NUR 112 - EXAM 1
A nurse in the preop unit is assessing a pts lab values before surgery. Which of the following should the nurse report to the provider? (select all that apply) a. potassium 3.9 b. sodium chloride 145 c. creatinine 2.8 d. blood glucose 235 e. WBC 17,850
c, d, e
A 17 year old pt with a leg fracture is sched. for surgery. She reports that she is living w/a friend and is an emancipated minor. She has a statement from the court for verification. Which intervention is most appropriate? a. witness the permit after consent is obtained by the surgeon b. call a parent or legal guardian to sign the permit, since the pt is under 18 c. obtain verbal consent, since written consent is not necessary for emancipated minors d. investigate your states nurse practice act r/t emancipated minors and informed consent
a
A nurse is preop teaching a pt scheduled for abdominal surgery. Which of the following statements by the nurse are appropriate? (select all that apply) a. take you BP med with a sip of water before surgery b. splint the abdominal incision with a pillow when coughing and deep breathing c. bedrest is recommended for the first 48 hrs d. antiembolism stocking are applied before surgery e. you may eat solid foods up to 4 hr before surgery
a, b, c
Discharge criteria for the phase II pt include (SATA) a. no nausea or vomiting b. ability to drive self home c. no respiratory depression d. written discharge instructions understood e. opioid pain medication given 45 min ago
C,D,E
A 59 year old man is sched. for herniorrhaphy in 2 days. During the preop evaluation he reports that he takes ginkgo daily. What is the priority intervention? a. inform the surgeon, since since the procedure may need to be resched, b. notify the anesthesia care provider, since this herb interferes with anesthetics c. ask the pt if he has noticed any side effects from taking this herbal supplement d. tell the pt to continue to take the herbal supplement up to the day before surgery
a
A adolescent pt has the following lab results: pH 7.3, PaCO2 60, HCO3 25, PaO2 90. Which of the following actions should the nurse anticipate? a. administering albuterol (ventolin) aersol b. increasing the adolescents IV fluids c. preparing sodium bicarbonate infusion d. encouraging adolescent to breathe into a paper bag
a
A nurse is assessing a pt who has hyperkalemia. Which of the following conditions is associated with this electrolyte imbalance? a. diabetic ketoacidosis b. heart failure c. cushing's syndrome d. thyroidectomy
a
A nurse is assisting an anesthesiologist in the delivery of nitrous oxide per face mask to a pt during the induction of anesthesia. Which of the following is a priority nursing action? a. assess O2 b. obtain BP c. palpate heart rate d. check temp
a
A nurse is caring for a newborn who has respiratory distress syndrome and is experiencing respiratory acidosis. The nurse is aware that respiratory acidosis is caused by which of the following? a. inadequate chest expansion b. retention of oxygen c. increased alveolar-capillary diffusion d. reduced production of free hydrogen ions
a
A nurse is caring for a pt who has lab finding of serum potassium 5.4. The nurse should assess for which of the following clinical manifestations? a. ECG changes b. constipation c. polyuria d. hypotension
a
A nurse is caring for a pt who has lab findings of serum NA 133 and K 3.4. Which of the following treatments can result in this lab findings? a. three tap water enemas b. 0.9% sodium chloride solution IV at 50mL/hr c. 5% dextrose in water solution with 20 mEq K+ IV at 80 mL/HR d. administration of glucocorticoids
a
A nurse is caring for a pt who is sched for an exploratory laparotomy. The pts temp is 102.2 orally. Which of the following is an appropriate action by the nurse? a. inform the surgeon of elevated temp b. transfer the pt to preop c. apply ice packs to the pts groin d. encourage the pt to increase intake of clear liquids
a
A nurse is caring for a pt who reports nausea nausea vomiting 2 day postop after hysterectomy. Which of the following actions should the nurse perform first? a. assess bowel sounds b. administer antiemetic med c. restart prescribed IV fluids d. insert prescribed NG tube
a
A nurse is planning care for a pt who has hypernatremia. Which of the following actions should the nurse anticipate in the plan of care? a. infused hypotonic IV fluids b. implement fluid restriction c. increase sodium intake d. administer sodium polystyrene sulfonate (Kayexalate)
a
A nurse is reviewing the ABG lab report for a pt who has chronic renal failure. Which of the following is an expected finding? a. pH 7.25, HCO3 19, PaCO2 30 b. pH 7.3, HCO3 26, PaCO2 50 c. pH 7.5, HCO3 20, PaCO2 32 d. pH 7.55, HCO3 30, PaCO2 31
