Adult II Exam 1

A patients blood pressure in the PACU has dropped from an admission blood pressure of 138/84 to 100/58 with a pulse change of 68 to 94. SpO2 is 98% on 3L of oxygen. In which order should the nurse take these actions? Put a comma and space between each answer choice (a, b, c, d, etc.) ____________________ a. Raise the IV infusion rate. b. Assess the patients dressing. c. Increase the oxygen flow rate. d. Check the patients temperature.

ANS: A, C, B, D The first nursing action should be to increase the IV infusion rate. Since the most common cause of hypotension is volume loss, the IV rate should be increased. The next action should be to increase the oxygen flow rate to maximize oxygenation of hypoperfused organs. Because hemorrhage is a common cause of postoperative volume loss, the nurse should check the dressing. Finally, the patient should be assessed for vasodilation caused by rewarming.

When caring for a patient during the second postoperative day after abdominal surgery, the nurse obtains an oral temperature of 100.8 F. Which action should the nurse take first? a. Have the patient use the incentive spirometer. b. Assess the surgical incision for redness and swelling. c. Administer the ordered PRN acetaminophen (Tylenol). d. Notify the patients health care provider about the fever.

ANS: A A temperature of 100.8 F in the first 48 hours is usually caused by atelectasis, and the nurse should have the patient cough and deep breathe. This problem may be resolved by nursing intervention, and therefore notifying the health care provider is not necessary. Acetaminophen will reduce the temperature, but it will not resolve the underlying respiratory congestion. Because evidence of wound infection does not usually occur before the third postoperative day, assessment of the incision is not likely to be useful.

A postoperative patient who has been receiving nasogastric suction for 3 days has a serum sodium level of 125 mEq/L (125 mmol/L). Which of these prescribed therapies that the patient has been receiving should the nurse question? a. Infuse 5% dextrose in water at 125 ml/hr. b. Administer IV morphine sulfate 4 mg every 2 hours PRN. c. Give IV metoclopramide (Reglan) 10 mg every 6 hours PRN for nausea. d. Administer 3% saline if serum sodium drops to less than 128 mEq/L.

ANS: A Because the patients gastric suction has been depleting electrolytes, the IV solution should include electrolyte replacement. Solutions such as lactated Ringers solution would usually be ordered for this patient. The other orders are appropriate for a postoperative patient with gastric suction.

A patient who is just waking up after having a general anesthetic is agitated and confused. Which action should the nurse take first? a. Check the O2 saturation. b. Administer the ordered opioid. c. Take the blood pressure and pulse. d. Notify the anesthesia care provider.

ANS: A Emergence delirium may be caused by a variety of factors. However, the nurse should first assess for hypoxemia. The other actions also may be appropriate, but are not the best initial action.

A patients family history reveals that the patient may be at risk for malignant hyperthermia (MH) during anesthesia. The nurse explains to the patient that a. anesthesia can be administered with minimal risks with the use of appropriate precautions and medications. b. as long as succinylcholine (Anectine) is not administered as a muscle relaxant, the reaction should not occur. c. surgery must be performed under local anesthetic to prevent development of a sudden, extreme increase in body temperature. d. surgery will be delayed until the patient is genetically tested to determine whether he or she is susceptible to malignant hyperthermia.

ANS: A General anesthesia can be administered to patients with MH as long as precautions to avoid MH are taken and preparations are made to treat MH if it does occur. Other factors besides succinylcholine administration are associated with MH. Predictions about whether MH will occur based on family history are inconsistent, and it may not be possible to delay surgery.

A patient is receiving 3% NaCl solution for correction of hyponatremia. During administration of the solution, the most important assessment for the nurse to monitor is a. lung sounds. b. urinary output. c. peripheral pulses. d. peripheral edema.

ANS: A Hypertonic solutions cause water retention, so the patient should be monitored for symptoms of fluid excess. Crackles in the lungs may indicate the onset of pulmonary edema and are the most serious of the symptoms of fluid excess listed. Bounding peripheral pulses, peripheral edema, or changes in urine output also are important to monitor when administering hypertonic solutions, but they do not indicate acute respiratory or cardiac decompensation.

