FINAL EXAM 311

The importance of correctly positioning a patient in the OR includes all of the following except: A. Prevent occlusion of vascular supply B. To prevent pressure on nerves or bony prominences C. Maintain hemostasis D. Maintain skeletal alignment to prevent injury to the patient

Maintain homestasis

A patient with a new-onset confusion and hypothermia is being admitted. When making room assignments, the charge nurse should take which action? A. Assign the patient to a room near the nurse's station B. Place the patient on telemetry to monitor for peaked T waves. C. Assign the patient to a semi-private room D. Place the patient in a room nearest to the water fountain.

A. Assign the patient to a room near the nurse's station

A patient has had 0.9% sodium chloride infusing at 150ml/hr for the past 26 hours. The patient begins to complain about difficulty breathing and bounding pulse. What is the nurses priority intervention. A. Auscultate the patients lungs B. Monitor the patient weight C. Elevate the patients legs D. Notify the health care-provider

A. Auscultate the patients lungs

The nurse receives the clients most recent blood work results. Which laboratory value is of greatest concern? A. Calcium of 15.5 mg/dL B. Potassium of 3.5 mEq/L C. Magnesium 1.6 mg/dL D. Sodium of 145 mEq/L

A. Calcium of 15.5 mg/dL

The nurse administers a diuretic to a patient with a fluid volume excess. What finding would indicate the treatment was effective? A. Decrease in weight B. Decrease in hematocrit C. Decrease in urine output D. Decrease in kidney function

A. Decrease in weight

8 hours after surgery, a nurse on the orthopedic floor identifies that a patient has not voided. Which actions by the nurse are appropriate: A. Have the patient assume a normal void position if able and run the water from the faucet B. Immediately catherize the patient C. Do a bladder scan and check for residual D. Palpate the patients bladder for fullness/distention

A. Have the patient assume a normal void position if able and run the water from the faucet C. Do a bladder scan and check for residual D. Palpate the patients bladder for fullness/distention

The correct way to scrub at the scrub sink is: A. Hold the hands higher than the elbows B. Scrub without friction C. Scrub for a minimum of 15 minutes D. Scrub from the elbows to hands

A. Hold the hands higher than the elbows

The nurse is assessing a newly admitted patient and notices hyperactive deep tendon reflexes. What potential electrolyte imbalance should the nurse suspect? A. Hypomagnesmia B. Hyperantremia C. Hypercalcemia D. Hypokalemia

A. Hypomagnesmia

The nurse is providing dietary for a patient with congestive heart failure. What instructions would indicate the patient needs for further education. A. I can use as much salt substitute as I want B. I will limit my fluid intake C. I will limit my sodium intake D. I will eat sweets and fats in moderation

A. I can use as much salt substitute as I want

The nurse determines that a patient's lab values reveals severe hypoatremia. What nursing diagnosis will be the priority for this patient? A. Risk for falls B. Acute confusion C. Ineffective breathing pattern D. Risk for injury

B. Acute confusion

The nurse is providing discharge teaching to a patient who has a laparoscopic inguinal hernia repair. Which of the following indicates the patient needs further teaching? A. I will have someone stay with me for 24 hours in case I feel dizzy B. I should wait until the long acting local anesthetic wears off before starting my prescribed pain medications C. It is important for me to ambulate around the house 4-5 times to promote circulation D. I will notify my surgeon if I experience increasing pain, start running a fever, or notice a lot of drainage on my bandage.

B. I should wait until the long acting local anesthetic wears off before starting my prescribed pain medications

The nurse is providing discharge teaching for a patient with renal failure. When discussing diet, what food should the nurse teach the patient to avoid to prevent hyperphosphetemia? A. Fresh fruit B. Milk C. Broth D. Pretzels

B. Milk

A nurse admits an older adults with acute renal failure and a potassium level of 6.4. Which medication should the nurse anticipate administering to lower the potassium level. A. Regular insulin B. Sodium polystyrene sulfonate C. Foresemide D. Sodium bicarbonate

B. Sodium polystyrene sulfonate

A patient presents to the emergency department with the complaint of vomiting and diarrhea for the past 48 hours. The nurse anticipates which fluid therapy initially? A. 3% sodium chloride B. 0.45% sodium chloride C. 0.9% sodium chloride D. Dextrose 10% in water

C. 0.9% sodium chloride

The nurse is caring for a patient with complaints of severe vomiting and diarrhea for 3 days. What order should the nurse question? A. Weigh the client daily B. Administer 0.9% sodium chloride at 150mL/hr C. Administer 3% saline at 150 mL/hr D. Monitor and record intake and output.

