia care unit (PACU) is restless and shouting at the nurse. the patient's oxygen saturation is 96%, and recent laboratory results are normal. Which action would the nurse take?

Assess for bladder distention. Because the patient's assessment indicates physiologic stability, the most likely cause of the patient's agitation is emergence delirium, which will resolve as the patient wakes up more fully. the nurse would look for a cause such as bladder distention. Although hypoxemia is the most common cause, the patient's oxygen saturation is 96%. Emergence delirium is common in patients recovering from anesthesia, so there is no need to notify the ACP. Orientation of the patient to bed controls is needed but is not likely to be effective until the effects of anesthesia have resolved more completely.

A patient has just arrived on the unit after a thyroidectomy. Which action would the nurse take first?

Assess the patient's respiratory effort.

Which action will the nurse include in the plan of care for a patient with right arm lymphedema?

Assist with application of a compression sleeve. A compression sleeve assists in improving lymphatic flow toward the heart.

The health care provider prescribes heparin infusion and daily partial thromboplastin time (PTT) testing for a patient with venous thromboembolism (VTE). Which action would the nurse include in the plan of care?

Avoid giving IM medications to prevent localized bleeding. A PTT of 65 seconds is within the therapeutic range. Vitamin K is used to reverse warfarin. Pulse quality is not affected by VTE.

After reviewing the electronic medical record for a patient who had transurethral resection of the prostate the previous day, which information requires the most rapid action by the nurse? Elevated temperature and pulse Bladder spasms and urine output Respiratory rate and lung crackles No prescription for antihypertensive drugs

Bladder spasms and urine output. Bladder spasms and lack of urine output indicate that the nurse needs to assess the continuous bladder irrigation for kinks and may need to manually irrigate the patient's catheter. The other information will also require actions, such as having the patient take deep breaths and cough and discussing the need for antihypertensive medication prescriptions with the health care provider, but the nurse's first action would be to address the problem with the urinary drainage system.

An older patient with a history of an abdominal aortic aneurysm arrives at the emergency department (ED) with severe back pain and absent pedal pulses. Which action would the nurse take first?

Check the patient's blood pressure. Because the patient appears to be experiencing aortic dissection, the nurse's first action should be to determine the hemodynamic status by assessing blood pressure. The other actions may also be done, but they will not provide information to determine what interventions are needed immediately.

When caring for a 58-yr-old patient with persistent uterine bleeding, which result would the nurse plan to monitor?

Complete blood count (CBC) Because anemia is a likely complication of persistent abnormal uterine bleeding, the nurse will need to monitor the CBC. Estrogen and GNRH levels are checked for patients with other problems, such as infertility. Serial hCG levels are monitored in patients who may be pregnant.

A patient who underwent a gastroduodenostomy (Billroth I) 12 hours ago reports increasing abdominal pain. The patient has no bowel sounds and 200 mL of bright red nasogastric (NG) drainage in the past hour. Which nursing action is the highest priority?

Contact the surgeon. Increased pain and 200 mL of bright red NG drainage 12 hours after surgery indicate possible postoperative hemorrhage, and immediate actions such as blood transfusion or return to surgery are needed (or both). Because the NG is draining, there is no indication that irrigation is needed. Continuing to monitor the NG drainage is needed but not an adequate response to the findings. The patient may need morphine, but this is not the highest priority action.

Which results are expected patient outcomes of thenurse providing thoroughpreoperative teaching? (Select all that apply.)

Decreased anxiety Reduced postoperative fear Shorter length of hospitalization Decreased development of complications Preoperative teaching increases patient satisfaction and can reduce postoperative fear, anxiety, and stress. Teaching may decrease the development of complications, length of hospitalization, and recovery time after discharge.

Which topic would the nurse discuss preoperatively with a patient who is scheduled for an open cholecystectomy?

Deep breathing and coughing. Preoperative teaching, demonstration, and re-demonstration of deep breathing and coughing are needed on patients having abdominal surgery to prevent postoperative atelectasis. Incisional care and the importance of completing antibiotics are better discussed after surgery, when the patient will be more likely to retain this information. the patient does not usually need information about medications that are used intraoperatively, and that topic should be discussed with the anesthesia provider.

Which topic would thenurse discuss preoperatively with a patient who is scheduled for an open cholecystectomy?

