Surgery assessment

A nurse is assessing a client who is admitted for elective surgery and has a history of Addison's disease. Which of the following findings should the nurse expect?

Hyper pigmentation

A nurse is providing teaching to a client about interventions to reduce the risk of developing cardiovascular disease. Which of the following statements by the client should indicate to the nurse the need for further teaching?

"Increasing my intake of foods containing trans-fatty acids can lower my risk.

A nurse is providing information about pain control for a client who has acute pain following a subtotal gastric resection. Which of the following client statements indicates an understanding of pain control?

"I will call for pain medication before the previous dose wears off."

A nurse is caring for a client who is in the immediate postoperative period following a partial laryngectomy. Which of the following parameters for the nurse assess first?

Airway patency

A nurse is caring for a client. For each potential nursing action, click to specify if the action is essential, nonessential or contraindicated for the client. Nurses notes: client has a 10.2 cm x 10.2 cm raised red and abscess on left thigh. Client reports area is warm and painful. Vital signs: temperature 39.6, blood pressure 118/56 heart rate 106, respiratory rate 22 post oximetry, 96. Diagnostic results: WBC 45,000 culture and sensitivity of left thigh abscess positive for methicillin resistant staphylococcus aureus (MRSA)

Anticipated: wear a cover gone when caring for a client, place the client in a private room Contraindicated: administer intravenous, penicillin, based antibiotic, restrict fluid intake Nonessential: initiate, supplemental oxygen

A client who has a history of myocardial infarction is prescribed aspirin 325 MG. The nurse recognizes that the aspirin is given due to which of the following actions of this medication?

Antiplatelet aggregate

A nurse is completing discharge teaching with a client following arthroscopic knee surgery. Which of the following instructions should the nurse include in the teaching?

Apply ice to the affected area

A nurse in the post anesthesia care unit is caring for a client who is postoperative following a thoracotomy and lobectomy. Which of the following postoperative assessments should the nurse give highest priority to?

Arterial blood gases

A nurse is preparing dietary instructions for a client who has episodes of biliary colic from chronic cholecystitis. Which of the following instructions should the nurse include in the teaching plan?

Avoid foods high in fat

A nurse is caring for a client who is one day postoperative following a total laryngectomy and has begun a soft diet. The client is not eating well and tells the nurse at the hospital food has no taste. Which of the following responses is appropriate for the nurse to make?

Because of your surgery, you have an altered ability to smell and taste

A nurse in a clinic is caring for a client requiring a hysterectomy who states that she has decided to delay having the surgery for several months. Which of the following statements should the nurse make?

Can you elaborate on your reasons for delaying the surgery?

A nurse is caring for a client who is one day postoperative following a subtotal thyroidectomy. The client reports a tingling sensation in the hands, the soles of the feet, and around the lips. for which of the following findings Should the nurse assess the client?

Chvostek's sign

A nurse is caring for a client who is four days postoperative following a right radical mastectomy. Which of the following activities should the nurse anticipate being the most difficult for this client to perform with her right hand?

Combing her hair

A nurse is caring for a client who is HIV positive and is one day postoperative following an appendectomy. The nurse should wear a gown as personal protective equipment when taking which of the following actions?

Completing a dressing change

A nurse is observing the closed chest drainage system of a client who is 24 hr post thoracotomy. The nurse notes, slow, steady bubbling in the suction control chamber. Which of the following actions should the nurse take?

Continue to monitor the clients respiratory status

A nurse is caring for a client who is 12 hours postoperative and has a chest tube to a disposable water seal drainage system with suction. The nurse should intervene for which of the following observations?

Continuous bubbling in the water-seal chamber

A nurse is assessing a client who has had staples removed from an abdominal bone postoperatively. The nurse notes separation of the wound edges with copious light brown serous drainage. Which of the following actions should the nurse perform first?

Cover the wound with a moist, sterile, gauze dressing

A nurse is developing a plan of care for a client who is postoperative. Which of the following interventions should the nurse include in the plan to prevent pulmonary complications?

