Med Surg Exam 2

The nurse is completing a preoperative assessment. The nurse notices the client is tearful and constantly wringing their hands. The client states, "I'm really nervous about this surgery. Do you think it will be ok?" What is the nurse's best response?

"What are your concerns?"

What is the best response by the nurse when the patient states, "I'm so nervous about my surgery"?

"Would you like to discuss the concerns that you have?"

A client is scheduled for an invasive procedure. What should the nurse document in the chart regarding the procedure?

A signed consent form from the client

An intraoperative nurse is applying interventions that will address surgical clients' risks for perioperative positioning injury. What factors contribute to this increased risk for injury in the intraoperative phase of the surgical experience? Select all that apply.

Absence of reflexes Diminished ability to communicate Loss of pain sensation

Why should the nurse be vigilant with assessment of perioperative risks on the older adult client? Select all that apply.

Ciliary action decreases, reducing the cough reflex. Fatty tissue increases, prolonging the effects of anesthesia. Liver size decreases, reducing the metabolism of anesthetics.

In which instance may a surgeon operate without informed consent?

Emergency situations

physical assessment musculoskeletal system

General inspection Posture Crepitation (grating sound as joint or bone moves) Abnormality in gait Goniometer, which provides a measure of ROM Head and neck: evaluate the temporomandibular joints Spine: lordosis, scoliosis, kyphosis Assess Strength in Upper extremities/Lower extremities Use of mobility aids Joints and bones Check for symmetry Evidence of redness Swelling or deformity Edema or tenderness Check ROM, strength, crepitus, nodules

A nurse on the surgical team has been assigned the role of scrub nurse. What action by the scrub nurse is appropriate?

Handing instruments to the surgeon and assistants

Which of the following is a duty of the registered nurse first assistant? Select all that apply.

Handling tissue Suturing Maintaining hemostasis Providing exposure at the operative field

When planning care for a client in the postoperative period, prioritize nursing diagnoses in the sequence from highest to lowest priority?

Impaired Gas Exchange Fluid Volume Deficit Altered Comfort Anxiety Risk for Infection

how to complete assessment of musculoskeletal system

Include data related to function ability; ADLs, IADLS, and ability to perform various activities. Note any problems related to mobility. Health history: family history, general health maintenance, nutrition, occupation, learning needs, socioeconomic factors, and medications—include OTC Assessment of pain and altered sensations Physical assessment: posture, gait, bone integrity, joint function, muscle strength and size, skin, neurovascular status

The nurse is aware that a religious group that refuses blood transfusions for religious reasons is:

Jehovah's Witnesses

A postanesthesia care unit (PACU) nurse is caring for a client with the following assessment data: pale, cool, moist skin; thready pulse of 122; blood pressure 78/60; urine output of 25 mL/h; temperature 99.2°F. What interventions by the nurse are appropriate? Select all that apply.

Maintain a patent airway. Frequently monitor neurological status. Administer blood products per orders. Apply oxygen per orders.

Which of the following is the most important initial nursing activity in the postoperative recovery area?

Maintain patient safety (airway and circulation)

The nurse is conducting a health history of a preoperative client. The client shares that she experienced vaginal itching and burning and labial swelling after her partner tried a new brand of condoms. The nurse suspects that the client:

May have a latex allergy.

During surgery a patient develops hypothermia. The circulating nurse would monitor the patient closely for which of the following?

Metabolic acidosis

During the admission history the client reports to the nurse of taking the usual dose of warfarin the previous day. What is an appropriate nursing action?

Notify the surgeon that the client took warfarin the day before surgery.

A nurse is monitoring a client recovering from moderate sedation that was administered during a colonoscopy. Which finding requires the nurse's immediate attention?

O2 sat of 85%

What is the major purpose of withholding food and fluid before surgery?

Prevent aspiration

The nurse is caring for a 79-year-old man who has returned to the postsurgical unit following abdominal surgery. The client is unable to ambulate and is now refusing to wear an external pneumatic compression stocking. The nurse should explain that refusing to wear external pneumatic compression stockings increases his risk of what postsurgical complication?

Pulmonary embolism

priority care for possible fracture

Reduction: restoration of the fracture fragments to anatomic alignment and positioning Closed fractures - control edema, pain management, assistive devices, education open fractures - Risk for infection, wound irrigation and debridement

A nurse is working as part of the surgical team in the semi-restricted area. Which of the following would be appropriate to wear? Select all that apply.