A patient who has been receiving diuretic therapy is admitted to the emergency department with a serum potassium level of 3.1 mEq/L. Of the following medications that the patient has been taking at home, the nurse will be most concerned about a. oral digoxin (Lanoxin) 0.25 mg daily. b. ibuprofen (Motrin) 400 mg every 6 hours. c. metoprolol (Lopressor) 12.5 mg orally daily. d. lantus insulin 24 U subcutaneously every evening.

ANS: A Hypokalemia increases the risk for digoxin toxicity, which can cause serious dysrhythmias. The nurse also will need to do more assessment regarding the other medications, but there is not as much concern with the potassium level.

The nurse in the outpatient clinic who notes that a patient has a decreased magnesium level should ask the patient about a. daily alcohol intake. b. intake of dietary protein. c. multivitamin/mineral use. d. use of over-the-counter (OTC) laxatives.

ANS: A Hypomagnesemia is associated with alcoholism. Protein intake would not have a significant effect on magnesium level. OTC laxatives (such as milk of magnesia) and use of multivitamin/mineral supplements would tend to increase magnesium level.

A patient with a dislocated shoulder is prepared for a closed, manual reduction of the dislocation with monitored anesthesia care (MAC). The nurse anticipates the administration of a. IV midazolam (Versed). b. inhaled desflurane (Suprane). c. epidural lidocaine (Xylocaine). d. eutectic mixture of local anesthetics (EMLA).

ANS: A IV sedatives such as the benzodiazipines are administered for MAC. Inhaled, epidural, and topical agents are not included in MAC.

The nurse obtains all of the following assessment data about a patient with deficient fluid volume caused by a massive burn injury. Which of the following assessment data will be of greatest concern? a. The blood pressure is 90/40 mm Hg. b. Urine output is 30 ml over the last hour. c. Oral fluid intake is 100 ml for the last 8 hours. d. There is prolonged skin tenting over the sternum.

ANS: A The blood pressure indicates that the patient may be developing hypovolemic shock as a result of fluid loss. This will require immediate intervention to prevent the complications associated with systemic hypoperfusion. The poor oral intake, decreased urine output, and skin tenting all indicate the need for increasing the patients fluid intake but not as urgently as the hypotension.

A preoperative patient in the holding area asks the nurse, Will the doctor put me to sleep with a mask over my face? The most appropriate response by the nurse is, a. A drug will be given to you through your IV line, which will cause you to go to sleep almost immediately. b. Only your surgeon can tell you for sure what method of anesthesia will be used. Should I ask your surgeon? c. General anesthesia is now given by injecting medication into your veins, so you will not need a mask over your face. d. Masks are not used anymore for anesthesia. A tube will be inserted into your throat to deliver a gas that will put you to sleep.

ANS: A The first step in general anesthesia is the injection of an intravenous (IV) induction agent, which rapidly induces sleep. The anesthesiologist (not the surgeon) determines the method of anesthesia used. Masks may still be used for inhalation, although many patients are intubated. Total IV anesthesia may be used for some patients but inhalation anesthetics also are commonly used.

The clinic nurse reviews the complete blood cell count (CBC) results for a patient who is scheduled for surgery in a few days. The results are white blood cell count (WBC) 10.2 103/L; hemoglobin 15 g/dL; hematocrit 45%; platelets 150 103/L. Which action should the nurse take? a. Send the CBC results to the surgery facility. b. Call the surgeon and anesthesiologist immediately. c. Ask the patient about any symptoms of a recent infection. d. Discuss the possibility of blood transfusion with the patient.

ANS: A The nurse should be sure that the CBC results, which are normal, are available at the surgical facility to avoid delay of the procedure. With normal results, there is no need to notify the surgeon or anesthesiologist, discuss blood transfusion, or ask about recent infection.

