Test 1 Practice Questions
A client is recovering from abdominal surgery. The statement by the client that most indicates the nurse needs to educate the client about pain and pain control is "Pain medication can control pain." "I will report to you when I am experiencing pain." "I should expect to have pain." "Pain relief may promote a quicker recovery."
"I should expect to have pain."
The wife of a client is concerned because her husband is requiring increasingly high doses of analgesia. She states, "He was in pain long before he got cancer because he broke his back about 20 years ago. For that problem, though, his pain medicine wasn't just raised and raised." What would be the nurse's best response?
"Much cancer pain is caused by tumor involvement and needs to be treated in a way that brings the client relief."
When developing a teaching plan for a patient scheduled for ambulatory surgery with epidural anesthesia, which of the following would the nurse include? "You shouldn't experience a headache after this type of anesthesia." "Normally, the blood pressure drops fairly low initially." "The anesthetic is introduced directly into the spinal cord." "You won't be able to move, but you'll be able to feel sensations."
"You shouldn't experience a headache after this type of anesthesia."
The health care provider ordered an IV solution for a dehydrated patient with a head injury. Select the IV solution that the nurse knows would be contraindicated. a. 0.9% NaCl b. 5% DW c. 0.45% NS d. 3% NS
. 5% DW
The physician schedules an elective surgical procedure for a patient who smokes cigarettes. When should the nurse recommend that the patient cease smoking before the surgical procedure to minimize risks associate with cigarette smoking? 1 to 2 months 3 to 4 months 2 weeks 3 weeks
1-2 months
A client has been prescribed a fentanyl patch for pain control. The nurse understands that this patch should be replaced every 12-24 hours. 36-60 hours. 24-36 hours. 48-72 hours.
48-72 hours.
The health care provider ordered an IV solution for a dehydrated patient with a head injury. Select the IV solution that the nurse knows would be contraindicated. a. 0.9% NaCl b. 5% DW c. 0.45% NS d. 3% NS
5% DW
The nurse is assessing a client who has been taking up to 4 grams of acetaminophen every day for undiagnosed pain. What reaction due to ingestion of acetaminophen will the nurse assess for? Excessive clotting of blood Abrupt onset of rash and pruritus Shortness of breath Sensitivity to hot and cold temperatures
Abrupt onset of rash and pruritus Explanation: The use of acetaminophen increases the risk of hepatotoxicity. Initial signs and symptoms of a drug-induced hepatitis include an abrupt onset of a rash and pruritus. Initial effects would not include excessive clotting of blood, shortness of breath, or sensitivity to hot and cold temperatures.
The nurse has been assigned to care for various clients. Which client is at the highest risk for a fluid and electrolyte imbalance? An 82-year-old client who receives all nutrition via tube feedings and whose medications include carvedilol and torsemide. A 45-year-old client who had a laparoscopic appendectomy 24 hours ago and is being advanced to a regular diet. A 79-year-old client admitted with a diagnosis of pneumonia. A 66-year-old client who had an open cholecystectomy with a T-tube placed that is draining 125 mL of bile per shift.
An 82-year-old client who receives all nutrition via tube feedings and whose medications include carvedilol and torsemide.
The nurse is reviewing lab work on a newly admitted client. Which of the following diagnostic studies confirm the nursing diagnosis of Deficient Fluid Volume? Select all that apply. An elevated hematocrit level A low urine specific gravity Electrolyte imbalance Low protein level in the urine Absence of ketones in urine
An elevated hematocrit level Electrolyte imbalance
A nurse knows that she must obtain a signed informed consent for which of the following procedures? Select all that apply. Arteriography Open reduction of a fracture Insertion of a urethral catheter Cystoscopy Insertion of a peripheral intravenous line Paracentesis
Arteriography Open reduction of a fracture Cystoscopy Paracentesis
The nurse determines that a patient is at risk for the development of thrombophlebitis. What interventions can the nurse provide to prevent this? (Select all that apply.) Assisting the patient with leg exercises Encouraging early ambulation Massaging the legs every 4 hours Avoiding placement of pillows or blanket rolls under the patient's knees Applying compression stockings only at night
Assisting the patient with leg exercises Encouraging early ambulation Avoiding placement of pillows or blanket rolls under the patient's knees
When administering a fentanyl patch, the last dose of sustained-release morphine should be administered at what point? Before respiratory assessment Immediately after the morning shower There are no administration requirements At the same time the first patch is applied
At the same time the first patch is applied
The nurse is aware that infection is a potential complication of surgery. Which intervention should the nurse implement to prevent infection? Select all that apply. Avoid touching sterile items unless necessary. Keep artificial nails clean and in good repair. Alert the surgical team of any breaches of sterile technique. Wear a long-sleeved, sterile gown and gloves. Remove hair from the surgical site using a razor.