Deep breathing and coughing. Preoperative teaching, demonstration, and re-demonstration of deep breathing and coughing are needed on patients having abdominal surgery to prevent postoperative atelectasis. Incisional care and the importance of completing antibiotics are better discussed after surgery, when the patient will be more likely to retain this information. the patient does not usually need information about medications that are used intraoperatively, and that topic should be discussed with the anesthesia provider.

An 82-year-old patient in a long-term care facility is newly diagnosed with hypothyroidism. Which prescribed drug would the nurse discuss with the health care provider?

Diazepam (Valium) Worsening of mental status and myxedema coma can be precipitated using sedatives, especially in older adults. The nurse should discuss the use of diazepam with the health care provider before administration. The other medications may be given safely to the patient.

A patient who has been receiving IV heparin infusion and oral warfarin (Coumadin) for a deep vein thrombosis (DVT) is diagnosed with heparin-induced thrombocytopenia (HIT) when the platelet level drops to 110,000/L. Which action will the nurse anticipate including in the plan of care?

Discontinuing the heparin infusion. All heparin is discontinued when HIT is diagnosed. The patient should be instructed to never receive heparin or LMWH. Warfarin is usually not given until the platelet count has returned to 150,000/L. The platelet count does not drop low enough in HIT for a platelet transfusion, and platelet transfusions increase the risk for thrombosis.

An older adult patient is being discharged from the ambulatory surgical unit after left eye surgery. the patient tells the nurse, "I don't know if I can take care of myself once I'm home." Which action would the nurse implement first?

Discuss patient concerns regarding self-care. The nurse's initial action would be to assess exactly the patient's concerns about self-care. Referral to home health care and assessment of the patient's support system may be appropriate actions but will be based on further assessment of the patient's concerns. Written instructions for care would be given to the patient, but these may not address the patient's stated concern about self-care.

A patient's T-tube is draining dark green fluid after gallbladder surgery. Which action would the nurse take?

Document the drainage characteristics. A T-tube normally drains dark green to bright yellow drainage so no action other than to document the amount and color of the drainage is needed. the other actions are not necessary.

What action will the nurse take when caring for a patient who has a radium implant for treatment of cervical cancer? Assist the patient to ambulate every 2 to 3 hours. Use gloves and gown when changing the patient's bed. Flush the toilet several times right after the patient voids. Encourage the patient to discuss any concerns by telephone.

Encourage the patient to discuss any concerns by telephone.

In thepostanesthesia care unit (PACU), a patient's vital signs are blood pressure 116/72 mm Hg, pulse 74 beats/min, respirations 12 breaths/min, and SpO2 91%. thepatient is sleepy but awakens easily. Which action would thenurse take?

Encourage the patient to take deep breaths. The patient's borderline SpO2 and sleepiness indicate hypoventilation. the nurse would stimulate the patient and remind the patient to take deep breaths. Placing the patient in a lateral position is needed when the patient first arrives in thePACU and is unconscious. the stable blood pressure and pulse indicate that no changes in fluid intake are required. the patient is not fully awake and has a low SpO2, indicating that transfer from thePACU to a clinical unit is not appropriate.

A patient who was recently diagnosed with benign prostatic hyperplasia (BPH) tells the nurse that he does not want to have a transurethral resection of the prostate (TURP) because it might affect his ability to have sexual intercourse. Which action would the nurse take?

Explain that TURP may cause retrograde ejaculation.

A patient who was admitted to the emergency department with severe abdominal pain is diagnosed with an ectopic pregnancy. The patient begins to cry and asks the nurse to leave her alone. Which action would the nurse take next?

Explain the reason for taking vital signs every 15 to 30 minutes. Because the patient is at risk for rupture of the fallopian tube and hemorrhage, frequent monitoring of vital signs is needed. The patient has asked to be left alone, so staying with her and encouraging her to discuss her feelings are inappropriate actions. Minimizing contact with her and closing the door of the room is unsafe because of the risk for hemorrhage. Because the patient has requested time to grieve, it would be inappropriate to provide teaching about options for pregnancy termination.