a
A nurse is reviewing the ABG results of a pt who the provider suspects has a metabolic acidosis. Which of the following results should the nurse expect to see? a. pH below 7.35 b. HCO3 above 26 c. PaO2 below 70 d. PaCP2 above 45
a
A nurse is reviewing the medical record of a pt who has metabolic acidosis. Which of the following conditions contribute to the development of metabolic acidosis? a. diarrhea b. vomiting c. hyperventilation d. salicylate intoxication
a
After admission of the postoperative pt to the clinical unit, which assessment data require the most immediate attention? a. O2 sat of 85% b. Resp rate of 13/min c. Temp of 100.4 F d. BP of 90/60
a
An overweight pt is sched. for a laparoscopic cholecystectomy at an outpatient surgery setting. The nurse knows that... a. surgery will involve multiple small incisions b. this setting is not appropriate for this procedure c. surgery will involve removing a portion of her liver d. the pt will need special prep because of obesity
a
During the administration of a hypertonic IV solution, the mechanism involved in equalizing the fluid concentration between ECF and the cell is a. osmosis b. diffusion c. active transport d. facilitated diffusion
a
The nurse's primary responsibility for the care of the pt undergoing surgery is.. a. developing an individualized plan of nursing care for the pt b. carrying out specific task r/t surgical procedures and policies c. ensuring that the pt has been assessed for safe administration of anesthesia d. performing a preop history and physical assessment to identify pt needs
a
The nursing care for a pt with hyponatermia includes? a. fluid restriction b. administration of hypotonic IV fluids c. administration of cation-exchange resin d. increased water intake for pt on nasogastric suction
a
To provide free water and intracellular fluid hydartion for a pt. with acute gastroenteritis who is NPO, the nurse would expect administration of which infusion? a. Dextrose 5% in water b. Dextrose 10% in water c. Lactated Ringer's solution d. Dextrose 5% in NS (0.9%)
a
When positioning a pt in preparation for surgery, the nurse understands that injury to the pt is most likely to occur as a result of: a. incorrect musculoskeletal alignment b. loss of perception of pain or pressure c. pooling of blood in peripheral vessels d. disregarding the pts need for modesty
a
Which of the following assessment findings should a nurse expect to find in a client who has hyperkalemia? a. Decreased muscle strength b. Decreased gastric motility c. Increased pulse rate d. Increased blood pressure
a
While in PACU, the pts BP drops from admission pressure of 126/82 to 107/78 with a pulse change of 70 to 94. The nurse administers oxygen and then? a. increases the rate of IV fluids b. notifies the anesthesia care provider c. performs nerovascular checks on lower extremities d. uses a cardiac monitor to assess the pts heart rhythm
a
What are the characteristics of the carbonic acid-bicarbonate buffer system (select all that apply)? a. CO2 is eliminated by the lungs b. nuetralized HCl acid to yield carbonic acid and salt c. H2CO3 formed by neutralization dissociates into H2O and CO2 d. Shift H+ in and out of cell in exhnage for other cations such as Na and K e. Free basic radicals dissociate into ammonia and OH- that combines with H+ to form water
a, b, c
A nurse is caring for a female pt who manifest indications of hypovolemia while in the PACU. Which of the following findings requires actions from the nurse? (select all that apply) a. urine output less than 25 b. hematocrit 48% c. BUN 24 d. tenting of skin over sternum e. apical pulse 62/min
a, b, c, d
A nurse is reviewing the health records of several pts in the postanesthesia care unit (PACU) to identify risk factors that can lead to postop complications. Which of the following pts are at risk for complications? (select all that apply) a. pt with WBC of 22,500 b. pt who uses an insulin pump c. a pt taking warfarin (coumadin) daily d. pt who had bowl prep e. pt who has BMI of 26
a, b, c, d
A nurse is planning care for a pt to prevent postop actelectasis. Which of the following interventions should the nurse include in the plan of care. (select all that apply) a. encourage the use of incentive spirometer q2h b. instruct to splint incision when coughing and deep breathing c. reposition pt q2h d. administer antibiotic therapy e. assist with early ambulation
a, b, c, e
