Test 1 - Intro to Med-Sure, Infusion Therapy, Care of Preoperative Patients, Care of Intraoperative Patients, & Care of Postoperative Patients

When the nurse arrives at 8 AM, a client has a 1000-mL bag of D5W hanging with 450 mL absorbed during the prior shift. The IV infusion is to deliver 100 mL per hour. At 11 AM the health care provider changes the order for the intravenous solution to 1000 mL 0.9% sodium chloride to be administered at 75 mL per hour and changes the dietary order from npo to clear liquids. From 1 PM to the end of the 12-hour shift at 8 PM, the client has 4 ounces of apple juice, a ½ cup of tea, a ½ cup of gelatin, and 6 ounces of water. How many milliliters should the nurse document as the client's total fluid intake for the 12-hour shift?

1515 mL

A nurse is hired to work in a health care facility that has a complete computer-based client information system. The nurse in charge knows that the newly hired nurse is knowledgeable about this system when the nurse says:

"Client information is immediately available when this system is used." Rationale: Data are immediately available to appropriate health team members without the need to depend on record/chart availability. There should be a reduction in medication errors with this type of system. The intent of these systems is to streamline documentation and record keeping for all appropriate health team members, including nurses. The intent of these systems is to streamline documentation and record keeping, thus increasing opportunities for more direct client care by nurses.

An older client who is living in a nursing home is admitted to the hospital to be treated with IV antibiotics for sepsis resulting from a urinary tract infection. The client becomes agitated and attempts to pull out the IV. The health care provider prescribes a stat dose of haloperidol (Haldol) 0.5 mg IM. The haloperidol is available in a vial that states there are 2 mg/mL. How much solution should the nurse administer?

0.25 mL

The nurse is caring for a newly admitted patient. Which intervention is the best example of a culturally appropriate nursing intervention?

Ask permission before touching a patient during the physical assessment. Rationale: Many cultures consider it disrespectful to touch a patient without asking permission, so asking a patient for permission is always culturally appropriate. The other actions may be appropriate for some patients but are not appropriate across all cultural groups or for all individual patients. Ethnicity may not be the most important factor in planning care, especially if the patient has urgent physiologic problems.

Which task is most appropriate for a nurse to delegate to unlicensed assistive personnel?

Assessing the blood pressure of a client before physical therapy. Rationale: Taking vital signs is an appropriate task to delegate to unlicensed assistive personnel; it is within their job description because it is a task that has manageable parameters. Emptying a portable wound drainage device involves surgical asepsis; it is not an appropriate task to delegate to unlicensed assistive personnel. Client education is not an appropriate task to delegate to unlicensed assistive personnel; it requires the education achieved by a professional nurse. Monitoring infusion rates involves an invasive line; this is not an appropriate task to delegate to unlicensed assistive personnel.

The nurse is having difficulty understanding a client's decision to have hospice care rather than an extensive surgical procedure. Which ethical principle does the client's behavior illustrate?

Autonomy. Rationale: The client is exhibiting the freedom to make a personal decision, and this reflects the concept of autonomy. Justice refers to fairness. Veracity refers to truthfulness. Beneficence refers to implementing actions that benefit others.

A patient is in stage 2 of general anesthesia. What action by the nurse is most important?

Being prepared to suction the airway. Rationale: During stage 2 of general anesthesia (excitement, delirium), the patient can vomit and aspirate. The nurse must be ready to react to this potential occurrence by being prepared to suction the patient's airway. Keeping the room quiet and calm does help the patient enter the anesthetic state, but is not the priority. Positioning the patient usually occurs during stage 3 (operative anesthesia). Keeping the patient warm is important throughout to prevent hypothermia.

A nurse is instructing a client to use an incentive spirometer. What client action indicates the need for further instruction?

Blowing vigorously into the mouthpiece. Rationale: The client should exhale before inhaling slowly and deeply through the spirometer to maximize lung expansion. Sitting in a chair will facilitate diaphragmatic excursion and help maximize lung expansion. Coughing will help remove secretions mobilized by use of a spirometer. The client's lips must form a seal around the mouthpiece to measure the volume of air inhaled.