Which potential cause of infection will the nurse consider as a risk in the plan of care for a patient immediately after a perineal radical prostatectomy? Urinary incontinence Prolonged urinary stasis Fecal wound contamination Suprapubic catheter placement

Fecal wound contamination The perineal approach increases the risk for infection because the incision is located close to the anus, and contamination with feces is possible. Urinary stasis and incontinence do not occur because the patient has a retention catheter in place for 1 to 2 weeks. A urethral catheter is used after the surgery.

Which information about glyburide would the nurse include when teaching a patient who has type 2 diabetes? Glyburide decreases glucagon secretion from the pancreas. Glyburide stimulates insulin production and release from the pancreas. Glyburide should be taken even if the morning glucose level is low. Glyburide should not be used for 48 hours after receiving IV contrast media.

Glyburide stimulates insulin production and release from the pancreas.

On thesecond postoperative day after abdominal surgery for removal of a large pancreatic cyst, a patient has an oral temperature of 100.8F (38.2C). Which action would thenurse take?

Have the patient use the incentive spirometer. A temperature of 100.8F (38.2C) in the first 48 hours is usually caused by atelectasis, and the nurse should have the patient deep breathe, cough, and use the incentive spirometer. Nursing intervention may resolve this problem, and therefore notifying the health care provider is not necessary. Acetaminophen or ice packs will reduce the temperature, but it will not resolve the underlying respiratory congestion.

Which actions will thenurse include in thesurgical time-out procedure before surgery? (Select all that apply.)

Have thepatient state name and date of birth. Verify the patient identification band number. Ask the patient to state the surgical procedure. These actions are included in surgical time-out procedure. IV line placement and identification of the patient by the surgeon are not included in the surgical time-out procedure.

The nurse is reviewing laboratory results and notes a patient's activated partial thromboplastin time (aPTT) level is 28 seconds. The nurse would notify the health care provider in anticipation of adjusting which medication?

Heparin The aPTT level is increased (prolonged) in heparin administration. aPTT is used to monitor whether heparin is at a therapeutic level (needs to be greater than the normal range of 30 to 40 sec). Prothrombin time (PT) and international normalized ratio (INR) are most commonly used to test for therapeutic levels of warfarin (Coumadin). Aspirin affects platelet function. Erythropoietin is used to stimulate red blood cell production.

How should the nurse explain the purpose of the heparin to the patient?

Heparin prevents the development of new clots

The nurse is caring for a patient living with asymptomatic chronic HIV infection. Which prophylactic measures will the nurse include in the plan of care? (Select all that apply.)

Hepatitis B vaccine Pneumococcal vaccine Influenza virus vaccine

Which data identified during thepreoperative assessment alerts thenurse that special protection techniques should be implemented during surgery?

History of spinal and hip arthritis Misalignment, pressure, or other insults to arthritic joints desensitized from an anesthetic may create long-term injury and disability; the patient with arthritis may require special positioning to avoid injury and postoperative discomfort. Preoperative anxiety (unless severe) and having a sip of water 3 hours before surgery are not contraindications to having surgery. An allergy to cats and dogs will not affect the care needed during the intraoperative phase.

A patient who has hypothyroidism and hypertension is prescribed levothyroxine (Synthroid). Which finding indicates that the nurse should contact the health care provider before administering the medication?

Increased thyroxine (T4) level

Which action would the nurse take when giving Lovenox to a patient with a lower leg venous thromboembolism (VTE)? Massage the site after giving the injection. Inject the drug into the abdominal subcutaneous tissue. Ejects the air bubble from the syringe before giving the drug. Check partial thromboplastin time (PTT) before giving the drug.

Inject the drug into the abdominal subcutaneous tissue. Low-molecular-weight heparin (LMWH) is administered subcutaneously in the abdominal area. The air bubble is not ejected before giving fondaparinux to avoid loss of drug. The other actions by the nurse are appropriate for LMWHs typically do not require ongoing PTT monitoring and dose adjustment.

A patient who has benign prostatic hyperplasia (BPH) with urinary retention is admitted to the hospital with elevated blood urea nitrogen (BUN) and creatinine. Which prescribed therapy would the nurse implement first?

Insert a urinary retention catheter.

A patient with endometriosis asks why she is being treated with an oral contraceptive. Which information would the nurse explain about this therapy?

