NS 103 Final

A pt. is brought to the emergency room after being lost in the woods for days without food or water. The nurse determines the pt. has fluid volume deficit. Which assessment findings indicate fluid volume deficit? Select all that apply. Tachycardia Dry mucous membranes Hypotension Oliguria Weak Pulse

All of the above **All symptoms are indicative of fluid volume deficit

Following surgery, a client is receiving 1,00 mL Normal Saline intravenously (IV) with 40 mEq KCL, which has been prescribed to be infused at 125 mL/h. The client states, "My IV hurts." What should the nurse do first?

Assess the IV site for signs of phlebitis **Potassium in an IV solution may be irritating to a vein. The nurse should assess the IV site before taking any of the other actions listed

A client has been unable to void since having abdominal surgery 8 hours ago. What intervention should the nurse perform?

Assist client to bedside toilet **Urinary retention is common following surgery with anesthesia

The nurse is caring for a client receiving a continuous infusion of narcotics for relief of postoperative pain. On assessment, the client's vital signs are as follows: HR 84, RR 11, BP 104/56, and oxygen saturation of 88% on room air. Which intervention should the nurse perform?

Assist the client to sit, cough, and deep breath **The client still has a RR of 11; it would be important to assist the client to sit and stimulate the client to take some deep breaths and cough

A client has been prescribed a continuous IV infusion of 0.9% normal saline at 150mL/hr. During the shift, the nurse notes the client's urine output has decreased too 10 mL/hr. The client appears to be anxious and restless. What is the priority nursing action? A). Weigh the patient B). Auscultate breath sounds C). Administer a diuretic D). Observe for jugular venous distention

Auscultate breath sounds **A patient receiving continuous IV therapy of normal saline and little urine output could develop pulmonary edema. The nurse should auscultate breath sounds for crackles.

A nurse monitors a patient admitted with fluid volume deficit who is receiving IV fluid therapy. The nurse should recognize a decrease in which symptom as an indication of adequate fluid replacement? A). Blood Pressure B). Heart rate C). Urine output D). Weight

Heart rate **When a patient has too little volume in their body, the heart rate is elevated to compensate. As the patient receives volume replacement, the heart rate should decrease to indicate treatment effectiveness.

The nurse notes a pt's arterial blood gas results are the following: pH 7.48, paCO2 28, HCo3 25. Which does the nurse suspect could be the cause of the imbalance? A). Excess vomiting B). Chronic obstructive pulmonary disease C). Hyperventilation D). Renal failure

Hyperventilation **The pt's ABG results indicate respiratory alkalosis. One of the primary causes of respiratory alkalosis is hyperventilation.

A pt with a nasogastric tube has 2,500mL of drainage over the past six hours. Which electrolyte imbalance should the nurse monitor the pt for? A). Hypernatremia B). Hypokalemia C). Hypermagnasemia D). Hypocalcemia

Hypokalemia ** Stomach contents are high in potassium. A pt with a nasogastric tube is at risk for low potassium level

A client who has been receiving long term diuretic therapy is admitted with dehydration. The nurse would assess which finding? A). Crackles B). Decreased heart rate C). Hypotension D). Jugular venous distention

Hypotension **A client with dehydration has low blood pressure. Other findings of fluid volume deficit include: increased pulse and respirations, weight loss, poor skin turgor, dry mucous membranes, etc

When the nurse asks the client who is to have abdominal surgery today if the client understands the procedure, the client replies, "No, not really; I talked about several different things with my surgeon, and I am just no sure." What should the nurse do?

Notify the surgeon of the client's expressed lack of understanding **It is the surgeons responsibility to discuss the planned procedure and review the risks, benefits, and alternatives to the planned procedure.