Encourage the use of an incentive spirometer

A nurse is assessing a client who is in skeletal traction. which of the following findings should the nurse identify as an indication of infection at the pin sites?

Fever

The nurse is caring for a postoperative client who has a chest tube connected to suction and a water seal drainage system. Which of the following indicates to the nurse at the chest tube is functioning properly?

Fluctuation of the fluid level within the water seal chamber

A nurse is preparing to witness informed consent for a client who is preoperative. The client asks the nurse, "Tatian are there other options besides surgery?" which of the following responses should the nurse make?

Have you discussed other treatments with your provider?

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

Instruct the client about the use of a sequential compression device. The nurse should instruct the client about the use of a sequential compression device to prevent deep-vein thrombosis, a postoperative complication.

A nurse is caring for a client who has an unrepaired femur fracture of the mid shaft. Which of the following techniques should the nurse use when performing an assessment of the clients neurovascular status?

Instruct the client to wiggle his toes.

A nurse is caring for a client who is 9 days postoperative following a total laryngectomy. The nurse removes the client's NG tube and initiates oral feedings. Which of the following statements should the nurse make?

It is no longer possible for you to choke on or aspirate food

A nurse is caring for a client who is postoperative following surgical repair of a mandibular fracture with fixed occlusion of the jaws in a closed position. Which of the following statements is the priority for the nurse to make?

Keep wire cutters with you at all times

A nurse is inserting an IV catheter for an older client in preparation for an outpatient procedure. Which of the following veins should the nurse select?

Median vein in the forearm The nurse should use the median vein because it is distal to other potential Venipuncture sites, and it avoids areas of flexion

A nurse is caring for a client who is postoperative following a laminectomy with spinal fusion. Which of the following actions should the nurse take?

Monitor sensory perception of the lower extremities

A nurse is caring for a client following an abdominal surgery. The client has a prescription for dressing changes every 4 hours and as needed. Which of the following objects should the nurse use to reduce skin irritation around the incision area?

Montgomery straps

A nurse is caring for a client who reports an area of redness, warmth, tenderness, and pain in the right calf. The nurse anticipates, which of the following orders will notify the provider of his findings?

Obtain a venous duplex ultrasound

A nurse is caring for a client with a ventricular pacemaker who is on ECG monitoring. The nurse understands that the pacemaker is functioning properly on which of the following appears on the monitor strip?

Pacemaker spikes before each QRS complex

A nurse is admitting a client who has acute pancreatitis. Which of the following provider prescriptions should the nurse anticipate?

Pantoprazole 80 mg IV bolus twice daily

A nurse is caring for a client who is postoperative following an open reduction and internal fixation of a fractured femur. Which of the following actions is the most important for the nurse to complete in the postoperative period?

Perform neurovascular checks of the extremities.

A nurse is caring for a client who has returned from the surgical suite following surgery for a fractured mandible. The client had an inter-maxillary fixation to repair and stabilize a fracture. Which of the following actions is the priority for the nurse to take?

Prevent aspiration

A nurse is caring for a client who was admitted with bleeding esophageal varices and has an esophagogastric balloon tamponade with a Sengstaken-Blakemore tube to control the bleeding. Which of the following actions should the nurse take?

Provide frequent oral and nares care

A nurse is caring for a client who is 1 day postoperative following a left radical mastectomy. Which of the following behaviors should alert the nurse to the possibility that the client is having difficulty adjusting to the loss of her breast?

Refusing to look at the dressing or surgical incision

A nurse is preparing a client for outpatient surgery. After the nurse inserts the IV catheter, the client reports pain in the insertion area. Which of the following actions should the nurse take?

Remove the catheter and insert another into a different site

A nurse is working with an assistive personnel, while caring for a surgical client who is 1 day postoperative. which task should the nurse take responsibility for completing?

Removing the abdominal dressing

A nurse is providing discharge, teaching to a client who has a Plaster of Paris walking cast on his lower left leg. Which of the following instructions to the nurse include?