It suppresses the menstrual cycle by mimicking pregnancy. Oral contraceptive hormones induce a pseudopregnancy, which suppresses ovulation and causes shrinkage of endometrial tissue. Menstrual bleeding does not occur during pregnancy. Vaginal atrophy and hot flashes are caused by synthetic androgens such as danazol or gonadotropin-releasing hormone agonists such as leuprolide. Although hormonal therapies will control endometriosis while the therapy is used, endometriosis will recur once the menstrual cycle is reestablished.

Which nursing assessment finding in a patient who recently started taking hormone replacement therapy (HRT) requires discussion with the health care provider about a possible change in therapy? Breast tenderness Left calf swelling Weight gain of 3 lb Intermittent spotting

Left calf swelling Unilateral calf swelling may indicate deep vein thrombosis caused by the changes in coagulation associated with HRT and would indicate that the HRT should be discontinued. Breast tenderness, weight gain, and intermittent spotting are common side effects of HRT and do not indicate a need for a change in therapy.

A patient who has diabetes is starting on intensive insulin therapy. Which type of insulin will the nurse explain for mealtime coverage?

Lispro (Humalog)

A patient has been diagnosed with urinary tract stones that are high in uric acid. Which foods will the nurse teach the patient to avoid or limit? (Select all that apply.) Milk Liver Spinach Chicken Cabbage Chocolate

Liver Chicken

The nurse is planning care for a patient with acute severe pancreatitis. Which outcome would the nurse identify as the highest priority?

Maintaining normal respiratory function

A patient who has diabetes and acute abdominal pain is admitted for an exploratory laparotomy. Which postoperative intervention would be the nurse's highest priority to promote wound healing?

Maintaining the patient's blood glucose within a normal range. Elevated blood glucose will impair wound healing in multiple ways. Ensuring adequate nutrition is important for the postoperative patient, but a higher priority is blood glucose control. A temperature of 102F will not impact wound healing. Application of a dry, sterile dressing daily may be ordered, but frequent dressing changes for a wound healing by primary intention is not necessary to promote wound healing.

After a transurethral resection of the prostate (TURP), a patient with continuous bladder irrigation reports painful bladder spasms. The nurse observes clots in the urine. Which action would the nurse take first?

Manually instill and withdraw 50 mL of saline through the catheter.

An older adult who takes medications for coronary artery disease and hypertension is newly diagnosed with HIV infection and is starting antiretroviral therapy. Which information will the nurse include in patient teaching?

Many drugs interact with antiretroviral medications. The nurse will teach the patient about potential interactions between antiretrovirals and the medications that the patient is using for chronic health problems. Treatment and monitoring of HIV infection is not affected by age. A patient beginning early ART is not a candidate for hospice. Progression of HIV is not affected by age although it may be affected by chronic disease.

Which action would the nurse include in the plan of care for a patient after endovascular repair of an abdominal aortic aneurysm?

Monitor fluid intake and urine output. Because renal artery occlusion can occur after endovascular repair, the nurse should monitor parameters of renal function such as intake and output. Chest tubes will not be needed for endovascular surgery, the recovery period will be short, and there will not be an abdominal wound.

The nurse notes a serum calcium level of 7.9 mg/dL for a patient who has chronic malnutrition. Which action would thenurse expect to take first? Monitor ionized calcium level. OR Check parathyroid hormone level.

Monitor ionized calcium level.

A patient who arrives at the emergency department with severe left knee pain is diagnosed with a patellar dislocation. Which information would the nurse plan to teach the patient first?

Monitored anesthesia care

A patient who had abdominal surgery yesterday is receiving morphine through a patient-controlled analgesia (PCA) pump. Which action by the nurse is a priority?

Monitoring respiratory rate. The patient's respiratory rate is the highest priority of care while using PCA medication because of the possible respiratory depression. The other areas also require assessment but do not reflect immediately life-threatening complications.

A pregnant woman with asymptomatic chronic human immunodeficiency virus (HIV) infection is seen at the clinic. The patient states, "I am very nervous about making my baby sick." Which information will the nurse include when teaching the patient?

Most infants born to HIV-positive mothers are not infected with the virus. Only 25% of infants born to HIV-positive mothers develop HIV infection, even when the mother does not use ART during pregnancy. The percentage drops to 1% when ART is used. Perinatal transmission can occur at any stage of HIV infection (although it is less likely to occur when the viral load is lower). ART can safely be used in pregnancy, although some ART drugs should be avoided.