A nurse is discussing culturally competent care at a nursing staff inservice. Which information should the nurse include when discussing patients cultures? A). Nurses should focus on patients cultures rather than ethnicity when providing care B). Nonverbal communication is important in very few cultures C). Cultures have little impact on how a patient will seek medical care D). Nurses should expect patients to adapt to the care provided regardless of culture

Nurses should focus on patients cultures rater than ethnicity when providing care **nurses should assess patient and make decisions regarding care based on culture rather than based on ethnicity or race

The registered nurse delegates tasks to an unlicensed assistive personnel (UAP). Which is not appropriate for the registered nurse to delegate to the UAP? A). Transporting a routine urine specimen to the laboratory B). Assisting a pt who has difficulty seeing food on a tray while eating C). Helping an older pt ambulate in the hall D). Observing a postoperative pt who is confused

Observing a postoperative pt who is confused

A nurse and a licensed practical nurse (LPN) are caring to a group of clients. Which tasks should the nurse delegate to the LPN? Select all that apply. A). Provide discharge instructions B). Obtain vital signs C). Administer sodium polysterene rectally D). Initiate a plan of care E). Catheterize a patient

Obtain vital signs Administer sodium polystyrene rectally Catheterize a patient

Following abdominal surgery, a client refuses to deep breathe and cough every 2 hours as prescribed. What should the nurse do first?

Explain the risks of not performing activities

The nurse is discharging a patient from the hospital who has a new prescription for furosemide. Which statement indicates a need for further teaching? A). "I should drink plenty of fluids." B). "I will use caution when I change positions." C). "I will limit my sun exposure and wear sunscreen." D). "I will limit my intake of potassium rich foods."

"I will limit my intake of potassium rich foods." **Furosemide is a potassium wasting diuretic

A nurse is caring for a pt with fluid volume excess who suddenly develops pulmonary edema. While waiting for help to arrive, the nurse should perform the actions in which order? -Call respiratory therapy to prepare a ventilator -Place patient in High-Folwers position -Recheck vital signs -Attach the patient to a pulse oximeter and cardiac monitor

1). Place the patient in High-Fowler's position 2). Attach the patient to a pulse oximeter and cardiac monitor 3). Recheck the vital signs 4). Call respiratory therapy to prepare a ventilator

A client is to receive a blood transfusion of packed red blood cells (PRBCs) for severe anemia. Place the steps in the order a nurse would follow to administer this product. -Checked the packed cells for abnormal color, clumping, gas bubbles, and expiration date -Remain with the client and watch for signs of a transfusion reaction. -Record baseline vital signs -Flush the intravenous tubing with normal saline solution. Begin blood transfusion. -Put on gloves, a gown, and a face shield -Verify the blood bag identification, ABO group, and Rh compatibility against the client information

1). Record baseline vital signs. 2). Check the packed cells for abnormal color, clumping, gas bubbles, and expiration date 3). Verify the blood bag identification, ABO group, and Rh compatibility against the client information 4). Put on gloves, a gown, and a face shield 5). Flush the intravenous tubing with normal saline solution. Begin blood transfusion 6).Remain with the client and watch for signs of a transfusion reaction.

Using the Intake and Output sheet, calculate the intake total. Use whole numbers only. Input: Output: Apple Juice- 4oz Water Pitcher- 32oz 500mL Soda- 8oz Soup- 2 cups x1 BM Breakfast: 75% Lunch: 100% Normal Saline: 50mL/hr

2200 **Apple juice 4oz x 30 mL= 120 Water pitcher 32oz x 30=960 Soda 8oz x 30=240 Soup 2 cups= 16oz x 30=480

A nurse prepares to administer 0.9% sodium chloride 1,000 mL IV over 8 hr. The drop factor of the manual IV tubing is 15 got/mL. The nurse should set the manual IV infusion to deliver how many gtt/min? Enter the nearest whole number only.