A nurse is providing info to a group of surgical nurses for the tx of malignant hyperthermia. Which of the following should the nurse include in the info? (select all that apply) a. infuse iced IV fluids b. provide 100% O2 c. place on a cooling blanket d. treat the condition while continuing surgery e. adminster IV dantrolene (Dantrium)
a, b, c, e
A nurse is admitting a pt who reports nausea, vomiting, and weakness. Upon assessment the pt has dry oral mucous membranes, temp (101.3), pulse 92/min, respiration 24/min, skin cool with tenting present, and bp 102/64. His urine is concentrated with high specific gravity. Which of the following are clinical manifestations of fluid volume deficit? (select all that apply) a. decreased skin turgor b. concentrated urine c. bradycardia d. low-grade fever e. tachypnea
a, b, d, e
A nurse is admitting an older adult pt who is experiencing dyspnea, weakness, and weight gain of 2lb with 1+ bilateral edema of the lower extremities. Upon assessment the pt has a temp of 99, pulse 96/min, repirations 26/min and o2 94% on 3 L oxygen via nasal cannula, and bp 152/96. Which of the following clinical manifestations are indicative of fluid volume excess? (select all that apply) a. dyspnea b.edema c. bradycardia d. hypertension e. weakness
a, b, d, e
An older woman was admitted to the medical unit with dehydration. Clinical indications of this problem are (select all that apply) a. weight loss b. dry oral mucosa c. full bounding pulse d. engorged neck veins e. decreased central venous pressure
a, b, e
A nurse is caring for a pt with metabolic alkalosis. Which of the following clinical manifestations should the nurse monitor for? (select all that apply) a. bicarbonate excess b. cardiac dysrhythmias c. flushing d. hyperactive reflexes e. lethargy
a, d
A pt is receiving positive pressure mechanical ventilation. Which of the following should the nurse implement to prevent complications? a. palpate skin for a "popping" sensation b. verify prescribed ventilator settings daily c. administer midazolam hydrochloride (Versed) as needed d. give pantoprazole (protonix) as prescribed e. reposition the endotracheal tube to the opposite side of the mouth
a, d, e
The nurse is caring for a pt undergoing surgery for a keen replacement. What is critical to the pts safety during the procedure? (select all that apply) a. universal protocol is followed b. the ACP is an anesthesiologist c. the pt has adequate health insurance d. the circulation nurse is a RN e. the pts allergies are conveyed to the surgical team
a, e
A client diagnosed with acute heart failure is prescribed furosemide (Lasix) daily. During the client's morning assessment, he tells the nurse that he is "feeling weak in the legs." Which of the following should the nurse take first? a. Withhold the furosemide b. Review the daily laboratory results c. Notify the primary care provider of the client's symptoms d. Provide an adequate breakfast for the client
b
A client is admitted with isotonic dehydration following 2 days of vomiting and diarrhea. Which of the following laboratory results should indicate to the nurse that the client has responded to fluid therapy? a. BUN 26 mg/dl b. Serum sodium 138 mEq/L c. Hct 56% d. Urine specific gravity 1.035
b
A client with heart failure is admitted following 3 days of vomiting. he is currently taking 40 mg of furosemide (Lasix) and 0.125 mg of dignxin (Lanoxin) daily. the nurse suspects hypokalemia. Which of the following should the nurse anticipate administering? a. Sodium polystyrene sulfonate (Kayexalate) 30g/day b. Normal saline with 40 mEq/L potassium at 100ml/hr c. Digoxin 0.125 mg/day d. Lactated Ringer's solution at 100 ml/hr
b
A nurse in a provider's office is collecting data from the mother of a 1 year old child. The pt states that her child is old enough for potty training. Following an education session by the nurse, the pt now states that her earlier ideas has changed. She is now willing to postpone potty training until the child is older. Learning has occurred in which of the following domains? a. cognitive b. affective c. psychomotor d. kinesthetic
b
A nurse in the ICU is caring for a pt who has acute respiratory distress (ARDS) and is receiving mechanical ventilation via endotracheal tube. The provider plans to extubate her within the next 24hr. Which of the following is an important criterion for extubating this pt? a. ability to cough effectively b. adequate tidal volume w/o positive pressure c. no indications of infection d. no need for supplemental oxygen
b