C. Administer 3% saline at 150 mL/hr

Four patients arrive at the emergency department at the same time. Which patient will the nurse see first? A. A teenager with a sprained ankle and excessive edema. B. An older adult with nausea and vomiting for 3 days and blood pressure 112/60 C. An infant with temperature of 102.2 and diarrhea for 3 days. D. A Middle Ages adult with abdominal pain who is moaning and holding the stomach.

C. An infant with temperature of 102.2 and diarrhea for 3 days.

What assessment should the nurse perform when administering magnesium oxide to identify if the patient is developing a dangerous side effect? A. Asses for hypertension B. Asses for tachycardia C. Asses for decreased deep tendon reflexes D. Asses for constipation

C. Asses for decreased deep tendon reflexes

When a patient is admitted to the PACU, what are the priority interventions the nurse performs? A. Assess the amount of urine output and the presence of bladder distention B. Review results of intraoperative laboratory values and medications received C. Assess for airway latency and quart of respirations and obtain vital signs D. Assess the surgical site, noting presence and character of drainage.

C. Assess for airway latency and quart of respirations and obtain vital signs

While assessing a patient lab values, the nurse associates a serum sodium level of 122 mEq/L with what electrolyte imbalance? A. Hypokalemia B. Hypernatremia C. Hypoantremia D. Hyperkalemia

C. Hypoantremia

After receiving change-of-shift report, which patient should the nurse assess first? A. A patient with a serum phosphorus level of 4.5 mg/dL who has multiple soft tissue calcium-phosphate predicates. B. Patient with serum sodium level of 145 mEq/L who has a dry mouth and is asking for a glass of water. C. Patient with serum magnesium level of 1.1 mEq/L who has tremors and hyperactive deep tendon reflexes. D. Patient with serum potassium level of 5.0 mEq/L who is complaining of abdominal cramping.

C. Patient with serum magnesium level of 1.1 mEq/L who has tremors and hyperactive deep tendon reflexes.

A patient has a serum calcium level of 7.0 mEq/L. Which assessment finding is most important for the nurse to report to the health care provider? A. The patient has numbness and tingling of the lips. B. The patient complains of generalized fatigue. C. The patient is expecting laryngeal stridor. D. The patient's bowels have not moved for 4 days.

C. The patient is expecting laryngeal stridor.

The health care provider has order a hypotonic intravenous solution to be administered. Which IV bag will the nurse prepare? A. Dextrose 5% in lactated ringers B. Lactated ringers C. 0.9% sodium chloride D. 0.45% sodium chloride

D. 0.45% sodium chloride

What vital sign readings should the nurse associate with the development of fluid volume deficit? A. Blood pressure of 110/80, pulse 72, respiratory rate of 18 B. Blood pressure of 142/86, pulse 68, respiratory rate 20 C. Blood pressure of 100/60, pulse 86, respiratory rate 16 D. Blood pressure of 82/58, pulse 115, respiratory rate 24

D. Blood pressure of 82/58, pulse 115, respiratory rate 24

The nurse is caring for a patient with hyperkalemia. Which body system assessment is the priority? A. Gastrointestinal B. Neurological C. Respiratory D. Cardiac

D. Cardiac

All of the following are true regarding the role of the scrub nurse except: A. Passing instruments to the surgeon and other assistants B. Maintaining accurate counts of sponges, sharps, and instruments C. Preparing the sterile field D. Checking the electrical equipment.

D. Checking the electrical equipment.

The client with hypophosphatemia who is undergoing intravenous phosphorus replacement suddenly has a positive trousseau sign. What is the correct interpretation of this finding? A. The hypophosphatema is worsening B. The client is dehydrated C. Rehydration is too rapid and over hydration is occurring. D. The phosphorus replacement is causing hypocalcemia.