An older adult patient who had a mitral valve replacement with a mechanical valve is taking warfarin. Which information would the nurse include in discharge teaching?

Need for frequent laboratory bloodtesting.

Which assessment finding for a patient who has been admitted with a right calf venous thromboembolism (VTE) requires immediate action by the nurse?

New onset shortness of breath New onset dyspnea suggests a pulmonary embolus, which will require rapid actions such as O2 administration and notification of the health care provider. The other findings are typical of VTE.

A 22-yr-old patient tells the nurse that she has not had a menstrual period for the past 3 months. Which action is most important for the nurse to take? Obtain a urine specimen for a pregnancy test. Ask about any recent stressful lifestyle changes. Measure the patient's current height and weight. Question the patient about prescribed medications.

Obtain a urine specimen for a pregnancy test. Pregnancy would always be considered a possible cause of amenorrhea in women of childbearing age. The other actions are also appropriate, but it is important to check for pregnancy in this patient because pregnancy will require rapid implementation of actions to promote normal fetal development such as changes in lifestyle, folic acid intake, and so on.

When caring for a preoperative patient on theday of surgery, which actions can thenurse delegate to assistive personnel (AP)? (Select all that apply.)

Obtain and document baseline vital signs. Remove nail polish and apply pulse oximeter. Transport the patient by stretcher to the operating room. Obtaining vital signs, removing nail polish, pulse oximeter placement, and transport of the patient are routine skills that are appropriate to delegate. Teaching patients about the preoperative routine and incentive spirometer use require critical thinking and should be done by the registered nurse.

A patient admitted with pneumonia has a total serum calcium level of 13.3 mg/dL. Which serum level would the nurse anticipate will be tested next?

Parathyroid hormone Parathyroid hormone (PTH) is the major controller of blood calcium levels. Although calcitonin secretion is a counter mechanism to PTH, it does not play a major role in calcium balance. Catecholamine and thyroid hormone levels do not affect serum calcium level.

Which patient who has arrived at the human immunodeficiency virus (HIV) clinic would the nurse assess first? Patient whose latest CD4+ count has dropped to 250/L. OR Patient who has had 10 liquid stools in the last 24 hours.

Patient who has had 10 liquid stools in the last 24 hours. The nurse should assess the patient who has diarrhea for dehydration and hypovolemia.

A patient who is human immunodeficiency virus (HIV)-infected has a CD4+ cell count of 400/L. Which factor is most important for the nurse to determine before the initiation of antiretroviral therapy (ART) for this patient?

Patient's ability to follow a complex medication regimen. Drug resistance develops quickly unless the patient takes ART medications on a strict, regular schedule.

A postoperative patient has not voided for 8 hours after return to the clinical unit. Which action would the nurse take first?

Perform a bladder scan. The initial action should be to assess the bladder for distention. If the bladder is distended, providing the patient with privacy (by walking with the patient to the bathroom) will be helpful. Because of the risk for urinary tract infection, catheterization should only be done after other measures have been tried without success. There is no indication of a fluid volume deficit.

An unconscious patient who was transferred from surgery to thepostanesthesia care unit (PACU) 15 minutes ago has an oxygen saturation of 89%. Which action would thenurse take first?

Perform the jaw-thrust maneuver. In an unconscious postoperative patient, a likely cause of hypoxemia is airway obstruction by the tongue, and the first action is to clear the airway by maneuvers such as the jaw thrust or chin lift. Increasing the oxygen flowrate and suctioning are not helpful when the airway is obstructed by the tongue. Elevating the patient's head will not be effective in correcting an obstruction but may help with oxygenation after the patient is awake.

A patient with blunt abdominal trauma from a motor vehicle crash undergoes peritoneal lavage. If the lavage returns brown fecal drainage, which action will the nurse plan to take next?

Prepare the patient for surgery. Return of brown drainage and fecal material suggests perforation of the bowel and the need for immediate surgery. Auscultation of bowel sounds, checking the temperature, and obtaining information about the accident are appropriate actions, but the priority is to prepare to send the patient for emergency surgery.

Which prescribed medication would the nurse expect will have the most rapid effect on a patient admitted to the emergency department in thyroid storm?