31 gtt/min

A nurse evaluates the arterial blood gas results of a client who is receiving supplemental oxygen. Which finding would indicate that the oxygen level is adequate? A). A pO2 of 80 mmHg B). A pO2 of 60mmHg C). A pO2 of 50 mmHg D). A pO2 of 45 mmHg

A pO2 of 80 mmHg **The normal pO2 level is 80 to 100 mmHg

The client has just returned to bed following the first ambulation since abdominal surgery. The client'a heart rate & BP are slightly elevated; Oxygen saturation is 91% on room air, but the client reports being "a little short of breath," but does not have dizziness or pain. What intervention should the nurse perform?

Allow the client to rest, then reassess **The client is experiencing activity intolerance which is common

A patient is determined to have hypomagnesemia. Which food does the nurse recognize as being rich source of magnesium? A). Milk B). Tomatoes C). Almonds D). Potatoes

Almonds **nuts are packed with magnesium

On the first day after surgery, a client has been breathing room air. The vital signs are normal, and the oxygen saturation is 88%. What should the nurse do first? Give oxygen by nasal cannula or assist with incentive spirometry

Assist with incentive spirometry **Using the incentive spirometry increases lung expansion and prevents the accumulation of secretions in postoperative clients

A patient is receiving continuous IV therapy via the left forearm. Upon assessment, the nurse notes that the site is red, swollen, and painful, and the surrounding tissues are hard. Which action should the nurse take first? A). Discontinue the existing IV line B). Initiate a new IV in the other extremity C). Apply a warm compress to the irritated site D). Determine if the client needs to continue IV therapy

Discontinue the existing IV line **The pt has symptoms of a complication with the IV. The nurse must first discontinue the IV.

A nurses caring for a patient with severe hyponatremia and extreme confusion. Which nursing action best advocates for this patients safety?

Placing the client in a room near the nurse's station

A patient has an order for intravenous therapy. After the nurse inserts the IV catheter, the pt reports pain in the insertion area. Which action should the nurse take? A). Remove the catheter and insert another into a different site B). Give an oral analgesic C). Initiate non-pharmacological pain relief measures D). Administer a local anesthetic

Remove the catheter and insert another into a different site **It is possible that the catheter is up against a valve or near a valve and is causing more pain than an IV catheter should.

A nurse assess a client who takes hydrochlorothiazide. The nurse recognizes which of the following as a potential complication associated with hypokalemia? A). Hypertension B). Diarrhea C). Hyperreflexia D). Shallow respirations

Shallow respirations **shallow respirations are a sign of weakness in the accessory muscles of breathing due to hypokalemia

A nurse performs an arterial blood gas on a patient. Results reveal the following values. Which is the appropriate analysis of the arterial blood gas? pH 7.22 paCO2 68 mmHG HCO3 26 mEq/L Oxygen saturation 80% A). Uncompensated respiratory acidosis B). Uncompensated metabolic acidosis C). Partially compensated respiratory acidosis

Uncompensated respiratory acidosis

The initial postoperative assessment is completed on a client who had an arthroscopy of the knee. Assessment of which parameter is no necessary every 15 mins during the first postoperative hour?

Urine output

A pt with an electrolyte imbalance has been put on a specialized diet. The patient's partner requests to bring food from home that is not allowed in the diet plan. Which response should the nurse make? A). "Why would you want to put your partner's health at further risk?" B). "Everyone likes food from home, but it can delay your partners recovery." C). "You will need to discuss your concerns about your partner's diet with the provider." D). "Let's try to find ways to incorporate foods your partner likes into the diet plan."

"Let's try to find ways to incorporate foods your partner likes into the diet plan."

A nurse is caring for a client who is gong to have a bone marrow biopsy under conscious sedation. The client expresses fear about the procedure and asked the nurse if the biopsy will hurt. Which response should the nurse make?

"The biopsy can be uncomfortable, but I will try to keep you as comfortable as possible." **This therapeutic communication technique is giving information. The nurse is providing factual details that the client might need for decision-making.

After completing the client teaching on the use of patient-controlled analgesia (PCA), what statement by the client will help the nurse determine that the client understands the use of the PCA?