A nurse is caring for a female pt who came to the ED reporting SOB and pain in the lung area. She states that she started taking blood control pills 3 wks ago and that she smokes. Her heart rate is 110/min, R 40/min, BP 140/80. Her ABG: pH 7.50 PaCO2 29 PaO2 60 HCO3 20 SaO2 80%. Which of the following is the priority intervention? a. prepare for mechanical ventilation b. administer o2 via face mask c. prepare to administer a sedative d. monitor for pulmonary embolism
b
A nurse is caring for a pt who displays systemic toxic reaction following a regional block. Which of the following actions by the nurse is appropriate? a. monitor serum creatinine levels b.prepare to administer IV thiopental (Pentothal) c. turn the pt to the right side d. administration 0.9% sodium chloride 500mL IV bolus
b
A nurse is caring for a pt who has NG tube attached to low intermittent suctioning. The nurse should monitor for which of the following electrolyte imbalance? a. hypercalcemia b. hyponatremia c. hyperphosphatemia d. hypomagnesmia
b
A nurse is caring for a pt who is receiving mechanical ventilation. When the nurse assesses the pt, she needs to know that the expected tidal volume for a pt receiving mechanical ventilation is? a. 5-7 mL/kg b. 7-9 mL/kg c. 9-11 mL/kg d. 11-13 mL/kg
b
A nurse is evaluating how well a pt learned the information presented in an instructional session about following a heart-healthy diet. The pt states that she understands what to do now. Which of the following actions by the nurse should assist the nurse in evaluation the pts learning? a. encourage the pt to ask questions b. ask the pt to explain how to select or prepare meals c. encourage the pt to fill out an evaluation form d. ask the pt if she has resources for further instruction on this topic
b
A pt. with a pH of 7.29 has metabolic acidosis. Which value is useful in determining whether the cause of the acidosis is an acid gain or a bicarbonate loss? a. PaCO2 b. Anion gap c. Serum Na+ levels d. Bicarbonate levels
b
During admission of the patient to the holding area or operating room before surgery the perop nurse must? a. verify the pts understanding of the risk of surgery b. ensure the pts identity w/ formal identification process c. prepare skin by scrubbing surgical site w/antimicrobial agent d. perform a preop assessment w/ pt history and physical exam
b
During the administration of any regional anesthetic, it is most important that the nurse a. monitor for ascending neurologic depression, and unconsciousness b. ensure that airway equipment, emergency drugs, and monitors are immediately available c. monitor the pts response to anesthesia, assessing the extent of loss of sensation d. have reversal drugs such as anticholinesterase agents (neostigmine (prostigmin) available in case of respiratory arrest)
b
Proper attire for the semi restricted area of surgery dept. is: a. street clothing b. surgical attire and head cover c. surgical attire, head cover, and mask d. street clothing with the addition of shoe covers
b
The nurse anticipates that treatment of the pt with hyperphosphatemia secondary to renal failure will include a. fluid restriction b. calcium supplements c. loop diuretic therapy d. magnesium supplements
b
The pt tells the nurse in the preoperative setting that she has notices she has a reaction when wearing rubber gloves. What is the most appropriate nursing intervention? a. notify the surgeon so the case can be cancelled b. ask additional questions to assess for possible latex allergy c. notify the OR staff immediately so that the latex-free supplies can be used d. no intervention is needed because the pts rubber sensitivity has not bearing on surgery
b
When a nurse is observing a pt draw up and mix insulin injections, which of the following best demonstrate that psychomotor learning has taken place? a. the pt is able to discuss the appropriate technique b. the pt is able to demonstrate the appropriate technique c. the pt states that he understands d. the pt is able to write the steps on a piece of paper
b
Activities that the nurse might preform in the role of a scrub nurse during surgery include (select all that apply) a. checking electrical equipment b. preparing the instrument table c. passing instruments to the surgeon and assistants d. coordinating activities occurring in the OR e. maintaining accurate counts of sponges, needles, and instruments
b, c, e
A charge nurse is leading a staff education about caring for a pt who has hypocalcemia. Which of the following statements by a staff nurse indicates the need for further teaching. a. "I should monitor for hand spasms during B/P cuff inflation. " b. "Pt who have a Vit D deficiency are at risk." c. "Pt who have hypocalcemia are at risk for pathologic fractures." d. "I should implement seizure precautions for a pt with hypocalcemia."