Report any numbness or pain in your toes

A nurse is assessing a client who is receiving one packed RBCs to treat intraoperative blood loss. The client reports chills and back pain and the clients blood pressure is 80/64MMHG. Which of the following action should the nurse take first?

Stop the infusion of blood

A nurse is caring for a 75-year-old male client who is experiencing difficulty breathing as shortness of breath. The nurse is caring for the client following a thoracentesis. (Select the 3 findings that require immediate follow up.)

Subcutaneous emphysema, decreased lung sounds, heart rate, 110/min and regular

A nurse is caring for a client who has a hip fracture that requires surgical repair. Which of the following health care professionals is responsible for obtaining informed consent from the client for the procedure?

Surgeon. The health care provider who will perform the treatment or procedure is responsible for obtaining informed consent from the client. The surgeon who is performing the surgical repair of the fracture would be responsible for obtaining informed consent.

A nurse is caring for an older adult client who has just returned from PACU after receiving a spinal anesthetic during knee surgery. For which of the following findings should the nurse notify the provider?

Systolic blood pressure changed from 140 to 120

A nurse at an outpatient surgery center is providing discharge teaching to a client and his spouse following surgical removal of a cataract. Which of the following should the nurse include in the teaching?

The client should wear dark glasses while outdoors

A client who is scheduled for a barium swallow asks the nurse why a laxative is necessary following the procedure. Which of the following responses should the nurse make?

The laxative helps eliminate the barium

A nurse is caring for a client who is scheduled for an elective surgical procedure. Which of the following actions should the nurse take regarding informed consent?

Witness the client's signature

A nurse is assessing a client who is 48 hours postoperative following abdominal surgery. Which of the following findings should the nurse report to the provider?

Yellow green drainage on the surgical incision

A nurse is caring for a client following a total laryngectomy. Which of the following is the primary observation in the clients care?

Need for suctioning

A nurse is providing care to a client who is on strict bedrest following surgery. The nurse assist the patient to the bedside to the commode and the client sustained an injury to the operative area which of the following types of torts has the nurse committed?

Negligence

A nurse is caring for a client who has had a Myocardial infarction. Upon his first visit to cardiac rehabilitation, he tells the nurse that he doesn't understand why he needs to be there, because there is nothing more to do, as the damage is done. Which of the following is the correct nursing response?

Cardiac rehabilitation can I undo the damage to your heart, but it can help you get back to your previous level of activity safely

A nurse is caring for a client who is 1 day postoperative following a transphenoidal hypophysectomy. While assessing the client, the nurse notes a large area of clear drainage seeping from the nasal packing. Which of the following should be the nurse's initial action?

Check the drainage for glucose A potential complication of hypophysectomy is cerebral spinal fluid leakage. Fluid leakage from the nose is a sign that this complication has occurred. The first action the nurse should take using the nursing process is to assess the drainage for the presence of glucose, which would indicate that the drainage is CSF.

A nurse on a medical surgical unit is caring for four clients who are 24 to 36 hours postoperative. Which of the following surgical procedures place is a client at risk for deep vein thrombosis?

Hip arthroplasty

A nurse is providing teaching to a client who is postoperative following coronary artery bypass graft surgery, and is receiving opioid medication's to manage discomfort. Aside from managing pain, which of the following desired effects of medication, should the nurse identify as most important for the clients recovery?

If facilitates the clients deep breathing

A nurse is caring for a client who was involved in a motor vehicle crash Medical history: client admitted following a head on motor vehicle crash with a tree. Client found unconscious in vehicle. Emergency services called and the client was brought into emergency department. Glasgow coma, scale score is seven Blood pressure 102/60, respiratory rate 24, pulse rate, 118 temperature 99 Fahrenheit pulse oximetry 94% The nurse should first address the clients__________followed by the clients ___________

The nurse should first address the clients circulatory status, followed by the clients level of consciousness

A nurse is caring for a client who experienced an open, right femur fracture, following a motor vehicle crash. Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing, two actions to nurse should take to address that condition, and to parameters the nurse should monitor to assess the client's progress.