"The machine will only give me the prescribed amount of pain medication even if i push the button too soon." **The client must be able to verbalize understanding about receiving no more pain medication than is prescribed no mater how many times the button is pushed.

A client scheduled for a hysterectomy paces the floor, repeatedly saying, "I just want this over." What should the nurse say to promote a positive surgical outcome for the client?

"What are your specific concerns about the surgery today?"

Prior to initiating intravenous therapy, the nurse notices the patient exhibiting nonverbal signs of anxiety. Which statement is appropriate for the nurse to say to the patient? A). "I'll be starting an IV that will add fluid directly to your blood stream." B). "I will be starting an IV, and it should not hurt." C). "A number 22 angiocatheter will be inserted into your forearm." D). "Try not to worry. It will not take long and will be over before you know it."

*I'll be starting an IV that will add fluid directly to your blood stream." **The nurse should explain what an IV is using simple terms. The nurse should not give unwarranted reassurance.

Which safety measures by the nurse would be most important to implement when caring for a client who is receiving 2 units of packed red blood cells (PRBCs)?

-Compare information on the identification bracelet with the tag on the blood bag -Infuse a unit of PRBCs in less than 4 hours -Stop the transfusion if a reaction occurs, but keep the line open -Inspect the blood bag for leaks, abnormal color, and clots

The nurse is evaluating a client who is using a incentive spirometer following abdominal surgery 1 day ago. The client is performing the procedure correctly when the client does which interventions?

-Inhales for 3-5 seconds following fully expanding the lungs -Coughs after using the spirometer -Is sitting upright

A nurse is observing a clients postoperative vital signs. Which nursing interventions should the nurse take?

-Monitor vital signs frequently -Increase IV fluid rate -Elevate the lower extremities -Administer oxygen -Notify the health care provider

The nurse is to administer midazolam 2.5mg. The medication is available in a 5mg/mL vial. How many mg should the nurse administer? calculate to the nearest tenth.

0.5mg 2.5/5 x 1= 2.5mg

Blood administration is prescribed for a client doing chemotherapy. The nurse is obtaining an infusion. Which intravenous solution is should be used?

0.9% Sodium Chloride

A nurse is caring for a client who is to receive a unit of packed RBCs. The nurse should prime the blood administration tubing using which IV solution? A). Lactated Ringer's B). 0.9% sodium chloride C). dextrose 5% in water D). dextrose 5% in 0.45% sodium chloride

0.9% sodium chloride

A nurse prepares to administer 1,000 mL RInger's Lactate IV over 6 hours. The nurse should set the IV pump to administer how many mL/hr? Round to the nearest whole number

167

A nurse administers vasopressin to a patient with diabetes insidious. The nurse should identify which finding as an indication that the medication is effective? A). A decrease in blood sugar B). A decrease in blood pressure C). A decrease in urine output D). A decrease in urine specific gravity

A decrease in urine output **The major manifestations of diabetes insipidus are excessive urination and extreme thirst. Vasopressin is used to control frequent urination, increased thirst, and a loss of water associated with diabetes insipidous. A decreased urine output is the desired response.

A nurse is providing teaching to a group of adult athletes about preventing the effects of dehydration on the body. Which manifestation should the nurse include in the teaching? A). Impaired motor control B). Drop in body temperature C). Increased appetite D). Decreased resting heart rate

A). Impaired motor control ** Impaired motor control is a symptom of dehydration. The body temperature increases in dehydration. A dehydrated person will lose their appetite and the heart rate increases

A patient who is dizzy, hypotensive, and weak has been prescribed an isotonic solution to replace fluid volume. Which fluid could the nurse give the patient? Select ally that apply. A). Normal Saline B). Lactated Ringers C). D5W in the bag D). 0.45% normal saline E).D10W