The circulating nurse and preoperative nurse are reviewing the chart of a patient scheduled for minimally invasive surgery (MIS). What information on the chart needs to be reported to the surgeon as a priority?

Consent for MIS procedure only. Rationale: All MIS procedures have the potential for becoming open procedures depending on findings and complications. The patient's consent should include this possibility. The nurse should report this finding to the surgeon prior to surgery taking place. Having allergies noted and an allergy band applied is the standard procedure. Not having any prior surgical or anesthesia exposure is not the priority. Maintaining NPO status as prescribed is the standard procedure although individual surgeons may not require being NPO for an entire 8 hours.

Which action should the nurse take first when a client's gravity flow IV rate is too slow?

Evaluate the appearance of the catheter insertion site. Rationale: If infiltration or phlebitis is responsible for the decreased flow rate, the IV catheter must be removed and restarted in a new site.Repositioning the client's arm will do nothing if the catheter is not in a vein. This is not the priority. If the catheter is not in a vein, adjusting the flow clamp will be unsafe because fluid will enter interstitial tissues. Although determining the amount of fluid that should have been infused will eventually will be done, this intervention will not resolve the cause of the problem. This is not the priority.

A client has surgery for the insertion of an implanted infusion port for chemotherapy. The client asks, "The doctor said after my chemotherapy is finished, the port will stay in, but it needs to be flushed routinely. How often does this have to be done?" What should the nurse tell the client about how often the port will most likely need to be flushed when not in use?

Every month. Rationale: Imported ports need to be flushed after each use and at least once a month between courses of therapy.

The nurse is preparing to witness the patient signing the operative consent form when the patient says, "I don't understand what the doctor said about the surgery." Which action should the nurse take next?

Notify the surgeon that the informed consent process is not complete. Rationale: The surgeon is responsible for explaining the surgery to the patient. The nurse should wait until the surgeon has clarified the surgery before having the patient sign the consent form. The nurse should communicate directly with the surgeon about the consent form rather than asking other staff to pass on the message. It is not within the nurse's legal scope of practice to explain the surgical procedure. No preoperative medications should be given until the patient understands the surgical procedure and signs the consent form.

A 38-yr-old woman is admitted for an elective surgical procedure. Which information obtained by the nurse during the preoperative assessment is most important to communicate to the anesthesiologist and surgeon before surgery?

The patient's report that her last menstrual period was 8 weeks ago. Rationale: This statement suggests that the patient may be pregnant and pregnancy testing is needed before administration of anesthetic agents. Although the other data may also be communicated with the surgeon and anesthesiologist, they will affect postoperative care and do not indicate a need for further assessment before surgery.

The nurse facilitates student clinical experiences in the surgical suite. Which action, if performed by a student, would require the nurse to intervene?

The student wears street clothes in the semirestricted area. Rationale: Wearing street clothes in the semirestricted area is not permitted. The surgical suite is divided into three distinct areas: unrestricted-staff and others in street clothes can interact with those in surgical attire; semirestricted-staff must wear surgical attire and cover all head and facial hair; and restricted-includes the operating room, the sink area, and clean core where masks are required in addition to surgical attire.

A nurse is assessing patients who have intravenous therapy prescribed. Which assessment finding for a patient with a peripherally inserted central catheter (PICC) requires immediate attention?

Upper extremity swelling is noted. Rationale: Upper extremity swelling could indicate infiltration, and the PICC will need to be removed. The initial dressing over the PICC site will be changed within 24 hours. This does not require immediate attention, but the swelling does. The dwell time for PICCs can be months or even years. Securement devices are being used more often now to secure the catheter in place and prevent complications such as phlebitis and infiltration. The IV will have one, but this does not take priority over the patient whose arm is swollen.

A health care provider orders thigh-high antiembolism stockings for a client with varicose veins. The client's thighs are heavier than the lower legs, and the stockings fit on the lower leg but are causing discomfort and indentations on the upper thighs. What should the nurse do?