D. The phosphorus replacement is causing hypocalcemia.

The PACU nurse uses the modified aldrete scoring system to determine if her patient can be safely discharged to the surgical floor. The nurse knows that the categories of the scale that need to be assessed are all of the following expect: A. Oxygen saturation B. Activity C. Level of consciousness D. Wound site, drains, or dressings

Wound site, drains, or dressings

Following a thyroidectomy, a patient complains of "a tingling feeling around my mouth." Which assessment should the nurse complete immediately? a. Presence of the Chvostek's sign b. Abnormal serum potassium level c. Decreased thyroid hormone level d. Bleeding on the patient's dressing

a. Presence of the Chvostek's sign

Which patient would be at most risk for developing a postoperative complication? A. A 60 year old patient who is obese, has diabetes, and hypertension. B. A 25 year old patient with a past history of smoking C. A 22 yer old patient undergoing a tonsillectomy D. A 60 year old patient with arthritis who's takes NSAIDS daily

A. A 60 year old patient who is obese, has diabetes, and hypertension.

Which of the following is highest priority when preparing a patient for surgery in the intra-operative setting? A. Apply safety straps and position the patient appropriately B. Prep and drape incision site C. Document the position of the patient D. Pad the patient's elbows

A. Apply safety straps and position the patient appropriately

Complications of hypothermia in surgery include all of the following except: A. Paresthesia B. Alteration in drug metabolism C. Impaired coagulation D. Increased risk for surgical site infections

A. Paresthesia

A nurse is assessing a patient. Which assessment finding should cause a nurse to further assess for extracellular fluid volume deficit? A. Postural hypotension B. Supple skin turgor C. Pitting edema D. Moist mucous membranes

A. Postural hypotension

The nurse is evaluating the effectiveness of the intravenous fluid therapy in a patient with hypernatremia. Which finding indicated goal achievement? A. Serum sodium concentration returns to normal. B. Urine output increases to 150mL/hr C. Systolic and diastolic blood pressure decreases. D. Large amounts of emesis and diarrhea decrease.

A. Serum sodium concentration returns to normal.

Which type of regional anesthesia is injective via lumbar puncture into the CSF? A. Spinal B. Topical C. Local D. Nerve

A. Spinal

A patient comes to the clinic complaining of frequent, watery stools for the past 2 days. Which action should the nurse take first? A. Obtain the baseline weight B. Check the patients blood pressure C. Draw blood for serum electrolyte levels. D. Ask about extremity numbness or tingling.

B. Check the patients blood pressure

The nurse is completing a health history on a patient that was admitted to the ED with excessive edema and a serum potassium of 7.2. What chronic medical problem would the nurse identify as a possible reason for symptoms. A. Hypertension for 15 years B. Chronic renal failure C. Congestive heart failure D. Prostate cancer

B. Chronic renal failure

The nurse is caring for an older adult with a fluid imbalance. What age-related change should the nurse associate with fluid imbalances in older adults? A. Increased kidney function B. Decreased perception of thirst. C. Higher percentage of total body water than younger adults. D. Efficient temperature regulation

B. Decreased perception of thirst.

A priority nursing intervention to assist a preoperative patient in coping with fear of postoperative pain would be to: A. Inform the patient that pain medication will be available B. Explain the pain management plan, including the use of a pain rating scale. C. Teach the patient to use guided imagery to help manage pain D. Describe the type of pain expected with the patients particular surgery

B. Explain the pain management plan, including the use of a pain rating scale.

The nurse is caring for patient in the PACU with the following vital signs: T-96.9, P-115, R-26, BP-82/52. The nurse knows that these are symptoms may be indicate of A. Pulmonary edema B. Hypovlemia C. A dysrhythmia D. A vasovagal response

B. Hypovlemia

A patient presents to the emergency department with reported of vomiting and diarrhea for the past 48 hours. The health care provider orders isotonic intravenous therapy. Which IV will the nurse prepare? A. 3% sodium chloride B. 0.225% sodium chloride C. 0.9% sodium chloride D. 0.45% sodium chloride

C. 0.9% sodium chloride

A patient is transferred from PACU to phase II recovery. The nurse should assess first for a patient airway, stable vital signs and then A. Complete the admission paperwork B. Assess dressing for bleeding C. Assess pain level according to the pain scale D. Offer the patient clear liquids.

C. Assess pain level according to the pain scale

All of the following are essential in preventing hypothermia in the OR except: A. Keeping the patient covered with warm blankets with exception of the surgical site B. Pre-warming the patient in the preoperative setting C. Closely monitoring that the temperature of the OR suite is on the warmer side D. Administering warm IV fluids.

