SI worksheets

type and amount of drainage

A patient who is 10 hours post op for an amputation at the shoulder of the right arm. At his period post op, what is this patient's priority assessment?

perform a neurovascular check on the affected extremity

A patient who recently had a cast placed on the right forearm for an ulnar fracture reports that their fingers feel "numb and tingly". The nurse should immediately do what?

performing neurovascular assessment

A patient with a cast for a fractured radius reports, "my fingers feel numb". What is the priority nursing action?

compartment syndrome

A patient with a leg fracture is scheduled for a fasciotomy. Which complication is identified as having caused the need for this type of surgery?

localized pain and warmth

A patient with osteomyelitis of the tibia may initially present with which assessment findings?

-don't get cast wet (fiberglass casts can get wet) -don't stick anything in the cast -don't bear weight during the first 48 hours -don't take anything off cast -don't lift with fingers while still drying -don't cut/trim edges -don't cover with plastic for long amounts of time -don't cover a wet cast

Cast care don'ts

call the surgery unit to explain to the client's concern, and ask if the client can wear the hearing aid to surgery

Prior to going to surgery, the client tells the nurse that it is not possible to hear without a hearing aid and asks to wear it to surgery and recovery. What is the nurse's best response?

the client smoked a cigarette at 0600

Prior to surgery, the client is to take nothing by mouth after 0400. Which statement indicates the client did not follow the preoperative directions?

O2 saturation of 85%

After admitting a postoperative patient to the clinical unit, which assessment data require the most immediate attention?

"the machine will only give me the prescribed amount of pain medication if I push the button too soon"

After teaching the client how to use the patient controlled analgesia (PCA) pumo, the nurse determines that the client understands the use of the PCA when the client makes which statement?

airway flow

A client arrives from surgery to the postanesthesia care unit. Which respiratory assessment should the nurse complete first?

initiate a time-out

A client is to have a below the knee amputation. Before surgery, what should the circulating nurse in the operating room do?

-crepitus -visible deformity -pain

A client who fell from a roof has a suspected right tibial fracture. Which manifestation should the nurse anticipate to see during the initial assessment. Select all that apply

notify the anesthesiologist

A client who is to receive general anesthesia has a serum potassium level of 5.8 mEq/L. What should be the nurse's first response?

compartment syndrome

A client with a new leg cast complains of severe pain of the affected extremity. After giving the client their prescribed dose of morphine, the client still is complaining of pain. The nurse suspects that the client has what?

position the patient in lateral recovery position

A patient is admitted to the PACU after major abdominal surgery. During the initial assessment the patient tells the nurse he thinks he is going to "throw up." A priority nursing intervention is to what?

on an empty stomach and keep the patient upright for 30 minutes

A patient is prescribed Alendronate for the treatment of osteoporosis. As the nurse you know you must administer this medication on what?

allow the patient a rest period before showering with the nurse's help

A patient recovering from an acute exacerbation of RA tells the nurse that she is too tired to bathe. What should the RN do for this patient?

a measurable loss of height

During a health screening event, which assessment finding would alert the nurse to the possible presence of osteoporosis?

-current use of medications, herbs, and vitamins -over the counter medication used in the last 6 weeks -steroid use in the last year -all drugs taken in the last 18 months

During the preoperative interview, the nurse obtains information about the client's medication history. Which information is necessary to record about the client? Select all that apply

tricyclic antidepressants

For a patient who is experiencing neuropathic pain, which medication would be MOST effective?

-get out of bed like you're pregnant -use high toilet seats -abduct legs with a pillow -place cushions on chairs or elevate seats -keep hip in neutral position -use pillow between legs for 6 weeks after surgery

Hip replacement do's

-don't adduct or internally rotate hip -don't put bed past 90 degrees of flexion -don't sit in low seats or toilet seats -don't cross legs at the hips or knees -don't put on own shoes and socks without assistance for the first 4-6 weeks after surgery -don't sit on chairs without arms -don't bend over to get out of bed

Hip replacement don'ts

administering adequate analgesics to promote relief or control of pain

In planning postoperative interventions to promote repositioning, ambulation, coughing, and deep breathing, which action should the nurse recognize will best enable the patient to achieve the desired outcomes?

-pallor -feeling of tingling in the extremity -affected extremity feels cooler to the touch than the unaffected extremity

Select all the signs and symptoms that will present in compartment syndrome?

-pain -pallor -pressure -paresthesia -paralysis -pulselessness

The 6 P's of compartment syndrome are what?