Propranolol

Which action will the perioperative nurse take after surgery is completed for a patient who received ketamine as an anesthetic agent?

Provide a quiet environment in the post anesthesia care unit. Hallucinations are an adverse effect associated with the dissociative anesthetics such as ketamine. Therefore, the postoperative environment should be kept quiet to decrease the risk of hallucinations. Because ketamine causes profound analgesia lasting into the postoperative period, higher doses of analgesics are not needed. Ketamine causes an increase in heart rate. Benzodiazepine may be used with ketamine to decrease the incidence of hallucinations and nightmares.

The nurse plans to provide preoperative teaching to an alert older man who has hearing and vision deficits. His wife answers most questions that are directed to the patient. Which action would the nurse take when doing the teaching?

Provide additional time for the patient to understand preoperative instructions and carry out procedures. The nurse should allow more time when doing preoperative teaching and preparation for older patients with sensory deficits. Because the patient has visual deficits, he will not be able to use written material for learning. the teaching should be directed toward both the patient and wife because both will need to understand preoperative procedures and teaching.

Which topic will the nurse include in the preoperative teaching for a patient admitted for an abdominal hysterectomy?

Purpose of ambulation and leg exercises. Venous thromboembolism is a potential complication after major surgery, and the nurse will instruct the patient about ways to prevent it. Vaginal sensation is decreased after a vaginal hysterectomy but not after abdominal hysterectomy. Most hysterectomies are not done for treatment of cancer. Unless the patient has cancer, chemotherapy and radiation will not be prescribed. Because the patient will still have her ovaries, her estrogen level will not decrease.

The nurse notes bilateral enlargement of the breasts during examination of a 62-yr-old male patient. Which action would the nurse take first?

Question the patient about current medications. Because gynecomastia is a possible side effect of drug therapy, asking about the current drug regimen is appropriate. The other actions may be needed, depending on the data that are obtained with further assessment.

An adult patient is admitted to the hospital with new-onset nephrotic syndrome. Which assessment data will the nurse expect?

Recent weight gain as well as Hypertension Proteinuria Foamy urine Hyperlipidemia

A patient informed of a positive rapid screening test result for human immunodeficiency virus (HIV) is anxious and does not appear to hear what the nurse is saying. Which action by the nurse is most important at this time?

Remind the patient to return for retesting to verify the results. After an initial positive antibody test result, the next step is retesting to confirm the results.

The nurse obtains a health history from a patient who is scheduled for elective hip surgery in 1 week. the patient reports use of garlic and Ginkgo biloba. Which action would the nurse take?

Report to the ACP - Both garlic and G. biloba increase the risk for bleeding. the nurse should discuss the herb and supplement use with the patient's health care provider. the nurse should not advise the patient to stop the supplements or to continue them without consulting with the health care provider and the anesthesia care provider.

A hospitalized patient who has diabetes received 38 U of NPH insulin at 7:00 AM. At 1:00 PM, the patient has been away from the nursing unit for 2 hours, missing the lunch delivery while awaiting a chest x-ray. Which nursing action would be the best way to prevent the patient from experiencing hypoglycemia?

Request that if testing is further delayed, the patient must eat lunch first. The action of NPH insulin peaks 4 to 12 hours after injection, which can result in hypoglycemia. Consistency for mealtimes assists with regulation of glucose, so the best option is for the patient to have lunch at the usual time. Waiting to eat until after the procedure is likely to cause hypoglycemia.

During the primary survey of a patient with severe leg trauma, the nurse observes that the patient's left pedal and posterior tibial pulses are absent, and the entire leg is swollen. Which action will the nurse take next?

Start normal saline fluid infusion. The assessment data indicate that the patient may have arterial trauma and hemorrhage. When a life-threatening injury is found during the primary survey, the nurse should immediately start interventions before proceeding with the survey. Although sending off blood for a complete blood count is indicated, administration of IV fluids should be started first. Completion of the primary survey and further assessment should be completed after theIV fluids are initiated.

Monitored anesthesia care (MAC) is going to be used for a closed, manual reduction of a patient's dislocated shoulder. Which action would thenurse anticipate?

Starting an IV For MAC, IV sedatives, such as the benzodiazepines, are given. Therefore, the patient needs IV access. Inhaled and epidural agents are not included in MAC. RNs who are trained and are allowed by agency protocols and state nurse practice acts can provide moderate to deep sedation. However, the provider of MAC must be an anesthesia care provider since it may be necessary to change to general anesthesia during the procedure.