C. Closely monitoring that the temperature of the OR suite is on the warmer side

A patient has a magnesium level of 1.3 mg/dL. Which assessment would help the nurse identify a likely cause of this value? A. Multivitamin/ mineral use B. Dietary protein intake C. Daily alcohol intake D. Over the counter laxative use

C. Daily alcohol intake

The nurse observes that the patient's calcium is elevated. when checking the phosphate level, what does the nurse expect to see? A. Increase B. Equal to calcium C. Decreased D. No change

C. Decreased

The nurse is caring for a patient post gallbladder surgery and asks about their pain level. The states "I am having pain in my abdomen where my incision is and rate it about 5/10. I also have an achy pain about 4/10 in my neck that was not there before surgery." The nurse knows which of the following could be a reason for the patient's pain? A. Loss of perception of pain B. Pooling of blood in peripheral vessels C. Improper positioning D. Hypothermia

C. Improper positioning

The long-term care nurse is evaluating the effectiveness of protein supplements for an older resident who has a low serum total protein level. Which assessment finding indicates that the patient's condition has improved? A. Absence of skin tenting B. Hematocrit 28% C. Blood pressure 110/ 72 mmHg D. Decreased peripheral edema

D. Decreased peripheral edema

A nursing student and instructor are preparing to administer potassium chloride intravenously. What statement made by the student indicated a need for further teaching? A. I will monitor the patients IV site closely during administration of this medication. B. I am going to program an infusion pump to administer this medication. C. I plan to monitor the patient cardiac rhythm during the administration of this medication. D. I have drawn up this medication for IV push administration.

D. I have drawn up this medication for IV push administration.

A patient is admitted to the PACU after major abdominal surgery. During the initial assessment the patient tells the nurse he thinks he is going to "throw up" a priority nursing intervention is to: A. Obtain vital signs, including O2 saturation B. Administer antiseptic medication as ordered. C. Increase the rate of the IV fluids D. Position patient in a side-lying recovery position.

D. Position patient in a side-lying recovery position.

A nurse is caring for a patient with peripheral intravenous (IV) therapy. Which task will the nurse assign to the nursing active personal? A. Starting peripheral intravenous therapy. B. Changing a peripheral intravenous dressing C. Regulating intravenous flow rate D. Recording intake and output.

D. Recording intake and output.

A patient with multiple draining wounds is admitted for hypovolemia. Which assessment would be the most accurate way for the nurse to evaluate fluid balance? A. Edema presence B. Skin Turgor C. Daily weight D. Urine output

Daily weight

A patient who is lethargic and exhibits Depp, rapid respirations has the following arterial blood gas results: pH 7.32, PaO2 88 mmHg, PaCO2 37 mmHg, 16 mEq/L. How should the nurse interpret these results? A. Metabolic alkalosis B. Respiratory alkalosis C. Metabolic acidosis D. Respiratory acidosis

Metabolic acidosis

The nurse is teaching about the process of passively moving water from an area of lower particle concentration to an area of higher particle concentration. Which process is the nurse describing? A. Filtration B. Active transport C. Osmosis D. Diffusion

Osmosis

The nurse is caring for a diabetic patient in renal failure who is in metabolic acidosis. Which laboratory findings are consistent with metabolic acidosis? A. pH 7.3, PaCO2 36 mmHg, HCO3 19 mEq/L B. pH 7.32, PaCO2 47 mmHg, HCO3 23 mEq/L C. pH 7.5, PaCO2 35 mmHg, HCO3 35 mEq/L D. pH 7.35, PaCO2 40 mmHg, HCO3 25 mEq/L

pH 7.3, PaCO2 36 mmHg, HCO3 19 mEq/L

Which blood gas result will the nurse expect to observe in a patient with respiratory alkalosis? a. pH 7.60, PaCO2 40 mm Hg, HCO3- 30 mEq/L b. pH 7.53, PaCO2 30 mm Hg, HCO3- 24 mEq/L c. pH 7.35, PaCO2 35 mm Hg, HCO3- 26 mEq/L d. pH 7.25, PaCO2 48 mm Hg, HCO3- 23 mEq/L

pH 7.53, PaCO2 30 mm Hg, HCO3- 24 mEq/L

Following an ear tube placement, a child in the PACU suddenly becomes tachycardia, tachypneic, and is having muscle rigidity. The PACU nurse suspects the patient is experiencing which of the following: A. Malignant hyperthermia B. Internal bleeding C. A heart dysrhythmia D. An anaphylactic reaction

A. Malignant hyperthermia

The patient who has undergone exploratory laparotomy and removal of a large intestinal tumor has a nasogastric tube in placed and IV running at 150ml/hr via an IV pump. Which data should be reported to the health care provider? A. Patient has negative pedal edema and an increasing level of conciseness B. On lung auscultation, crackles in all fields are noted. C. Intake is 1800 mL, NGT output is 550mL, and foley output is 950 mL. D. The pump keeps sounding an alarm indicating the high pressure been reached.