Ask the health care provider if an elastic bandage can be used in place of the stockings. Rationale: An elastic bandage can be adjusted to the varying proportions of the client's legs and can be used when the legs are too large or too small for the stockings. Replacing stockings with knee-high stockings requires a health care provider's order. Leaving the stockings off is unsafe; this permits venous stasis. Rolling the top of the stockings to below the knees will increase the pressure in the popliteal space, which increases venous stasis and the risk of thrombophlebitis.

A nurse is monitoring a patient after moderate sedation. The provider has prewritten discharged orders and the patient's spouse is asking if they can leave. What action by the nurse is best?

Assess the patient using the modified Aldrete scale. Rationale: Prior to discharging the patient after a moderate sedation procedure, the nurse must assess the patient's readiness for discharge. The nurse uses an evidence-based assessment tool such as the modified Aldrete score. This tool provides a more thorough evaluation than just assessing for gag reflex and ability to follow directions. The nurse should not begin providing instructions until the patient is ready to be discharged.

The circulating nurse is plugging in a piece of equipment and notes that the cord is frayed. What action by the nurse is best?

Get another piece of equipment. Rationale: The circulating nurse is responsible for patient safety. If an electrical cord is frayed, the risk of fire or sparking increases. The nurse should obtain a replacement. The nurse should also tag the original equipment for repair as per agency policy. Checking the equipment is not important as the nurse should not even attempt to use it. Calling maintenance or requesting maintenance per facility protocol is important, but first ensure patient safety by having a properly working piece of equipment for the procedure about to take place. The charge nurse probably does need to know of the need for equipment repair, but ensuring patient safety is the priority.

A nurse is caring for several postoperative clients who had abdominal surgery. What independent nursing intervention can help prevent the development of thrombophlebitis?

Helping the client to perform in-bed exercises. Rationale: Inactivity causes venous stasis, hypercoagulability, and external pressure against the veins, all of which lead to thrombus formation; early ambulation or exercise of the lower extremities reduces the occurrence of this complication. Although encouraging adequate fluieds may help, it is not an independent nursing intervention. Postoperative clients often are npo until peristalsis returns. Massaging is contraindicated because any developing clot may dislodge. Appying SCDs is helpful, but it is not an independent activity; a sequential compression device requires a health care provider's order.

Intravenous orders state that the client is to receive 1 liter of fluid every 8 hours. If the equipment delivers 15 drops/mL, at what rate should the nurse regulate the flow?

31 gtt/mL

A client drank 7.5 oz of orange juice, 6 oz of tea, and 8 oz of eggnog. How many milliliters of fluid were consumed by the client?

645 mL

At the beginning of the shift at 7 AM, a client has 650 mL of normal saline solution left in the intravenous bag, which is infusing at 125 mL/hr. At 9:30 AM the health care provider changes the IV solution to Ringer's lactate, which is to infuse at 100 mL/hr. What total amount of intravenous solution should the client have received by the end of the eight-hour shift?

863 mL

A patient in the operating room has developed malignant hyperthermia. The patient's potassium is 6.5 mEq/L (6.5 mmol/L). What action by the nurse takes priority?

Administer 10 units of regular insulin. Rationale: For hyperkalemia in a patient with malignant hyperthermia, the nurse administers 10 units of regular insulin in 50 mL of 50% dextrose. This will force potassium back into the cells rapidly. Nifedipine is a calcium channel blocker used to treat hypertension and dysrhythmias, and should not be used in a patient with malignant hyperthermia. Assessing the urine for blood or myoglobin is important, but does not take priority. Monitoring the patient for dysrhythmias is also important due to the potassium imbalance, but again does not take priority over treating the potassium imbalance.

A nurse prepares to flush a peripherally inserted central catheter (PICC) line with 50 units of heparin. The pharmacy supplies a multidose vial of heparin with a concentration of 100 units/mL. Which of the syringes shown below will the nurse use to draw up and administer the heparin?