The nurse notes that a patient who was admitted with diabetic ketoacidosis has rapid, deep respirations. Which action should the nurse take? a. Notify the patients health care provider. b. Give the prescribed PRN lorazepam (Ativan). c. Start the prescribed PRN oxygen at 2 to 4 L/min. d. Encourage the patient to take deep, slow breaths.

ANS: A The rapid, deep (Kussmaul) respirations indicate a metabolic acidosis and the need for actions such as administration of sodium bicarbonate, which will require a prescription by the health care provider. Oxygen therapy is not indicated because there is no indication that the increased respiratory rate is related to hypoxemia. The respiratory pattern is compensatory, and the patient will not be able to slow the respiratory rate. Ativan administration will slow the respiratory rate and increase the level of acidosis.

A 42-year-old patient is recovering from anesthesia in the postanesthesia care unit (PACU). On admission to the PACU, the blood pressure (BP) is 124/70. Thirty minutes after admission, the blood pressure falls to 112/60, with a pulse of 72 and warm, dry skin. The most appropriate action by the nurse at this time is to a. increase the rate of the IV fluid replacement. b. continue to take vital signs every 15 minutes. c. administer oxygen therapy at 100% per mask. d. notify the anesthesia care provider (ACP) immediately.

ANS: B A slight drop in postoperative BP with a normal pulse and warm, dry skin indicates normal response to the residual effects of anesthesia and requires only ongoing monitoring. Hypotension with tachycardia and/or cool, clammy skin would suggest hypovolemic or hemorrhagic shock and the need for notification of the ACP, increased fluids, and high-concentration oxygen administration.

When caring for an alert and oriented elderly patient with a history of dehydration, the home health nurse will teach the patient to increase fluid intake a. in the late evening hours. b. if the oral mucosa feels dry. c. when the patient feels thirsty. d. as soon as changes in level of consciousness (LOC) occur.

ANS: B An alert, elderly patient will be able to self-assess for signs of oral dryness such as thick oral secretions or dry-appearing mucosa. The thirst mechanism decreases with age and is not an accurate indicator of volume depletion. Many older patients prefer to restrict fluids slightly in the evening to improve sleep quality. The patient will not be likely to notice and act appropriately when changes in LOC occur.

When the nurse is evaluating the fluid balance for a patient admitted for hypovolemia associated with multiple draining wounds, the most accurate assessment to include is a. skin turgor. b. daily weight. c. presence of edema. d. hourly urine output.

ANS: B Daily weight is the most easily obtained and accurate means of assessing volume status. Skin turgor varies considerably with age. Considerable excess fluid volume may be present before fluid moves into the interstitial space and causes edema. Hourly urine outputs do not take account of fluid intake or of fluid loss through insensible loss, sweating, or loss from the gastrointestinal tract or wounds.

Intravenous potassium chloride (KCl) 60 mEq is prescribed for treatment of a patient with severe hypokalemia. Which action should the nurse take? a. Administer the KCl as a rapid IV bolus. b. Infuse the KCl at a rate of 20 mEq/hour. c. Give the KCl only through a central venous line. d. Add no more than 40 mEq/L to a liter of IV fluid.

ANS: B Intravenous KCl is administered at a maximal rate of 20 mEq/hr. Rapid IV infusion of KCl can cause cardiac arrest. Although the preferred concentration for KCl is no more than 40 mEq/L, concentrations up to 80 mEq/L may be used for some patients. KCl can cause inflammation of peripheral veins, but it can be administered by this route.

The home health nurse notes that an elderly patient has a low serum protein level. The nurse will plan to assess for a. pallor. b. edema. c. confusion. d. restlessness.

ANS: B Low serum protein levels cause a decrease in plasma oncotic pressure and allow fluid to remain in interstitial tissues, causing edema. Confusion, restlessness, and pallor are not associated with low serum protein levels.