Scrub clothes Caps

informed consent

Should be in writing should explain the procedure and any risks, description of benefits and alternatives, offer answers to any questions, instruct patient that they may withdrawal consent, statement informing patient if protocol differs from customary procedure must be given freely without coercion Patient must be at least 18 years of age (unless emancipated minor) Consent must be obtained by physician Patient's signature must be witnessed by professional staff member

The nurse is caring for a 78-year-old man who has had an outpatient cholecystectomy. The nurse is getting him up for his first walk postoperatively. To decrease the potential for orthostatic hypotension and consequent falls, what should the nurse have the client do?

Stand upright for 2 to 3 minutes prior to ambulating.

The nurse is educating a client scheduled for elective surgery. The client currently takes aspirin daily. What education should the nurse provide with regard to this medication?

Stop taking the aspirin 7 days before the surgery, unless otherwise directed by your physician.

The perioperative nurse is preparing to discharge a female client home from day surgery performed under general anesthetic. What instruction should the nurse give the client prior to the client leaving the hospital?

The client should not drive herself home.

What evidence does the nurse understand indicates that a patient is ready for discharge from the recovery room or PACU? (Select all that apply.)

The patient is arousable but falls back to sleep rapidly. The patient has a blood pressure within 10 mm Hg of the baseline. The patient has sonorous respirations and occasionally requires chin lift.

In which zone of the surgical area are street clothes allowed?

Unrestricted

Which intervention should the nurse implement during the intraoperative period to protect the client from injury? Select all that apply.

Verify scheduled procedure with client. Assess the client for allergies. Confirm the consent form is signed.

The nurse is caring for a client during the immediate postoperative period and is assessing for signs of shock. What signs and symptoms indicate that the client may be in shock?

Weak and rapid pulse rate

Scoliosis

a lateral curving deviation of the spine

lordosis

abnormal anterior curvature of the lumbar spine (swayback)

MRI safety precautions

absolutely no metal in or on patient

kyphosis

an increased forward curvature of the thoracic spine that causes a bowing or rounding of the back, leading to a hunchback or slouching posture

how to relieve some cast discomfort

antihistamine for scratching

when does preoperative teaching begin

at the time the patient decides to have the surgery

A registered nurse who is responsible for coordinating and documenting client care in the operating room is a

circulating nurse

complications of having a cast

compartment syndrome, pressure ulcer, disuse syndrome, delayed union or nonunion of fracture

what is explained in preoperative teaching

deep breathing, coughing, incentive spirometry how to splint the incision during these deep breathing or coughing exercises take pain medicine so breathing exercises can be performed comfortably mobility and active body movement pain management cognitive coping strategies

why is an MRI used

gives a much more detailed diagnostic image than CT scan

crepitus

grating or crackling sound or sensation may occur with movement of ends of a broken bone or irregular joint surface

cast care

keep dry, do not ruin padding, do not insert foreign objects, do not put weight on cast for 48 hours till dry, do not cover with PLASTIC, report swelling discoloration of toes or fingers, pain during motion, and burning or tingling under the cast, cushion rough edges, watch for s/s of infection or pressure areas

The client complains of weakness and dizziness as the nurse assists the client to sit on the side of the bed. The nurse recognizes the client is experiencing:

orthostatic hypotension

roles of the scrub nurse

performing hand hygiene setting up sterile equipment, tables, and sterile field preparing sutures, ligatures, and special equipment anticipating the instruments and supplies that will be required as surgical incision is closed the scrub nurse and circulating nurses count all the needles, sponges, and instruments to be sure they are accounted for and not retained as a foreign body in the pt labels tissue specimens

A client is scheduled to have surgery to address a cleft palate. The nurse will be preparing this client for which type of surgery?

reconstructive

signs and symptoms of post op infection

redness, warmth, edema, tenderness

assessment of post-op patients

review baseline status assess airway first, respirations, cardiovascular fx, surgical site, fx of CNS, check all IVs and equipment reassess VS every 15 min or PRN

initial signs and symptoms of malignant hypothermia

tachycardia, dysrhythmia, hypotension, muscle rigidity, cardiac arrest caused by anesthesia

roles of circulating nurse

verifies consent manages/monitors OR protects pt safety responsible for time-out before surgery begins monitors aseptic technique coordinates movement of related personnel (medical, x-ray, lab) implements fire safety continually assesses pt for signs of injury or issue and implements proper interventions ensures cleanliness, proper temperature, humidity, appropriate lighting, safe function of equipment, availability of supplies and materials documents