Always use a 10-mL syringe when flushing PICC lines because a smaller syringe creates higher pressure, which could rupture the lumen of the PICC.

The postoperative nurse is caring for a patient who reports feeling "something popped" after vomiting. What action by the nurse is a priority?

Apply a sterile nonadherent dressing. Rationale: The priority is to protect the wound when a dehiscence occurs. All other actions would be performed but are not the priority.

A nurse is caring for a group of patients on the medical-surgical unit with the help of one float registered nurse (RN), one unlicensed assistive personnel (UAP), and one licensed practical/vocational nurse (LPN/LVN). Which assignment, if delegated by the nurse, would be inappropriate?

Check for the presence of bowel sounds and flatulence by UAP. Rationale: Assessment requires RN education and scope of practice and cannot be delegated to an LPN/LVN or UAP. The other assignments made by the RN are appropriate.

Which action describes how the scrub nurse protects the patient with aseptic technique during surgery?

Changes gloves after touching the upper arm of the surgeon's gown. Rationale: The sleeves of a sterile surgical gown are considered sterile only to 2 inches above the elbows, so touching the surgeon's upper arm would contaminate the nurse's gloves. Shoe covers are not sterile. Personal protective equipment is designed to protect caregivers, not the patient, and is not part of aseptic technique. Staff members such as the circulating nurse do not have to perform a surgical scrub before entering the OR.

Which topic is most important for the nurse to discuss preoperatively with a patient who is scheduled for an open cholecystectomy?

Deep breathing and coughing. Rationale: Preoperative teaching, demonstration, and re-demonstration of deep breathing and coughing are needed on patients having abdominal surgery to prevent postoperative atelectasis. Incisional care and the importance of completing antibiotics are better discussed after surgery, when the patient will be more likely to retain this information. The patient does not usually need information about medications that are used intraoperatively.

A nurse inspects a two-day-old intravenous site and identifies erythema, warmth, and mild edema. The client reports tenderness when the area is palpated. What should the nurse do first?

Discontinue the infusion. Rationale: The clinical findings indicate the presence of inflammation. The intravenous catheter should be removed to prevent the development of thrombophlebitis. Irrigating the IV tubing or slowing the rate of the infusion is unsafe. It may further irritate the vein and precipitate a thrombophlebitis. Although an analgesic may relieve the discomfort, it is not an intervention that will resolve the problem.

A patient is having robotic surgery. The circulating nurse observes the instruments being inserted, and then the surgeon appears to "break scrub" when going to the console and sitting down. What action by the nurse is best?

Document the time the robotic portion of the procedure begins. Rationale: During a robotic operative procedure, the surgeon inserts the articulating arms into the patient, and then "breaks scrub" to sit at the viewing console to perform the operation. The nurse should document the time the robotic portion of the procedure began. There is no need for the other interventions.

Which action should the perioperative nurse take to best protect the patient from burn injury during surgery?

Ensure correct placement of the grounding pad. Rationale: Care must be taken to correctly place the grounding pad and all electrosurgical equipment to prevent injury from burns or fire. It is important to ensure that fire extinguishers are available and that sprinklers protect everyone in the operating room in the event of a fire, but placing the grounding pad will best prevent injury to the patient. Verifying that electrosurgical equipment is working properly does not protect the patient unless the grounding pad is placed correctly.

Which actions will the nurse include in the surgical time-out procedure before surgery (Select all that apply.)?

Have the patient state name and date of birth, verify the patient identification band number, and ask the patient to state the surgical procedure. Rationale: These actions are included in surgical time-out procedure. IV line placement and identification of the patient by the surgeon are not included in the surgical time-out procedure.

hich data identified during the preoperative assessment alerts the nurse that special protection techniques should be implemented during surgery?

History of spinal and hip arthritis. Rationale: The patient with arthritis may require special positioning to avoid injury and postoperative discomfort. Preoperative anxiety (unless severe) and having a sip of water 3 hours before surgery are not contraindications to having surgery. An allergy to cats and dogs will not affect the care needed during the intraoperative phase.