-assess the client's skin integrity -maintain proper body alignment -assess the client's neurovascular function

The client with a cervical spinal cord injury is admitted to the rehabilitation unit with skeletal traction. What nursing actions are a priority? Select all that apply

assess the ariway patency and quality of respirations and obtain vital signs

What are the priority interventions that the nurse performs when admitting a patient to the PACU?

clean the pins with half hydrogen peroxide and half normal saline

What is the priority nursing intervention for a patient with external fixation in place?

methotrexate takes 4-6 weeks to become therapeutic

When discussing treatment with a patient with newly diagnosed RA, the nurse explains that an expected outcome of methotrexate is what?

notify the healthcare provider to obtain consent for surgery

When receiving preoperative forms, the nurse notices that the patient's informed consent is not signed. Which action would the nurse take?

notify the surgeon of the clients expressed lack of understanding

When the nurse asks the client who is having abdominal surgery today if the client understand the procedure, the client replies, "no not really; I talked about several different things with my surgeon, and I'm just not sure." What should the nurse do next?

the WBC is 1500

When the nurse is reviewing laboratory data for a patient who is taking methotrexate. Which information is most important to communicate to the health care provider?

presence of green sputum

Which assessment finding in a patient 3 days post op indicates they may have developed pneumonia?

-monitoring oxygen saturation -assess bilateral lung sounds -ambulate the halls with the patient -instruct on incentive spirometry use

Which nursing care measures are useful in the prevention of postoperative respiratory complications? Select all that apply

yellow/green/foul smelling drainage

purulent

bright red drainage

sanguineous

pink/brown drainage

serosanguineous

brown/clear drainage

serous

a 75 year old patient with repair of femoral neck fracture after a fall

Which patient would be the highest risk for postoperative hypothermia?

"my pain is so severe that it hurts to stretch or elevate my arm"

Which statement by a patient, who just received a cast on the right arm for a fracture, requires you to notify the physician immediately?

IV antibiotics are usually required for several weeks

Which statement by the nurse indicates understanding of acute osteomyelitis?

you can drink black coffee up to two hours before surgery

While performing preoperative teaching, the patient asks when to stop drinking coffee before the surgery. Which response by the nurse is accurate

cover the surgical site in saline soaked sterile gauze

The nurse enters a room of a patient who is 4 hours postoperative for an appendectomy and sees that the surgical site has opened and the sutures are no longer intact. What should the nurse do first?

absence of nausea and vomiting

The nurse evaluates the effectiveness of an administered dose of Ondansetron (Zofran) by monitoring for what?

restlessness

The nurse is assessing a client recovering from anesthesia. Which finding is an early indicator of hypoxemia?

immobilizing the affected extremity

The nurse is caring for a patient immediately after the patient sustained a hip fracture. Which nursing action is performed first?

tell the patient that you are here to help and understand that this is a difficult transition

The nurse is caring for a patient who had a recent right above the knee leg amputation. What would the nurse do to help the patient with body image disturbances?

psychosocial integrity

The nurse is preparing a preoperative teaching plan for a client who is undergoing a bilateral breast reduction. Which aspect of the plan is the priority?

petechiae on the neck and chest

The nurse is providing postoperative care two days after a patient underwent surgical repair of a fractured femur. Which assessment finding indicates the need for immediate nursing intervention?

heat producing liniments can be used with other heat devices

The nurse teaches a client about heat and cold treatments to manage arthritis pain. Which of the following client statements indicates that the client still has a knowledge deficit.

blurred vision

The nurse teaches the patient receiving atropine to expect which side effect?

aquatic exercise

The nurse teaches the patient with RA that one of the most effective methods of aerobic exercise is what?

supine position with head elevated

In what position would the nurse place a postoperative, conscious patient in order to prevent respiratory problems?

fat embolism

A patient sustained a fracture of the femur. The patient has become confused, restless, has a respiration rate of 30, and has petechiae. Based on the location of the fracture and the presenting symptoms, this patient is most likely experiencing what type of complication associated with this fracture?

excess edema and other problems are prevented when the leg is elevated for the first 24 hours

A patient tells the nurse "I know i just got a long leg cast on my leg this morning, but i really want to try walking with my crutches." The nurse informs that patient that this activity is not permitted based on what rationale?

ask the client if any family members had trouble when they had surgery

Before surgery, a client expresses a fear of surgery because 10 years ago the client's sister died in surgery related to complications of anesthesia. What should the nurse do?

-move joints above and below fracture -cover with bag in shower -use hair dryer on low heat for itching -lift cast with palms that are not dry -apply ice for first 24 hours after application -elevate extremity above heart for 48 hours after application

Cast care do's