While caring for a patient with abdominal surgery the first postoperative day, the nurse notices new bright-red drainage about 6 cm in diameter on the dressing. In response to this finding, the nurse should first a. reinforce the dressing. b. take the patients vital signs. c. recheck the dressing in 1 hour for increased drainage. d. notify the patients surgeon of a potential hemorrhage.

ANS: B New bright-red drainage may indicate hemorrhage, and the nurse should initially assess the patients vital signs for tachycardia and hypotension. The surgeon should then be notified of the drainage and the vital signs. The dressing may be changed or reinforced, based on the surgeons orders or institutional policy. The nurse should not wait an hour to recheck the dressing

A diabetic patient who uses insulin to control blood glucose has been NPO since midnight before having a mastectomy. The nurse will anticipate the need to a. withhold the usual scheduled insulin dose because the patient is NPO. b. obtain a blood glucose measurement before any insulin administration. c. give the patient the usual insulin dose because stress will increase the blood glucose. d. administer a lower dose of insulin because there will be no oral intake before surgery.

ANS: B Preoperative insulin administration is individualized to the patient, and the current blood glucose will provide the most reliable information about insulin needs. It is not possible to predict whether the patient will require no insulin, a lower dose, or a higher dose without blood glucose monitoring.

When the nurse caring for a patient before surgery has a question about a sedative medication to be given before sending the patient to the surgical suite, the nurse will communicate with the a. surgeon. b. anesthesiologist. c. circulating nurse. d. registered nurse first assistant (RNFA).

ANS: B The anesthesiologist is responsible for prescribing preoperative medications. The RNFA and surgeon are responsible for the surgery, but not for the preoperative sedation. The circulating nurse does not have authority to make a change in any medication.

A postoperative patient has not voided for 7 hours after return to the postsurgical unit. Which action should the nurse take first? a. Notify the surgeon. b. Perform a bladder scan. c. Assist the patient to ambulate to the bathroom. d. Insert a straight catheter as indicated on the PRN order.

ANS: B The initial action should be to assess the bladder for distention. If the bladder is distended, providing the patient with privacy (by walking with them to the bathroom) will be helpful. Catheterization should only be done after other measures have been tried without success because of the risk for urinary tract infection. There is no indication to notify the surgeon about this common postoperative problem unless all measures to empty the bladder are unsuccessful.

Data that were obtained during the perioperative nurses assessment of a patient in the preoperative holding area that would indicate a need for special protection techniques during surgery include a. a stated allergy to cats and dogs. b. a history of spinal and hip arthritis. c. verbalization of anxiety by the patient. d. having a sip of water 2 hours previously.

ANS: B The patient with arthritis may require special positioning to avoid injury and postoperative discomfort. Preoperative anxiety and having a sip of water 2 to 3 hours before surgery are not unusual for the preoperative patient. An allergy to cats and dogs will not impact the care needed during the intraoperative phase.

During recovery from anesthesia in the postanesthesia care unit (PACU), a patients vital signs are blood pressure 118/72, pulse 76, respirations 12, and SpO2 91%. The patient is sleepy but awakens easily. Which action should the nurse take at this time? a. Place the patient in a side-lying position. b. Encourage the patient to take deep breaths. c. Prepare to transfer the patient from the PACU. d. Increase the rate of the postoperative IV fluids.

ANS: B The patients borderline SpO2 and sleepiness indicate hypoventilation. The nurse should 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 the PACU and is unconscious. The stable BP 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 the PACU is not appropriate.

Before the administration of preoperative medications, the nurse is preparing to witness the patient signing the operative consent form when the patient says, I do not really understand what the doctor said. Which action is best for the nurse to take? a. Provide an explanation of the planned surgical procedure. b. Notify the surgeon that the informed consent process is not complete. c. Administer the prescribed preoperative antibiotics and withhold any ordered sedative medications. d. Notify the operating room staff that the surgeon needs to give a more complete explanation of the procedure.

