Final Review

In the teaching plan for a client is to have out patient (ambulatory) surgery, the nurse should include the instruction to

"Be sure that you have someone who can drive you home."

A client on Airborne Precautions asks the nurse to leave his door open. What is the nurse's best reply?

"I have to keep your door shut at all times. I'll open the curtains so that you don't feel so closed in."

Before discharge, the nurse confirms that the client understands antibiotic therapy for a wound infection by which statement?

"I need to take the antibiotic until the prescription is finished."

You are caring for a client in the postoperative period. The client states, "I don't want to use my pain medication because it will make me dependent, and I won't get better as fast." Which response is most important when explaining the use of pain medication?

"You will heal more quickly with decreased pain levels. Dependence only occurs when it is administered for an extended period of time."

A circulating nurse provides care in a surgical department that has multiple surgeries scheduled for the day. The nurse should know to monitor which client most closely during the intraoperative period because of the increased risk for hypothermia?

A 74-year-old woman with a low body mass index

Which client does the nurse consider to be at increased risk for infection?

Adult with type 1 diabetes mellitus

The nurse is preparing to administer a prescribed IV antibiotic to a client admitted with a serious infection. Which action is most important to do first?

Assess the client for allergies.

Your postoperative client suddenly presents with hypotension; rapid, thready pulse; oliguria; and cold, pale skin. You suspect hemorrhage. What would be your first nursing action?

Assess the post op dressing

A nurse is preparing to administer a client's scheduled dose of subcutaneous heparin. To reduce the risk of needlestick injury, the nurse should perform what action?

Avoid recapping the needle before disposing of it.

A client is admitted with a fever of 102.8° F, origin unknown. Assessment reveals cloudy, foul-smelling urine that is dark amber in color. Orders have just been written to obtain urine and blood cultures and to administer an antibiotic intravenously stat. The nurse will complete these orders in which sequence?

Blood and urine cultures, ampicillin dose

A client allergic to penicillin is being evaluated for a gram-negative infection. Which antimicrobial drug class would the health care provider be cautious in prescribing because of a possible cross-sensitivity and/or allergic reaction?

Cephalosporins

A long-term care facility is the site of an outbreak of infectious diarrhea. The nurse educator has emphasized the importance of hand hygiene to staff members. The use of alcohol-based cleansers may be ineffective if the causative microorganism is identified as what?

Clostridium difficile

A client has a concentration of S. aureus located on his skin. The client is not showing signs of increased temperature, redness, or pain at the site. The nurse is aware that this is a sign of a microorganism at which of the following stages?

Colonization

You are packing a client's abdominal wound with sterile gauze. You drop some of the gauze onto the client's abdomen 4 inches away from the wound. What should you do?

Discard the gauze packing and repack the wound with new Iodoform gauze.

You are the nurse in the preoperative holding area. What is included in the care you give to each client? Select all that Apply

Establish an intravenous line Verify surgical site and mark site Take measures to ensure the client's comfort

The older adult client has been lying in a supine position for the last 3 hours. The nurse who is repositioning this client would be most concerned with examining which of the following bony prominences of the client? Select all that apply.

Heels Elbows Sacrum Back of the head

The nurse is caring for a client with a large leg wound that has been slow to heal. Which action by the nurse is most appropriate?

Help the client choose high-protein items at meals.

An elderly client who is bedridden is admitted to the unit because of a pressure ulcer that can no longer be treated in a community setting. During your assessment of the client, you find that the ulcer extends into the muscle and bone. At what stage would document this ulcer?

IV

The nurse is creating the care plan for a 70-year-old obese client who has been admitted to the postsurgical unit following surgery. This client's age and increased body mass index mean that they are at increased risk for what complication in the postoperative period?

Infection

The anesthetist is coming to the unit to see a client prior to their surgery. What information is most important to inform the anesthetist about?

Latex allergy

Surgical asepsis is a requirement in the restricted zone of the operating suite. What personal protective equipment should the scrub nurse wear at all times in the restricted zone of the operating room?

Mask covering the nose and mouth

The nurse places a client in isolation. Isolation techniques have the potential to break the chain of infection by interfering with what component of the chain of infection?

Mode of transmission

You are the circulating nurse. Which task are you solely responsible for?

Monitoring the client and documents

If a client is not turned every 2 hours, the effect could be:

Occlusion of the capillary bed and tissue ischemia

The nurse is reviewing the medication history of a client who will be taking an antibiotic. During antibiotic therapy, a significant drug interaction may occur with which drug group?

Oral contraceptives

Your client has undergone an abdominal surgery. While turning the client, wound dehiscence with evisceration occurs. What is your first response?

Place saline-soaked sterile dressings on the wound.

The nurse is assessing a client's skin for local signs of infection. Which signs does the nurse assess for? Select all that Apply

Redness Warmth Pain Swelling

The nurse is doing preoperative education with a 61-year-old client who has a 40year history of cigarette smoking. What is the best instruction to give to this client?

Stop smoking 4 to 8 weeks before the scheduled surgery to enhance pulmonary function and decrease infection.

The nurse is caring for a postoperative client who needs daily dressing changes. The client is 3 days post-op and should be going home the next day. Up until now, the client has refused to learn how to change the dressing. What would indicate to the nurse the client's readiness to learn how to change the dressing? Select all that Apply

The client expresses interest in the dressing change. The client looks at the incision. The client assists in opening the packages of dressing material for the nurse.

A client comes to the emergency department with a fever, diarrhea, and general malaise. Which information obtained during assessment does the nurse communicate immediately to the health care provider?

The client having just returned from a 14-day trip to Asia

Upon entering the operating room, the client informs the nurse that his grandmother spiked a 104°F temperature in the OR and nearly died 15 years ago. What relevance does this information have regarding the client?

The client is at risk for malignant hyperthermia.

In anticipation of a client's scheduled surgery, the nurse is teaching her to perform deep breathing and coughing to use postoperatively. What action should the nurse teach the client?

The client should take a deep breath, exhale through the mouth, take a short breath, and cough from deep in the lungs.

An obese, older client develops an infected decubitus on the sacrum during his hospital stay. Approximately 2 weeks after the client has gone home, the client returns to the hospital with pneumonia. The distinction between these two infections is:

The decubitus is termed a health care-associated infection, and the pneumonia is termed a community-acquired infection.

What is the best rationale for intubation during a surgical procedure?

The tube provides an airway for ventilation.

When a client is on aminoglycoside therapy, the nurse will monitor the client for which indicators of potential toxicity of the medication?

Tinnitus and hearing loss

What is the best rationale for health care providers receiving the influenza vaccination on a yearly basis?

To decrease risk of transmission to vulnerable clients

The nurse would explain to a client that which of the following is the reason for removing nail polish from the client's nails prior to surgery?

assessment of hypoxia

Before administering the preoperative medication, the nurse should

ensure that the informed consent has been signed.

The nurse notes that a postoperative ambulatory surgery client cannot be discharged to home if which of the following factors is present?

inability to void

During drug therapy for pneumonia, a female client develops a superinfection. The nurse explains that this infection is caused by

large doses of antibiotics that kill normal flora.

Which of the following nursing measures should be implemented after administration of preoperative medications?

place the client on bedrest

The nurse is changing a client's dressing on his appendectomy incision. The edges of the wound are approximated, and no drainage is noted. This wound appears to be healing by

primary intention

When the postsurgical client complains of shortness of breath, the nurse should immediately:

raise the head of the bed to 30 degrees.

During the preoperative interview, the client's statement that would alert the nurse to an increased risk during surgery is "I

take a couple of aspirin every day for my headaches."