After abdominal surgery, a patient with protein calorie malnutrition is receiving parenteral nutrition (PN). Which data is the best indicator that the patient is receiving adequate nutrition?

Surgical incision is healing normally. Because poor wound healing is a possible complication of malnutrition for this patient, normal healing of the incision is an indicator of the effectiveness of the PN in providing adequate nutrition. Blood glucoseis monitored to prevent the complications of hyperglycemia and hypoglycemia, but it does not indicate that the patient's nutrition is adequate. The intake and output will be monitored, but do not indicate that the PN is effective. The albumin level is in the low-normal range but does not reflect adequate caloric intake, which is also important for the patient.

A patient who has hyperthyroidism is treated with radioactive iodine (RAI). What information would the nurse include in discharge teaching?

Symptoms of hypothyroidism will occur as the RAI therapy takes effect.

A patient requests a prescription for birth control pills to control severe abdominal cramping and headaches during her menstrual periods. Which action would the nurse take first?

Take the patient's personal and family health history.

Which assessment finding for an adult admitted with Graves' disease requires the most rapid intervention by the nurse?

Temperature 103.8F (40.4C)

An experienced nurse orients a new nurse to thepostanesthesia care unit (PACU). Which action by thenew nurse would indicate that theorientation was successful?

The new nurse positions an unconscious patient on the side upon arrival from surgery. The patient would initially be placed in the lateral "recovery" position to keep the airway open and avoid aspiration. Avoid the Trendelenburg position because it increases the work of breathing. the patient is placed supine with the head elevated after regaining consciousness.

A 53-yr-old woman who is experiencing menopause is discussing the use of hormone therapy (HT) with the nurse. Which information about the risk of breast cancer will the nurse provide?

The patient and her health care provider must weigh the benefits of HT against the risks of breast cancer.

Which patient action indicates accurate understanding of the nurse's teaching about administration of aspart (NovoLog) insulin?

The patient cleans the skin with soap and water before the injection.

A patient arrives at the outpatient surgical center for a scheduled laparoscopy under general anesthesia. Which information requires the nurse's intervention to maintain patient safety?

The patient is planning to drive home after surgery. The patient should not drive after general anesthesia. the nurse will need to help the patient identify a means of safe transportation home. Clear liquids only require a minimum preoperative fasting period of 2 hours. the patient's experience with anesthesia and the patient's insurance coverage are important to establish, but these are not safety issues.

The nurse at theeye clinic made a follow-up telephone call to a patient who underwent cataract extraction and intraocular lens implantation theprevious day. Which information is thepriority to communicate to thehealth care provider?

The patient reports eye pain rated 5 (on a 0 to 10 scale). Postoperative cataract surgery patients usually experience little or no pain, so pain at a level 5 on a 10-point pain scale may indicate complications such as hemorrhage, infection, or increased intraocular pressure. the other information given by the patient indicates a need for patient teaching or follow-up does not indicate that complications of the surgery may be occurring.

Which finding indicates a need to contact the health care provider before the nurse administers metformin (Glucophage)?

The patient's estimated glomerular filtration rate is 42 mL/min. The glomerular filtration rate indicates possible renal impairment, and metformin should not be used in patients with significant renal impairment.

A 38-yr-old woman is admitted for an elective surgical procedure. Which information obtained by the nurse during the preoperative assessment must be communicated to the anesthesiologist and surgeon before surgery?

The patient's report that her last menstrual period was 8 weeks ago. A last menstrual period 8 weeks ago in a woman of childbearing age suggests that the patient could be pregnant and pregnancy testing is needed before administration of anesthetic agents. Although the other data may also be communicated with the surgeon and anesthesiologist, they will affect postoperative care and do not indicate a need for further assessment before surgery.

A patient is on the surgical unit after a total abdominal hysterectomy. Which finding requires contacting the health care provider?

Urine output of 125 mL in the first 8 hours after surgery The decreased urine output indicates possible low blood volume and further assessment is needed to assess for possible internal bleeding. Decreased bowel sounds, minor drainage on the dressing, and abdominal pain with coughing are expected after this surgery.