ANS: B The surgeon is responsible for explaining the surgery to the patient, and the nurse should wait until the surgeon has clarified the surgery before having the patient sign the consent form. The nurse should communicate directly with the surgeon about the consent form rather than asking other staff to pass on the message. It is not within the nurses legal scope of practice to explain the surgical procedure. No preoperative medications should be administered until the patient signs the consent form.

A patient is to receive atropine before surgery. The nurse teaches the patient to expect a. dizziness. b. weakness. c. dry mouth. d. forgetfulness.

ANS: C Anticholinergic medications decrease oral secretions, so the patient is taught that a dry mouth is an expected side effect. Weakness, forgetfulness, and dizziness are side effects associated with other preoperative medications such as opioids and benzodiazepines.

The long-term care nurse is evaluating the effectiveness of protein supplements on a patient who has low serum total protein level. Which of these data indicate that the patients condition has improved? a. Hematocrit 28% b. Good skin turgor c. Absence of peripheral edema d. Blood pressure 110/72 mm Hg

ANS: C Edema is caused by low oncotic pressure in individuals with low serum protein levels; the absence of edema indicates an improvement in the patients protein status. Good skin turgor is an indicator of fluid balance, not protein status. A low hematocrit could be caused by poor protein intake. Blood pressure does not provide a useful clinical tool for monitoring protein status.

Which topic is most important for the nurse to discuss preoperatively with a patient who is scheduled for a colon resection? a. Care for the surgical incision b. Medications used during surgery c. Deep breathing and coughing techniques d. Oral antibiotic therapy after discharge home

ANS: C Preoperative teaching, demonstration, and redemonstration 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.

An alert 82-year-old who has poor hearing and vision is receiving preoperative teaching from the nurse. His wife answers most questions directed to the patient. Which action should the nurse take when doing the teaching? a. Use printed materials for instruction so that the patient will have more time to review the material. b. Direct the teaching toward the wife because she is the obvious support and caregiver for the patient. c. Provide additional time for the patient to understand preoperative instructions and carry out procedures. d. Ask the patients wife to wait in the hall in order to focus preoperative teaching with the patient himself.

ANS: C 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 the wife because both will need to understand preoperative procedures and teaching.

After a new nurse has been oriented to the postanesthesia care unit (PACU), the charge nurse will evaluate that the orientation has been successful when the new nurse a. places a patient in the Trendelenburg position when the blood pressure (BP) drops. b. assists a patient to the prone position when the patient is nauseated. c. turns an unconscious patient to the side when the patient arrives in the PACU. d. positions a newly admitted unconscious patient supine with the head elevated.

ANS: C The patient should initially be positioned in the lateral recovery position to keep the airway open and avoid aspiration. The prone position is not usually used and would make it difficult to assess the patients respiratory effort and cardiovascular status. The Trendelenburg position is avoided because it increases the work of breathing. The patient is placed supine with the head elevated after regaining consciousness.

A patient who has begun to awaken after 30 minutes in the postanesthesia care unit (PACU) is restless and shouting at the nurse. The patients oxygen saturation is 99%, and recent lab results are all normal. Which action by the nurse is most appropriate? a. Insert an oral or nasal airway. b. Notify the anesthesia care provider. c. Orient the patient to time, place, and person. d. Be sure that the patients IV lines are secure.

ANS: D Because the patients assessment indicates physiologic stability, the most likely cause of the patients agitation is emergence delirium, which will resolve as the patient wakes up more fully. The nurse should ensure patient safety through interventions such as raising the bed rails and securing IV lines. Emergence delirium is common in patients recovering from anesthesia, so there is no need to notify the ACP. Insertion of an airway is not needed because the oxygen saturation is good. Orientation of the patient is needed but is not likely to be effective until the effects of anesthesia have resolved more completely.

A surgical patient received a volatile liquid as an inhalation anesthetic during surgery. Postoperatively the nurse should monitor the patient for a. tachypnea. b. myoclonia. c. hypertension. d. incisional pain.