c
A nurse has administered midazolam (Versed) IV bolus to a pt before a procedure. The pts BP is 86/40 and pulse is 134/min. Which of the following is an appropriate action by the nurse? a. administer naloxone (Narcan) IV b. administer morphine IV c. administer 0l9% sodium chloride IV bolus d. administer atropine IV
c
A nurse is assessing a pt for Chovsteks sign. Which of the following techniques should the nurse use to preform this test? a. apply bp cuff to the pts arm b. place the stethoscope bell over the pts carotid artery c. tap lightly on the pts check d. ask the pt to lower his chin to his chest
c
A nurse is caring for a client who has insulin-dependent diabetes mellitus and is experiencing acidosis. The client is receiving IV insulin therapy, and laboratory values are being monitored. Which of the following findings should the nurse report to the PCP? a. Urine output of 30 ml/hr b. Blood glucose of 180 mg/dl c. Serum potassium of 3.0 mEq/L d. BUN of 18 mg/dl
c
A nurse is caring for a pt who reports a headache following an epidural regional nerve block. Which of the following is an appropriate nursing action? a. decrease the pts fluid intake b. apply pressure to puncture site c. place the pts head of the bed flat d. instruct the pt to lie prone
c
A nurse is caring for a pt whose ABG results show a pH 7.3 and PaCO2 50. The nurse correctly determines that the pt has? a. metabolic acidosis b. metabolic alkalosis c. respiratory acidosis d. respiratory alkalosis
c
A nurse is preparing to administer oral potassium. The client's potassium level is 5.5 mEq/L. Which of the following actions should the nurse take? a. Administer the medication as prescribed because the laboratory result is low b. Discontinue the medication because the laboratory result is within the expected reference c. Withhold the medication because the laboratory result is high d. Give the medication because the laboratory result is approaching high
c
A nurse is providing preoperative teaching for a pt who is sched. for a mastectomy the next day. Which of the following pt statements indicates that the pt is ready to learn? a. "I don't want my spouse to see my incision." b. "Will you be able to give me pain med after my surgery?" c. "Can you tell me about how long the surgery will take?" d. "My roommate listens to everything I say."
c
A nurse notes that a client's serum sodium is 155 mEq/L. The primary care provider prescribes IV fluids. the nurse should question which of the following orders? a. 1,000 mL 0.9% saline b. 1,000 mL 5% Dextrose with water c. 1,000 mL 3% saline d. 1,000 mL 5% Dextrose and 0.45% saline
c
A patient is admitted to the PACU after major abdominal surgery. During the initial assessment the pt tells the nurse he thinks he is going to throw up. a priority nursing intervention would be to. a. increase the rate of the iv fluid b. obtain vital signs, including o2 saturation c. position pt in lateral recovery position d. administer antiemetic medication as ordered
c
A pt is sched for surgery requiring general anesthesia at an ambulatory surgical center. The nurse ask him where he ate last. He replies that he had a light breakfast a couple of hours before coming to the surgery center. What should the nurse do first? a. tell the pt to come back tomorrow, since he ate a meal b. proceed with the preop checklist including site identification c. notify the anesthesia care provider of when and what the pt last ate d. have the pt void before administering any preop meds
c
A pt. with chronic kidney disease has hyperphosphatemia. What is a commonly associated electrolyte imbalance? a. hypokalemia b. hyponatremia c. hypocalcemia d. hypomagnesemia
c
Intravenous induction for general anesthesia is the method of choice for most pt because a. the pt is not intubated b. the agents are non explosive c. induction is rapid and pleasant d. emergence is longer but with fewer complications
c
The nurse is preparing to discharge a pt from the ambulatory surgery center following an inguinal hernia repair. The nurses delays the release of the pt upon discovering that the pt? a. had IV morphine 45 min ago b. o2 sat of 92% c. has not voided since before surgery d. had one episode of vomiting 30 min ago
c
The nurse provides postop instructions for an adult patient after cataract surgery. Which written statement, if provided by the nurse, would be the most appropriate? a. "to avoid contamination of the eye use aseptic tech. when applying eye drops." b."conjunctivitis may result if the eye is contaminated with wet or dirty eye patches." c. "to prevent infection in the eye, wash your hands before changing the eye patch or using eye drops." d. "coughing and bending over can cause increased intraocular pressure, resulting in retinal damage or displacement of the incraocular lens."