A). Normal Saline B). Lactated Ringers C). D5W in the bag

Which intervention is appropriate for the nurse to delegate to the unlicensed assistive personnel (UAP) when caring for the client experiencing acute pain? Select all that apply. A. Turn the television to the guided imagery channel B. Check client 15 minutes after taking pain medication C. Reposition the client D.Provide soothing music

A, C, D ** Medication administration cannot be delegated to a UAP

The nurse reviews lab results and notes the client's potassium level is 6.5 mEq/L. The client reports palpitations. Which is the priority intervention for the nurse? A). Continue to monitor B). Assess deep tendon reflexes C). Administer IV insulin and glucose D). Administer furosemide PO

Administer IV insulin and glucose **IV insulin should be given. This helps shift potassium form the extracellular space to the intracellular space, which lowers the serum K level

A patient is prescribed an infusion of IV magnesium sulfate. The nurse assesses the patient and determines the respiratory rate to be 9 breaths per minute. After stopping the infusion, which is the priority action? A). Place the patient on oxygen B). Check the patients deep tendon reflexes C). Draw a magnesium level D). Administer calcium gluconate

Administer calcium gluconate **The nurses primary concern should be administering the antidote for magnesium.

Immediately following pelvic surgery, a client has an indwelling urinary catheter. Which intervention would be helpful to prevent catheter-related urinary tract infections?

Advocate for limited use of indwelling urinary catheter

A client arrives from surgery to the post anesthesia care unit (PACU). Which respiratory assessment should the nurse complete first? A. Airway flow B. Respiratory rate

Airway Flow **Airway flow is always the first assessment. Once the nurse establishes that the client as a patent airway, the pule oximeter is applied to measure the oxygen saturation, the respiratory rate is counted, and the breath sounds are auscultated.

The nurse cares for a client admitted to the hospital with an electrolyte imbalance. The health care provider orders seizure precautions. Which interventions should the nurse initiate? Select all that apply. A). Apply pads to the side rails B). Have a supplemental oxygen available C). Insert a urinary catheter D). Remove all linen from the bed E). Set up bedside suction equipment

Apply pads to the side rails Have supplemental oxygen available Set up bedside suction equipment **The upper side rails are raised to prevent the client from falling on to the floor during a seizure. The side rails are also padded up to prevent injury due to hitting the hard plastic rails during a seizure

Upon the admission assessment of a Hispanic patient being prepped for surgery, the nurse realizes that the pt does not speak English. Which action is appropriate by the nurse to prepare the pt. for surgery?

Arrange hospital translator's presence during informed consent

A nurse obtains an arterial blood gas sample from a pt. To prevent bleeding following the procedure, the nurse plans to allow time for which activity after the arterial blood is drawn? A). Hold a warm compresss directly over the puncture site for 5 minutes B). Apply pressure to the puncture site by applying gauze for 5 minutes C).Encourage the pt. to open and close the hand rapidly for 5 minutes

B). Apply pressure to the puncture site by applying gauze for 5 minutes

A nurse monitors for the presence of pitting edema in a pt with fluid volume excess. The nurse presses the fingertips of the middle and index fingers against the shin and holds pressure for 5 seconds. The nurse notes that the indentation is approximately 6mm deep and the skin is prolonged in returning to baseline. The nurse documents that the pt has which level of pitting edema? A). 1+ B). 2+ C). 3+ D). 4+

C). 3+

On the day of surgery, a client with diabetes who takes insulin on a sliding scale is to have nothing by mouth and all medications withheld. The clients 6 am glucose level is 300mg/dL. What should the nurse do?

Call HCP for further instruction *** the nurse should notify the surgeon directly for specific prescriptions based on the client's glucose level

A nurse enters room and finds a client not responding tho verbal stimuli. After notifying the rapid response team, which action should the nurse take?

Check for a carotid pulse **Recognition of cardiac arrest involves assessing for 10 seconds or less if the pt has a pulse, if no pulse then start compressions at a rate of 100 beats per min x 30 then give 2 effective breaths

The nurse is removing the clients staples from an abdominal incision when the client sneezes and the incision splits open, exposing the intestines. Which action should the nurse take?