The nurse should identify that the client is most likely experiencing compartment syndrome. Compartment syndrome occurs following a fracture due to increased edema of the extremity or restriction buy a cast or splint. It is identified by the five Ps: pain, Tyler, pulselessness, paresthesia, and paralysis. Compartment syndrome is a medical emergency. The nurse's priorities are to loosen the dressing to the splint and assess the client's peripheral pulses. A pulse volume recorder may be necessary to detect the peripheral pulses. The nurse should frequently monitor the client's neurovascular function to detect any changes that may indicate further progression of compartment syndrome. The nurse should also monitor and treat the clients pain using prescribed opioids.

A nurse is caring for a 45-year-old client in the emergency department. The nurse is reviewing the client stated to prepare the clients plan of care Complete the diagram by dragging the choices below to specify what condition decline is most likely experiencing, two actions to be taken, and to parameters to monitor for Vital signs blood pressure 128/82, temperature of 101°F Nurses notes, admitted to the ER, accompanied by partner. Alert and oriented X.3. Skin warm and dry, no discoloration noted. Client reports substernal chest pain that radiates to the left shoulder and neck. Rate pain as eight on a scale of 0 to 10. Pain increases with aspiration and lying down. Client reports decreased pain when sitting upright and leaning forward. Heart sounds regular with a pericardial friction rub auscultated left lower sternal border. Lungs clear to auscultation with occasional nonproductive cough. No peripheral edema noted.

The nurse should obtain an echocardiogram and obtain a prescription for an NSAID such as ibuprofen because the client is most likely experiencing pericarditis due to a respiratory infection. The nurse should monitor the clients pain as well as for pulses paradoxus, which is a manifestation of cardiac tamponade and is a medical emergency.

A nurse is caring for a female client. Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing, two actions. The nurse should take to address that condition in to parameter is the nurse should monitor to assess clients progress.

The nurse should request a prescription for artificial tears and provide a call environment for the client because the client is most likely experiencing hyperthyroidism. The nurse should monitor the clients T3 and T4 to identify worsening of the clients hyperthyroidism and check the clients temperature in blood pressure frequently to monitor for manifestations of thyroid storm.

A nurse is assessing a client who is in skeletal traction. The nurse should correct which of the following findings?

The weights rest against the foot of the bed

A nurse is teaching the partner of a client who had an acute myocardial infarction (MI) about the reason blood was drawn from the client. Which of the following statements should the nurse make regarding cardiac enzyme studies?

These tests help determine the degree of damage to the heart tissues

A nurse is caring for a client who has a Jackson - Pratt (JP) drain in place after surgery for an open reduction and internal fixation. The nurse should understand that the JP drain was placed for which of the following purposes?

To prevent fluid from accumulating in the wound

A nurse is caring for a client in the emergency department. Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing, two actions. The nurse should take to address that condition, and to parameters. The nurse should monitor to assess the clients progress.

Upon recognizing an analyzing the client, cues of anemia, jaundice, and acute vaso-occlusive symptoms, the nurses priority hypothesis is that this client is most likely experiencing sickle cell anemia. It is important to generate solutions and take actions that will improve anemia and reduce the cycling of blood cells. Therefore, the nurse should draw a type in crossmatch and administer oxygen to increase tissue, perfusion and improve gas exchange, thereby, reducing signaling of red blood cells. To evaluate these interventions, the nurse should monitor the clients hydration status, and their abdomen for splenic tenderness, which may indicate damage from episodes of ischemia and hypoxia.

a nurse is caring for a client on the medical surgical unit. Complete the diagram by dragging from the choices below

Upon recognizing and analyzing the client, Cuz of abdominal pain and acute onset of diarrhea after the administration of a high dose, IV antibiotics, the nurses priority hypothesis is that this client is most likely experiencing C. Dificile colitis. It is important to generate solutions and take actions that will protect others from infection and treat the symptoms of volume depletion caused by diarrhea. Therefore, the nurse should prepare to start IV fluids and place the client on contact precautions. To evaluate therapy, the nurse should monitor the client's serum potassium and for signs of volume depletion (hypotension) as these can be a consequence of severe diarrhea