NUS111: SAFETY AND SECURITY REVIEW

The nurse is evaluating the client's understanding of diet teaching aimed at promoting wound healing following surgery. The nurse would conclude teaching was ineffective if the client selects which of the following? Baked chicken, mashed potatoes, broccoli, and strawberries Grilled salmon, rice pilaf, green beans, and cantaloupe Turkey breast, baked sweet potato, asparagus, and an orange Cheeseburger, french fries, coleslaw, and ice cream

Cheeseburger, french fries, coleslaw, and ice cream Explanation: Important nutrients for wound healing include protein; vitamins A, B-complex, C, and K; arginine, magnesium, copper, and zinc; and water. The diet should be sufficient in carbohydrates and low to moderate in fats. The cheeseburger option is high in fat and low in vitamin C.

A 30-year-old man is currently in the preoperative holding area on call for his tympanoplasty (eardrum reconstruction) that will be performed this morning. The nurse has administered the preanesthetic as ordered. What action should the nurse prioritize at this point in the patient's care? Teaching the patient about pain management and the appropriate use of oral analgesics postoperatively Teaching the patient the correct technique for performing deep-breathing and coughing exercises Ensuring the patient's safety by keeping him in bed and discouraging him from ambulating Performing a thorough respiratory assessment including breath sounds, respiratory rate, and oxygen saturation levels

Ensuring the patient's safety by keeping him in bed and discouraging him from ambulating Explanation: If a preanesthetic medication is administered, the patient is kept in bed with the side rails raised, because the medication can cause lightheadedness or drowsiness. It would normally be ineffective to perform patient teaching around pain or postoperative exercises after the administration of a preanesthetic due to the patient's decreased level of consciousness (LOC). Assessment should be performed prior to surgery, but there is no particular indication for an emphasis on respiratory assessment.

You are admitting an insulin-dependent patient to the same-day surgical suite for carpal tunnel surgery. You know that this patient may be at risk for which metabolic disorder? Adrenal insufficiency Thyrotoxicosis Impaired acid base balance Hyperglycemia

Hyperglycemia Explanation: The patient with diabetes who is undergoing surgery is at risk for hypoglycemia and hyperglycemia. Hyperglycemia during the surgical procedure is a risk based on the body's defense mechanism to raise the blood sugar in the event of stress. Patients who have received corticosteroids are at risk of adrenal insufficiency. Patients with uncontrolled thyroid disorders are at risk for thyrotoxicosis. Because the kidneys are involved in excreting anesthetic medications and their metabolites and because acid-base status and metabolism are also important considerations in anesthesia administration, surgery is contraindicated when a patient has acute nephritis, acute renal insufficiency with oliguria or anuria, or other renal problems.

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. No action is needed, because the client takes warfarin on a continuing basis. Put a note on the preoperative checklist before sending the client into surgery. Tell the client to inform the circulating nurse before the anesthesia is administered.

Notify the surgeon that the client took warfarin the day before surgery. Explanation: Warfarin (Coumadin), an anticoagulant, places the client at risk for excessive bleeding during the intraoperative and postoperative periods.

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. Raise the head of the bed 30 degrees. Maintain a patent airway. Frequently monitor neurological status. Administer blood products per orders. Apply oxygen per orders. Apply a warming blanket.

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

The nurse is preparing a client for surgery. The nurse would notify the surgeon if the client made which of the following statements? "I took my Coumadin as usual last evening." "I took two Tylenol last evening for a headache." "I have not had any metformin for the past week." "I took my lisinopril this morning." "I took two aspirins for joint pain this morning."

"I took my Coumadin as usual last evening." "I took two aspirins for joint pain this morning."

A surgical client has been transferred to the holding area. What nursing intervention(s) promote safe and effective nursing care? Select all that apply. Identify the client using two identifiers. Verify the surgical site and mark it appropriately. Maintain an aseptic environment. Review the medical records. Apply grounding devices to the client. Provide oral fluids to the patient.

Identify the client using two identifiers. Verify the surgical site and mark it appropriately. Review the medical records.