The night before surgery, a client is unable to sleep despite adequate sedation. The client asks the nurse to stay for a while. Based on an understanding of the client's behavior, what should be the nurse's initial response?

Indicate that the client's inability to sleep has been noticed. Rationale: Insomnia often is caused by anxiety. By stating an observation about the client's activity, the nurse communicates both concern and recognition that there may be more covert problems that the client wishes to verbalize. The other actions deny the client's request and cuts off communication.

The nurse documenting the patient's progress in the care plan in the electronic health record before an interprofessional discharge conference is demonstrating competency in which QSEN category?

Informatics and technology. Rationale: The nurse is displaying competency in the QSEN area of informatics and technology. Using a computerized information system to document patient needs and progress and communicate vital information regarding the patient with the interprofessional care team members provides evidence that nursing practice standards related to the nursing process have been maintained during the care of the patient.

A nurse prepares to insert a short peripheral venous catheter. What actions will the nurse take to ensure patient safety? (Select all that apply.)

Perform hand hygiene before inserting the catheter, verify that the prescription is appropriate for peripheral infusion, and choose a distal site on the patient's nondominant arm. Rationale: Best practices for the insertion of a short peripheral venous catheter include hand hygiene prior to the procedure, verification of the prescription for intravenous therapy and its appropriateness for infusion through a short peripheral catheter, and placement of the catheter in a distal site, away from an area of joint flexion and when possible in the patient's nondominat arm. Surgical masks are needed for central venous catheter placement but not for short peripheral venous catheter placement.

A patient on the postoperative nursing unit has a blood pressure of 156/98 mm Hg, pulse 140 beats/min, and respirations of 24 breaths/min. The patient denies pain, has normal hemoglobin, hematocrit, and oxygen saturation, and shows no signs of infection. What would the nurse assess next?

Psychosocial status. Rationale: After ensuring the patient's physiologic status is stable, these manifestations would lead the nurse to assess the patient's psychosocial status. Anxiety especially can be demonstrated with elevations in vital signs. Cognitive and nutrition status are not related. Family stress is a component of psychosocial status.

The nurse is caring for clients in the operating room. What physiologic function should the nurse consider that clients lose last during the induction of general anesthesia?

Respirations. Rationale: There is no respiratory movement in stage 4 of anesthesia; before this stage, respirations are depressed but present. The gag reflex is lost in the first phase of stage 3 of anesthesia. The corneal reflex is lost in the second phase of stage 3 of anesthesia. Consciousness is lost in stage 2.

The nurse uses the Situation-Background-Assessment-Recommendation (SBAR) format to communicate a change in patient status to a health care provider. In which order should the nurse make the following statements?

Situation - "This is the nurse on the surgical unit. After assessing the patient, I am very concerned about increased shortness of breath over the past hour." Background - "The patient was admitted yesterday with heart failure and has been receiving furosemide (Lasix) for diuresis, but urine output has been low." Assessment - "The patient has crackles audible throughout the posterior chest, and the most recent oxygen saturation is 89%. Her condition is very unstable." Recommendation - "The patient needs to be evaluated immediately and may need intubation and mechanical ventilation."

The nurse works in a clinic located in a community with many Hispanics. Which strategy, if implemented by the nurse, would decrease health care disparities for the Hispanic patients?

Teach clinic staff about Hispanic health beliefs. Rationale: Health care disparities are caused by stereotyping, biases, and prejudice of health care providers. The nurse can decrease these through staff education. The other strategies may also be addressed by the nurse but will not directly impact health disparities.

The nurse interviews a patient scheduled to undergo general anesthesia for a bilateral hernia repair. Which information is most important to communicate to the surgeon and anesthesiologist before surgery?

The patient's father died after general anesthesia for abdominal surgery. Rationale: The information about the patient's father suggests that there may be a family history of malignant hyperthermia and that precautions may need to be taken to prevent this complication. Current research indicates that having clear liquids 3 hours before surgery does not increase the risk for aspiration in most patients. Patients are instructed to discontinue aspirin 1 to 2 weeks before surgery. The patient should be offered caffeinated beverages postoperatively to prevent a caffeine-withdrawal headache, but this does not have preoperative implications.