Cover the abdominal organs with sterile saline-soaked dressings **When a wound eviscerates, the nurse should cover the open area with a sterile dressing moistened with sterile normal saline and then cover it with a dry dressing

A pt is diagnosed with hypernatremia. Which IV fluid does the nurse anticipate the primary health care provider ordering? A). 0.9% Sodium Chloride B). Lactated Ringer's C). Dextrose 10% in water D). 0.45% Normal Saline

D). 0.45% Normal Saline ** A pt. with hypernatremia is often treated with hypotonic fluid. 1/2 normal saline is hypotonic fluid. Al other options are not considered hypotonic.

A pt. records a history of acid reflux and frequent use of oral antacids. For which acid base imbalance would the nurse assess? A). Respiratory acidosis B). Respiratory alkalosis C). Metabolic acidosis D). Metabolic alkalosis

D). Metabolic alkalosis **Oral antacids commonly contain bicarbonate or other alkaline components. Excessive use can lead to metabolic alkalosis

When receiving a client from the postoperative care unit after right above the knee amputation, which should the nurse assess next after obtaining vital signs?

Dressing **The client is at a high risk for hypovolemia and hemorrhage. The dressing should be checked often. Checking for hemorrhage is a greater priority than assessing pain level.

A nurse admits a patient who has a serum calcium level of 12.3 mg/dL. Which assessment finding would the nurse expect to observe? A). Muscle spasms B). Hyperactive bowels sounds C).Heart rate 110 D).Drowsiness

Drowsiness

Which nursing intervention is most important in preventing postoperative complications?

Early ambulation

A nurse assesses a client who has a peripheral IV with a continuous infusion. Which findings would indicate the client has developed phlebitis? Select all that apply. A). Erythema B). Damp Dressing C). Throbbing pain D). Warmth at insertion site E). Red steak along vessel

Erythema Throbbing pain Warmth at insertion site Red streak along vessel **Phlebitis is characterized by erythema, warmth, pain, and streak formation. A damp dressing indicates infiltration

A nurse must administer a dose of potassium chloride. 40 mEq of potassium chloride is ordered to be given IV one time. Which is the appropriate nursing action? A). Give the medication in a 500mL bag of fluid B). Use a 10 mL normal saline flush after administration C). Infuse slowly over 5 minutes D). Administer the dose with food

Give the medication in a 500 mL bag of fluid **Potassium must be diluted. IV potassium is given in a larger volume of IV fluid and would not need to be followed by a normal saline flush

The nurse is preparing to administer a preoperative medication. Which actions should the nurse take?

Have the client empty the bladder **Having the client empty the bladder before the premedication will make the client comfortable and safe for the client

While in the postoperative acute care unit (PACU), the pts. BP drops from an admission pressure of 126/82 to 100/62 with a pulse change of 68 to 94. The nurse administers oxygen. What other intervention should the nurse perform?

Increase the rate of IV fluids **The most common cause of hypotension in the post anesthesia period is unreplaced fluid and blood loss. This situation does not warrant further assessment. The nurse needs to administer IV fluids.

What is the expected therapeutic effect of metoclopramide prescribed as a premedication for a client about to undergo a gastroduodenoscopy?

Increased gastric emptying **metoclopramide is an anitmetic

A patient with chronic kidney failure is admitted to the hospital. Lab results indicate the patient hs hyperkalemia. Which action should the nurse take first? A). Order a low potassium diet B). Administer sodium polysterene C). Initiate cardiac monitoring D). Give a potassium wasting diuretic

Initiate cardiac monitoring **The patient should be placed on a cardiac monitor first because hyperkalemia places the patient at risk for cardiac arrhythmias.