ANS: D Because volatile liquid inhalation agents are rapidly metabolized, postoperative pain occurs soon after surgery. Hypertension and tachypnea are not associated with general anesthetics. Myoclonia may occur with nonbarbiturate hypnotics but not with the inhaled inhalation agents.

A patient is taking a potassium-wasting diuretic for treatment of hypertension. The nurse will teach the patient to report symptoms of adverse effects such as a. personality changes. b. frequent loose stools. c. facial muscle spasms. d. generalized weakness.

ANS: D Generalized weakness progressing to flaccidity is a manifestation of hypokalemia. Facial muscle spasms might occur with hypocalcemia. Loose stools are associated with hyperkalemia. Personality changes are not associated with electrolyte disturbances, although changes in mental status are common manifestations with sodium excess or deficit.

The nurse notes that the oxygen saturation is 88% in an unconscious patient who was transferred to the postanesthesia care unit (PACU) 10 minutes previously. Which action should the nurse take first? a. Elevate the patients head. b. Suction the patients mouth. c. Increase the oxygen flow rate. d. Perform the jaw-thrust maneuver.

ANS: D 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 flow rate and suctioning are not helpful when the airway is obstructed by the tongue. Elevating the patients head will not be effective in correcting the obstruction but may help with oxygenation after the patient is awake.

Spironolactone (Aldactone), an aldosterone antagonist, is prescribed for a patient as a diuretic. Which statement by the patient indicates that the teaching about this medication has been effective? a. I will try to drink at least 8 glasses of water every day. b. I will use a salt substitute to decrease my sodium intake. c. I will increase my intake of potassium-containing foods. d. I will drink apple juice instead of orange juice for breakfast.

ANS: D Since spironolactone is a potassium-sparing diuretic, patients should be taught to choose low potassium foods such as apple juice rather than foods that have higher levels of potassium, such as citrus fruits. Because the patient is using spironolactone as a diuretic, the nurse would not encourage the patient to increase fluid intake. Teach patients to avoid salt substitutes, which are high in potassium.

When the nurse interviews a patient who is to have outpatient surgery using a general anesthetic, which information is most important to communicate to the surgeon and anesthesiologist before surgery? a. The patient drinks 3 or 4 cups of coffee every morning before going to work. b. The patient takes a baby aspirin daily but stopped taking aspirin 10 days ago. c. The patient drank 4 ounces of apple juice 3 hours before coming to the hospital. d. The patients father died after receiving general anesthesia for abdominal surgery.

ANS: D The information about the patients father suggests that there may be a family history of malignant hyperthermia and that precautions may need to be taken to prevent this complication. Current research indicates that having clear liquids 3 hours before surgery does not increase the risk for aspiration in most patients. Patients are instructed to discontinue aspirin 1 to 2 weeks before surgery. The patient should be offered caffeinated beverages postoperatively to prevent a caffeine-withdrawal headache, but this does not have preoperative implications.

A 24-year-old who takes a diuretic and a -blocker to control blood pressure is scheduled for abdominal surgery. Which patient information is most important to communicate to the health care provider before surgery? a. Pulse rate 59 b. Hematocrit 35% c. Blood pressure 142/78 d. Serum potassium 3.3 mEq/L

ANS: D The low potassium level may increase the risk for intraoperative complications such as dysrhythmias. Slightly elevated blood pressure is common before surgery because of patient anxiety. The heart rate would be expectedin a patient taking a -blocker. The hematocrit is in the low normal range but does not require any intervention before surgery.

A patient in surgery receives a neuromuscular blocking agent as an adjunct to general anesthesia. At completion of the surgery, it is most important that the nurse monitor the patient for a. nausea. b. confusion. c. bronchospasm. d. weak chest-wall movement.

ANS: D The most serious adverse effect of the neuromuscular blocking agents is weakness of the respiratory muscles leading to postoperative hypoxemia. Nausea and confusion are possible adverse effects of these drugs, but they are as great a concern as respiratory depression. Because these medications decrease muscle contraction, laryngospasm and bronchospasm are not concerns.