A nurse teaches a patient who is prescribed a central vascular access device. Which statement will the nurse include in this patient's teaching?

"Ask all providers to vigorously clean the connections prior to accessing the device." Rationale: Patients should be actively engaged in the prevention of catheter-related bloodstream infections and taught to remind all providers to perform hand hygiene and vigorously clean connections prior to accessing the device. The other statements are incorrect.

A nurse is preparing a patient for discharge after surgery. The patient needs to change a large dressing and manage a drain at home. What instruction by the nurse is most important?

"Wash your hands before touching the drain or dressing." Rationale: All options are appropriate for the patient being discharged after surgery. However, for this patient who is changing a dressing and managing a drain, infection control is the priority. The nurse instructs the patient to wash hands often, including before and after touching the dressing or drain.

The postanesthesia care unit (PACU) nurse is caring for an older patient following a lengthy surgery. What assessment finding would indicate an effect of hypothermia?

Bradycardia. Rationale: Bradycardia is the immediate postoperative patient can indicate anesthesia effect or hypothermia. Older adults are at higher risk for hypothermia because of age-related changes in temperature regulation, decreased body fat, or prolonged exposure to cool environments, such as an OR suite. Tachycardia, hypotension, or rapid, shallow respirations are not symptoms of hypothermia.

A nurse prepares to insert a peripheral venous catheter in an older adult patient. What action will the nurse take to protect the patient's skin during this procedure?

Place a washcloth between the skin and tourniquet. Rationale: To protect the patient's skin, the nurse will place a washcloth or the patient's gown between the skin and tourniquet. The other interventions are methods to distend the vein but will not protect the patient's skin.

A patient has received intravenous anesthesia during an operation. What action by the postanesthesia care nurse is most important when the patient arrives in the PACU?

Place the patient on a cardiac monitor and pulse oximeter. Rationale: Intravenous anesthetic agents have the potential to cause respiratory and circulatory depression. The nurse should ensure that the patient is on a cardiac monitor and pulse oximeter. Muscle relaxants are not indicated for this patient at this time. Intravenous anesthetics have a lower rate of postoperative nausea and vomiting than other types. Shivering can occur in any patient, but is more common after inhalation agents.

A registered nurse (RN) is watching a nursing student change a dressing and perform care around a Penrose drain. What action by the student warrants intervention by the RN?

Securing the drain's safety pin to the sheets. Rationale: The safety pin that prevents the drain from slipping back into the patient's body would be pinned to the patient's gown, not the bedding. Pinning it to the sheets will cause it to pull out when the patient turns. The other actions are appropriate.

A patient arrives at the outpatient surgical center for a scheduled laparoscopy under general anesthesia. Which information requires the nurse's preoperative intervention to maintain patient safety?

The patient is planning to drive home after surgery. Rationale: After outpatient surgery, the patient should not drive that day and will need assistance with transportation and home care. Clear liquids only require a minimum preoperative fasting period of 2 hours. The patient's experience with anesthesia and the patient's insurance coverage are important to establish, but these are not safety issues.

A client is admitted to the surgical unit from the postanesthesia care unit with a Salem sump nasogastric tube that is to be attached to wall suction. Which nursing action should the nurse implement when caring for this client?

Use normal saline to irrigate the tube. Rationale: Patency of the tube should be maintained to ensure continued suction. Use of normal saline minimizes fluid and electrolyte disturbances during irrigation. The stomach is not considered a sterile body cavity, so medical asepsis is indicated. Care must be take when withdrawing the tube to avoid traumatizing the mucosa. Ice chips and water represent fluid intake, which must be approved by the health care provider; being hypotonic in nature, such intake may lower the level of serum electrolytes.

What is the primary purpose of evidence-based nursing?

Using results from research to improve the outcome of nursing care. Rationale: Evidence-based practice is the integration of the best current evidence and practices to make decisions about patient care. The best source of evidence is research.