A nurse reviews a patients lab report. The serum calcium level is 15.1 mg/dL. Which action should the nurse perform first? A). Limit dietary calcium B). Initiate intravenous fluids C). Monitor for fractures D). Measure calf circumference

Initiate intravenous fluids **The normal calcium level is 9.0 to 10.5 mg/dL

A nurse is providing preoperative teaching for a client who is scheduled for a gastrectomy. Which information regarding prevention of postoperative complications should the nurse include in the teaching?

Instruct the use of incentive spirometer **Instructing on the use of the incentive spirometer is the only option that prevents postoperative complications by expanding the lungs to prevent atelectasis.

The nurse is reviewing the lab results for a preoperative pt. Which study result should be brought to the attention of the surgeon immediately?

Serum K of 2.0 mEq/L

A patient with a fluid imbalance has orders for an indwelling urinary catheter. After catheter placement, the patient insists on walking to the hospital lobby to visit with family. What instruction should the nurse teach the patient? A). Place the drainage bag on the floor when sitting down B). Keep the drainage bag below the bladder at all times C). Clamp the catheter drainage tubing while visiting with family D). Loop the drainage tubing below its point of entry into the drainage bag

Keep the drainage bag below the bladder at all times **Keeping the urinary catheter drainage bag below the level of the bladder at all times helps prevent backflow of the urine into the bladder and possibly causing a UTI

The nurse observes the client with an intermittent compression device in place after hip surgery. What should the nurse do?

Make sure the client is comfortable when in the device

A client has had a nasogastric tube connected to low intermittent suction. The client is at risk for which complication?

Muscle cramping **Muscle cramping is a sign of hypokalemia. Potassium is an electrolyte lost with nasogastric suctioning. Confusion is seen with hypercalcemia. Edema is seen with protein deficit or fluid volume overload. tremors are seen with hypomagnesemia.

The nurse assess a client who has just received morphine sulfate. The client's BP is 90/50mm Hg; pulse rate, 58bpm; RR 4 breaths/min. The nurse should check the client's chart for which prescription to administer?

Naloxone **Naloxone is the antidote for morphine sulfate or any opioid drug

A nurse assesses a patient who has a sodium level of 116 mEq/L. Which finding should the nurse expect to observe? Select all that apply. A). Nausea and vomiting B). Extreme thirst C). Flushed skin D). Confusion E). Muscle weakness

Nausea and vomiting Confusion Muscle weakness **A sodium level of 116 mEq/L is critical value indicating hyponatremia

During a preoperative physical exam, the nurse is alerted to the possibility of compromised respiratory function after surgery in a pt. with which problem?

Obesity **Obesity causes mechanical compression of the diaphragm, lungs, and chest cavity, which can lead to respiratory complications

A nurse reviews a client's arterial blood gas results. The results are below. Which acid-base imbalance does the nurse identify? pH 7.5 CO2 47 HCO3 29 A). Uncompensated respiratory alkalosis B). Uncompensated metabolic alkalosis C). Partially compensated respiratory alkalosis D). Partially compensated metabolic alkalosis

Partially compensated metabolic alkalosis

A client is admitted to the post anesthesia care unit (PACU) following a left hip replacement. The initial nursing assessment is: T 97.0 F, Pulse 90, RR 14, and BP 128/80. What action should the nurse take?

Place client on right side **During immediate postanesthesia period, Client should be positioned on the side to maintain an open airway and promote drainage of secretions

A nurse is caring for an older client with fluid imbalance. The nurse recognizes the client is at risk for skin breakdown. Which intervention should the nurse use to help maintain skin integrity? A). Reposition the client twice a shift B). Massage bony prominences C). Remove excess moisture D). Apply cornstarch powder

Remove excess moisture **The client needs to have excess moisture removed from the skin to prevent further breakdown.