The nurse discovers that the client did not sign the operative consent before receiving the preoperative medication. The appropriate nursing action is: To have the client sign the consent immediately To have the client's next of kin sign the consent For the nurse to sign the consent with verbal permission of the client To notify the surgeon

To notify the surgeon Explanation: Preoperative medication can impair the thinking ability of the client. FFor informed consent to be valid, the client must be competent to give consent. The surgery will be canceled.

Which nutrient plays an important role in normal blood clotting? Zinc Vitamin K Vitamin C Protein

Vitamin K Explanation: Vitamin K is important for normal blood clotting. The other nutrients are not involved in clotting.

The nurse suspects the client is developing postoperative pneumonia. Which clinical manifestation would support the nurse's conclusion? Select all that apply. Wheezes Chills Crackles Afebrile Tachypnea

Chills Crackles Tachypnea

A client is scheduled for an invasive procedure. What should the nurse document in the chart regarding the procedure? A report from the dietician A signed consent form from the client A detailed urinalysis report A signed consent form from the client's family

A signed consent form from the client Explanation: A signed consent is required and is important for initiating invasive procedures. The nurse should therefore check for the signed consent form of the client. Checking a report from the dietitian or a signed consent form from the client's family is not necessary. A urinalysis report might be required if the physician requests it, but is not required before performing an invasive procedure.

The nurse is admitting the older adult to the PACU. Which information about this client would be most important for the PACU nurse to obtain? What procedure was performed? What was estimated blood loss? Are family members available? Does the client have a history of dementia-like symptoms?

Does the client have a history of dementia-like symptoms? Explanation: Acute confusion is a common side effect of anesthesia in older adults. The nurse needs to know whether any confusion displayed by the client is a result of the surgery and anesthesia or a usual state for the client.

Which of the following factors may contribute to rapid and shallow respirations in a postoperative client? Select all that apply. Pain Constricting dressings Abdominal distention Obesity Effects of analgesics and anesthesia

Pain Constricting dressings Abdominal distention Obesity

Which health care profession has the ultimate responsibility to provide appropriate information regarding a nonemergent surgery? Nurse Physician Case manager Certified nurse's aide

Physician Explanation: It is the physician's responsibility to provide appropriate information. It is not the responsibility of the nurse, case manager, or certified nurse's aide to gain informed consent.

The nurse in the preoperative area has just medicated her client according to the anesthesiologist's orders. What is the nurse's priority action at this time? Place the side rails in the up position and make sure the call button is in reach. Take the client to the bathroom. Have the family go to the waiting room. Take the client's vital signs.

Place the side rails in the up position and make sure the call button is in reach. Explanation: Immediately after giving the medications, the nurse instructs the client to remain in bed; he or she places side rails in the up position and ensures that the call button is within easy reach. Once the client has been preoperatively medicated you do not get them up to the bathroom. The nurses' immediate responsibility after preoperatively medicating the client is not to take the clients' vital signs or to send the family to the waiting room.

A 76-year-old client had surgery for an abdominal hernia. The PACU nurse observes that the client is confused and is trying to climb out of the bed and pull at the cardiac monitor lines. At this time, what interventions by the nurse are appropriate? Select all that apply. Reorient the client. Assess for hypoxia. Assess urine output. Administer opioid pain medication per orders. Ambulate the client. Apply wrist restraints.

Reorient the client. Assess for hypoxia. Assess urine output. Explanation: The nurse should provide reassurance and reorient the client as needed. Hypoxia and urinary retention may cause acute confusion in the older adults postoperatively, so it would be appropriate for the nurse to assess for hypoxia and urine output. Opioid pain medications may cause further confusion; the physician should be consulted about the type and dosage of the pain medication. Ambulating the client may present safety concerns, especially if the client is bleeding or hypoxic.

The nurse is reviewing the pre-admission laboratory findings of the client scheduled for surgery. Which laboratory value would be of greatest concern to the nurse? sodium 138 mEq/L calcium 9.8 mg/dL white blood cell count 7.2 cells/mm potassium 6.2 mEq/L

potassium 6.2 mEq/L Explanation: Hyperkalemia places the client at risk for surgical complications. The sodium level, calcium level, and white blood cell count are within normal limits.