c
The nurse should be alert for which manifestations in a pt receiving a loop diuretic? a. restlessness, agitation b. paresthesias and irritability c. weak, irregular pulse and poor muscle tone d. increased BP and muscle spasms
c
What is an example of an IV solution that would be appropriate to tx. an extracellular fluid volume deficit? a. D5W b. 3% saline c. Lactated Ringer's solution d. D5W in 1/2 NS (0.45%)
c
When a patient is admitted to the PACU, what are the priority interventions the nurse performs? a. assess the surgical site, noting presence and character of drainage. b. assess the amount of urine output and the presence of bladder distention. c. asses for airway patency and quality of respirations, and obtain vitals. d. Review the results of intraoperative lab values and medications received.
c
Which pt would be at great risk for potential development of hypermagnesmia? a. 83 year old man with lung cancer and HTN b. 65 year old woman with HTN taken B-adrenergic blockers c. 42 year old woman with systemic lupus erythematosus and renal failure d. 50 year old man with benign prostatic hyperplasia and a UTI
c
A nurse is obtaining informed consent for a pt who is having a paracentesis. Which of the follwoing are appropriate nursing actions? (select all that apply) a. explain to the pt the purpose of having the procedure b. inform the pt of risks to having the procedure c. ensure the pt understood the info about the procedure d. witness the pt signing the informed consent form e. determine if the pt is mentally capable of understanding the reason for the procedure
c, d, e
Preop considerations for older adults include (select all that apply) a. only use large print education materials b. speaking louder for pts with hearing aids c. recognizing that sensory deficits may be present d. providing warm blankets to prevent hypothermia e. teaching important info early in the morning
c,d
A nurse is performing an admission assessment on a pt who has hypovolemia due to vomiting and diarrhea. Which of the following is an expected finding? Select all that apply. a. hot dry skin b. HTN c. tachycardia d. syncope e. decreased skin turgor
c,d,e
A 70 kg postoperative pt has an average urine output of 25 ml/hour during the first 8 hours. the priority nursing intervention given this assessment would be to a. preform a straight catheterization to measure the amount of urine in the bladder. b. notify the physician and anticipate obtaining blood work to evaluate renal function. c. continue to monitor the pt bc this is a normal finding during this time period. d. evaluate the pts fluid volume status since surgery and obtain a bladder ultrasound
d
A nurse is admitting a pt who has been vomiting for 24 hr. Arterial blood gases are obtained. Based on the lab findings, which of the following conditions should the nurse expect? a. respiratory acidosis b. respiratory alkalosis c. metabolic acidosis d. metabolic alkalosis
d
A nurse is caring for a pt who has arrived in the PACU following a total hip arthoplasty. The pt is not responding to verbal stimuli. Which of the following actions should the nurse perform first? a. compare and contrast the peripheal pulses b. apply warm blanket c. assess the pts dressings d. place the pt in lateral position
d
A nurse is caring for a pt who is dehydrated. Which of the following clinical manifestations should the nurse assess for that is indicative of fluid volume deficit? a. most skin b. distended neck veins c. increased urinary output d. tachycardia
d
A nurse is caring for an older adult pt in a long-term care facility. The pt has become weak and confused. He ate 40% of his breakfast and lunch. Upon assessment, the pts temperature was 100.9, pulse 92/min, respiration 20/min, blood pressure 108/60. He has lost 3/4 lb a reports dizziness when assisted to the bathroom. He also has a nonproductive cough with diminished breath sounds in the right lower lobe. Which following actions should the nurse take? a. initiate fluid restriction to limit intake b. observe for signs of HTN c. encourage the pt to ambulate to promote oxygenation d. monitor respiration for SOB
d
A nurse is performing a neurological assessment on a client who has dehydration. The nurse notes that the client's mental status has changed, and she now appears confused and lethargic. Which of the following is the priority nursing action? a. Document the change in status in the nursing notes b. Reassess neurological status in 2 hours c. Increase the IV flow rate d. Report this finding to the client's primary care provider