A nurse is caring for a client who has syndrome of inappropriate antidiuretic hormone and a sodium level of 123 mEq/L. Which treatment should the nurse anticipate? A). Maintain an IV of 0.45% sodium chloride B). Restrict fluid intake C). Provide a low sodium diet D). Administer desmopressin orally

Restrict fluid intake **Clients who has SIADH have an increased amount of antidiuretic hormone, which results in excess fluid volume. This excess fluid dilutes the sodium level in the blood, causing dilution hyponatremia

A nurse provides nutritional teaching to a patient diagnosed with hypercalcemia. Which food should the nurse recommend the patient avoid? A). Carrots B). Salmon C). Chicken breast D). Baked potato

Salmon **Salmon is high in calcium

During a postoperative review of systems, the client reveals a history of renal disease. Which preoperative diagnostic study should the HCP prescribe?

Serum creatinine **Serum creatinine will provide more information about the renal function

A pt. scheduled for a hip replacement surgery in the early afternoon is NPO but receives and east a breakfast tray with clear liquids on the morning of surgery. What response does the nurse expect when the surgeon is notified?

Surgery will be done as scheduled **The American Society of Anesthesiologists issued NPO guidelines that permit the consumption of clear liquids until 6-8 hours before surgery for all healthy clients undergoing elective procedures requiring general anesthesia, regional anesthesia or sedation/analgesic

A client is to be discharged from same-day surgery 7 hours after his inguinal hernia repair. Which of the following indicates this client is ready to be discharged?

The client voids 500mL of urine **Urinary elimination in the first 8 hours postoperatively is a requirement before the client can be discharged from same-day surgery

An experienced nurse supervises a nurse graduate care for a patient with hyperphosphatemia. Which action by the nurse graduate would need correcting? A). The nurse graduate encourages a diet high in calcium B). The nurse graduate administers a phosphate binder between meals C). The nurse graduate assesses for Chvostek's and Trousseau's sign D). The nurse graduate removes clutter from the patient's room

The nurse graduate administers a phosphate binder between meals **Phosphate binders must be given wit food to help bind with food and decrease the phosphate level through excretion.

hen the nurse administers IV midazolam, the client oxygen saturation drops from 94% to 86% and begin to go into respiratory arrest. What action should the nurse perform?

Ventilate with a bag-valve mask

The nurse is preparing to administer medication to a postoperative client. Which health care provider prescription is written correctly on the chart?

Hydromorphone 5mg every 3hrs as needed for pain

Which intervention should the nurse encourage the unlicensed assistive personnel to assist with in the care of postoperative clients? Select all that apply. -empty and measure indwelling urinary catheter collection bags -Reposition clients for pain relief -Tell the nurse if clients report they are having pain

All of the above

A nurse is caring for a client who reports nausea and vomiting 1 day postoperative following left shoulder surgery. Which action should the nurse perform?

Assess bowel sounds in all quandrants **Using the nursing process, the first step is assess the client. This enables the nurse to check for peristalsis and will guide further interventions

A nurse is planning care for a patient who has diagnosis of diabetes insipidus. Which intervention should the nurse include in the plan of care? A). Measure the blood glucose level every 4 hours B). Administer a diuretic C). Initiate fluid restrictions D). Check urine specific gravity

Check urine specific gravity **The nurse should check the clients urine specific gravity to monitor urine concentration in a client who has diabetes insipidus

A client who is scheduled for an open cholecystectomy has a 20-pack-year history of smoking. Which postoperative complication is the client most at risk for?

Collapse of a lung **Postoperatively because of pain, in addition to having residual lung damage from smoking, this client will have increased risk of respiratory problems such as atelectasis that can lead to pneumonia

Which intervention should the nurse implement for pulmonary emboli prophylaxis?

Have the client perform leg exercises every hr while awake **Performing leg exercises will help prevent stasis of blood in the lower extremities, which can lead to blood clot formation

A nurse is caring for a pt. immediately following a procedure that required spinal anesthesia. Which of the findings indicates the client is experiencing a complication of anesthesia?

Headache **Complications of spinal anesthesia includes headache, nausea, vomiting, & pain. Cardiac arrest is rare but can occur.