PrepU Exam 2
The client reports chest pain. The nurse uses which of the following questions to assess the pain further. Select all answers that apply.
-"How long have you experienced this pain?" -"Rate the pain on a scale of 0 to 10, with 10 being the worst possible pain." -"What aggravates your chest pain?"
The surgical nurse is preparing to send a client from the pre-surgical area to the OR and is reviewing the client's informed consent form. What are the criteria for legally valid informed consent? Select all that apply.
-Consent must be freely given. -Consent must be obtained by a health care provider. -Signature must be witnessed by a professional staff member.
The nurse is applying for a position as a circulating nurse in the operating room (OR). Which activities will the nurse expect to complete in this role? Select all that apply.
-Manage surgical specimens. -Prepare the site for surgery. -Assist with client positioning.
The nurse is reviewing a list of surgical clients. Which clients would the nurse recognize as having the greatest risk for complications during the intraoperative or postoperative period? Select all that apply.
-The 27-year-old client with non-insulin dependent diabetes. -The 70-year-old client who takes no routine medications.
Which patient does the nurse recognize as being most likely to be affected by sickle cell disease?
A 14-year-old African American boy
The nurse is obtaining a history from a patient with severe psoriasis. What question would be the most important to ask this patient to determine a genetic predisposition?
"Does anyone in your family have more than one autoimmune disease?"
A client is receiving morphine through a patient-controlled analgesia (PCA) system following surgery. The nurse states to the client
"Only you are to push the button for medication."
A client with early stage rheumatoid arthritis asks the nurse what to do to help ease the symptoms of the disease. What would be the best response by the nurse?
"The health care provider could prescribe anti-inflammatory drugs."
A client with a terminal illness grimaces and begins to cry when being turned and repositioned in bed. Which action will the nurse take at this time?
Ask the client to rate the pain.
The nurse is planning care for a client with severe fatigue secondary to anemia. What concept will the nurse use as the basis for planning interventions?
Assisting in prioritizing activities
A nurse is caring for an older client who has been admitted to the unit with iron-deficiency anemia. What would the nurse suspect?
Blood loss from the gastrointestinal or genitourinary tract
When a nurse asks a patient to describe the quality of the pain, what type of descriptive term does the nurse expect the patient to use?
Burning
An adult client has been diagnosed with iron-deficiency anemia. What nursing diagnosis is most likely to apply to this client's health status?
Fatigue related to decreased oxygen-carrying capacity
The nurse is describing normal erythrocyte physiology to a client who has a diagnosis of anemia. The nurse should explain that the erythrocytes consist primarily of which substance?
Hemoglobin
A patient with uncontrolled diabetes is scheduled for a surgical procedure. What chief life-threatening hazard should the nurse monitor for?
Hypoglycemia
What type of immunoglobulin is most likely involved with allergic reactions?
IgE
A nurse is providing education to a client with iron deficiency anemia who has been prescribed iron supplements. What should the nurse include in health education?
Iron will cause the stools to darken in color.
The nurse is administering an analgesic to an older adult patient. Why is it important for the nurse to assess the patient carefully?
Older people are more sensitive to drugs.
A new nursing graduate is working at the hospital in the medical-surgical unit. The preceptor observes the nurse emptying a patient's wound drain without gloves on. What important information should the preceptor share with the new graduate about standard precautions?
Standard precautions should be used with all patients to reduce the risk of transmission of blood-borne pathogens.
A client reports abdominal pain as "8" on a pain intensity scale of 0-10 thirty minutes after receiving an opioid intravenously. Her past medical history includes partial-thickness burns to approximately 60% of her body several years ago. The nurse assesses
That the client's past experiences with pain may influence her perception of current pain
The nurse should determine that a client is coughing effectively after surgery if the nurse observes which of the following activities?
The client takes a deep abdominal breath and then "huff" or "hack" coughs three or four times.
For a client diagnosed with pernicious anemia, the nurse emphasizes the importance of lifelong administration of
Vitamin B12
A client with a history of atrial fibrillation has contacted the clinic reporting an accidental overdose on prescribed warfarin. The nurse should recognize the possible need for which antidote?
Vitamin K
A client comes to the emergency department complaining of difficulty breathing and feeling strange after eating a shrimp cocktail. The client is leaning forward with a respiratory rate of 36 breaths per minute. The nurse suspects anaphylaxis. What is the nurse's priority action?
maintaining an open airway
A client has been given a patient-controlled analgesia (PCA) device to control postoperative pain. The client expresses concern about administering too much of the analgesic and accidentally overdosing. What topic should the nurse teach the client about?
the limits on dose and frequency that are programmed into the PCA