d
A nurse is preparing an instruction session about managing stress incontinence for an older adult. Which of the following actions should the nurse take first when meeting the pt? a. encourage the pt to participate actively in learning b. select instructional materials appropriate for the older adult c. identify goals the nurse and the pt agree are reasonable d. determine what the pt knows about stress incontinence
d
A preop nurse is caring for a pt who is having a colon resection. WHich of the following is an appropriate nursing action? a. encourage the pt to void after med administration b. administer antibiotics 30 min prior to surgical incision c. remove half using a manual razor d. remove nail polish on fingers and toes
d
A priority nursing intervention to assist a preop pt in coping with fear of postop pain would be to? a. inform the pt that pain med will be available b. teach the pt to use guided imagery c. describe the type of pain expected with the pts particular surgery d. explain the pain management plan, including the use of a pain rating scale
d
A pt becomes restless and agitatied in the postanesthesia care unit (PACU) as he begins to regain consciousness. The first action the nurse should take is? a. turn the patient into a lateral position b. orient the pt and tell him the surgery is over c. administer the ordered postop pain med d. check the pts o2 sat and pulse
d
A pt who normally takes 40 units of insulin at bedtime ask the nurse what to do about her dose the night before surgery. The best response would be to have her... a. skip her insulin dose at bedtime and eat a light breakfast in the morning b. take her usual dose at bedtime and eat a light breakfast in the morning c. eat a moderate meal before bedtime and then take half of her insulin dose d. get instructions from her surgeon or health care provider on any insulin adjustments
d
During a preoperative review of systems, the pt. reveals a hx. of renal disease. This finding suggests the need for which preoperative diagnostic test? a. ECG and chest x-ray b. serum glucose and CBC c. ABGs and coagulation tests d. BUN, serum creatinine, and electrolytes
d
During the postop care of a 76 year old pt, the nurse monitors the pts intake and output carefully, knowing that the pt is at risk for fluid and electrolyte imbalances primarily because a. older adults have an impaired thirst mechanism and need reminding to drink fluids b. water accounts for a greater percentage of body weight in the older adult than in younger adult c. older adults are more likely than younger adults to lose extracellular fluid during surgical procedures d. small losses of fluid are more significant because of body fluids account for only about 50% of body weight in older adults
d
In a pt. with a positive Chvostek's sign, the nurse would anticipate IV administration of which med? a. calcitonin b. Vit. D c. loop diuretics d. calcium gluconate
d
In a pt. with sodium imbalances, the primary clinical manifestations are t/t alterations in what body system? a. kidneys b. cardiovascular system c. musculoskeletal system d. CNS
d
The nurse is unable to flush a central venous access device and suspects occlusion. The best nursing intervention would be to? a. apply warm moist compresses to the insertion site b. attempt to force 10mL of normal saline into the device c. place the pt on the left side with head-down position d. instruct the pt to change positions, raise arm, and cough
d
When scrubbing at the scrub sink, the nurse should a. scrub from elbows to hand b. scrub without mechanical friction c. scrub for a minimum of 10 minutes d. hold the hands higher than the elbows
d
Which of the following is the prioroty assessment a nurse should make when caring for a client who has a calcium level of 8.1 mg/dl? a. Deep tendon reflexes b. Bowel sounds c. Peripheral pulses d. Cardiac rhythm
d
Which pt. is at risk for hypernatremia? a. has a deficiency of aldosterone b. has prolonged vomiting and diarrhea c. receives excessive IV 5% dextrose solution d. Has impaired consciousness and decreased thirst sensitivity
d
A pt is admitted to the ED with a RR of 7/min. ABG reveal the following values. Which of the following is an appropriate analysis of the ABGs? pH - 7.22 PaCO2 - 68 Base excess - 2 PaO2 - 78 Saturation 80% Bicarbonate 28
respiratory acidosis