B. On lung auscultation, crackles in all fields are noted

A patient who was involved in a motor vehicle crash has had a tracheostomy placed to allow for continued mechanical ventilation. How should the nurse interpret the following blood gas results: pH 7.48, PaO2 85 mm Hg, PaCO2 32mm Hg, and HCO3 25 mEq/L? A. Metabolic alkalosis B. Respiratory alkalosis C. Metabolic acidosis D. Respiratory acidosis

B. Respiratory alkalosis

A patient is scheduled for a colon surgery and is to receive general anesthesia. Which data collected during the nursing history and physical should cause the most concern for the patient when thinking about post-operative recovery? A. Drinks alcohol on a rare occasion B. Smokes 2 packs of cigarettes per day C. History of latex allergy D. Blood pressure reading of 136/80

B. Smokes 2 packs of cigarettes per day

A patient who is taking potassium-wasting diuretic for treatment of hypertension complains of generalized weakness. Which action is appropriate for the nurse to take? A. Asses for facial muscle spasms B. Suggest that the health care provider order a basic metabolic panel C. Recommend the patient avoid drinking orange juice with meals. D. Ask the patient about loose stools.

B. Suggest that the health care provider order a basic metabolic panel

A patient is receiving a 3% saline continuous IV infusion for hyponatremia. Which assessment data will require the most rapid response by the nurse? A. The blood pressure increases from 120/80 to 142/94 mm Hg B. There are crackles throughout both lung fields. C. The patient's radial pulse is 105 beats/min D. There is sediment and blood in the patients urine.

B. There are crackles throughout both lung fields.

A patient is admitted for a bowel obstruction and has had a nasogastric tube set to low intermittent suction for the past 3 days. Which arterial blood gas values will the nurse expect to observe? A. Metabolic alkalosis B. Respiratory alkalosis C. Metabolic acidosis D. Respiratory acidosis

Metabolic alkalosis

A nurse is assessing a client for signs of hypocalcemia. What action should the nurse perform to assess for the presence of trousseau's sign? A. Asses the biceps, triceps, and brachioradial reflexes of the arm, wrist and observe hyper stimulation B. Apply a blood pressure cuff to the patients upper arm, inflate the cuff to a reading higher than the patients systolic blood pressure for 1-4 minutes, observe for carpopedal spasms. C. Tap the facial nerve anterior to the earlobe and just below the zygomatic arch, observe for facial twitching on the same side as the stimulus. D. Instruct the patient to hyperventilate, and observe for muscle spasms of the hands or feet.

B. Apply a blood pressure cuff to the patients upper arm, inflate the cuff to a reading higher than the patients systolic blood pressure for 1-4 minutes, observe for carpopedal spasms.

A patient with a diagnosis of acute renal failure has an intake 2000 ml and a urine output of 200 ml for the past 24 hours. What assessment by the nurse is most important? A. Check urine specific gravity B. Auscultate breath sounds C. Palpate peripheral pulses D. monitor blood pressure

B. Auscultate breath sounds

A 2 year old child is brought into the emergency department after ingesting a medication that causes respiratory depression. For which acid-base imbalance will the nurse most closely monitor this child? A. Metabolic alkalosis B. Respiratory alkalosis C. Metabolic acidosis D. Respiratory acidosis

Respiratory acidosis

The home health nurse cares for an alert and oriented older adult patient with a history of dehydration. Which instructions should the nurse give this patient related to fluid intake? A. Increase fluids if your mouth feels dry. B. Drink more fluids in the late evening C. More fluids are needed if you feel thirsty D. If you feel confused, you need to drink.

A. Increase fluids if your mouth feels dry.

The nurse is caring for a patient with ulcerative colitis and dehydration. What assessment finding should the nurse identify as the best indicator of fluid volume status over 3 days? A. Stool count of 8 diarrhea episodes within 24 hours. B. Weight loss of 2 kg over 2 days. C. A 24 hour urine output of 1,000ml D. Daily intake of 2,400 ml and an output of 1,600 ml

B. Weight loss of 2 kg over 2 days.