Avoid touching sterile items unless necessary. Alert the surgical team of any breaches of sterile technique. Wear a long-sleeved, sterile gown and gloves.
Which action by the nurse indicates understanding of one basic principle of providing effective pain management? Awakening a new postoperative client to take pain medication Administering pain medications on a PRN (as needed) basis Continuing to provide around-the-clock pain medications 72 hours after a surgical procedure Administering a dose of an analgesic agent via client-controlled analgesia (PCA) during rounds
Awakening a new postoperative client to take pain medication
A volume-depleted patient would present with which of the following diagnostic lab results? BUN-to-creatinine ratio of 24:1 Urinary output of 1.2 L/24 hours Urine specific gravity of 1.02 Capillary refill time of 3 seconds
BUN-to-creatinine ratio of 24:1 Explanation: A BUN-to-serum creatinine concentration ratio greater than 20:1 is indicative of volume depletion. The other results are within normal range.
A client is diagnosed with syndrome of inappropriate antidiuretic hormone (SIADH). The nurse informs the client that the physician will order diuretic therapy and restrict fluid and sodium intake to treat the disorder. If the client doesn't comply with the recommended treatment, which complication may arise? Cerebral edema Hypovolemic shock Severe hyperkalemia Tetany
Cerebral edema
The nurse suspects the client is developing postoperative pneumonia. Which clinical manifestation would support the nurse's conclusion? Select all that apply. Chills Crackles Wheezes Afebrile Tachypnea
Chills Crackles Tachypnea
A nurse is preparing to insert a peripheral intravenous access device into the arm of a client. When preparing the skin for insertion, which of the following should the nurse use to prevent possible health-care associated bloodstream infections? Povidone-iodine Alcohol Chlorhexidine Normal saline
Chlorhexidine
The nurse is caring for a young adult client with a diagnosis of cerebral palsy who has been admitted for the relief of painful contractures in his lower extremities. When creating a nursing care plan for this client, what variables should the nurse consider? Select all that apply. Client's gender Client's comorbid conditions Type of procedure be performed Changes in neurologic function due to the procedure Prior effectiveness in relieving the pain
Client's comorbid conditions Type of procedure be performed Changes in neurologic function due to the procedure Prior effectiveness in relieving the pain
A nurse caring for a patient who is receiving an IV solution via a central vein suspects the complication of an air embolism. Which of the following are signs and symptoms consistent with that diagnosis? Select all that apply. Crackles on auscultation Cyanosis Hypertension Shoulder pain Dyspnea Tachycardia
Cyanosis Shoulder pain Dyspnea Tachycardia
Which of the following activities are nursing activities in the preoperative phase of care? Select all that apply. Ensuring that the sponge, needle, and instrument counts are correct Discussing and reviewing the advanced directive document Beginning discharge planning Establishing an intravenous line Administering medications, fluid, and blood component therapy, if prescribed
Discussing and reviewing the advanced directive document Establishing an intravenous line Beginning discharge planning
Which of the following is a clinical manifestation of fluid volume excess (FVE)? Select all that apply. Distended neck veins Crackles in the lung fields Shortness of breath Decreased blood pressure Bradycardia
Distended neck veins Crackles in the lung fields Shortness of breath
A postoperative client is being discharged home after minor surgery. The PACU nurse is reviewing discharge instructions with the client and the client's spouse. What actions by the nurse are appropriate? Select all that apply. Provide information on health promotion topics. Have the spouse review when to notify the physician. Have the client sign his or her advance directive form. Discuss wound care. Educate on activity limitations.
Educate on activity limitations. Discuss wound care. Have the spouse review when to notify the physician. Provide information on health promotion topics.
What action by the nurse best encompasses the preoperative phase? Educating clients on signs and symptoms of infection Documenting the application of sequential compression devices (SCDs) Monitoring vital signs every 15 minutes Shaving the client using a straight razor
Educating clients on signs and symptoms of infection
The nurse is reviewing a preoperative informed consent when preparing the client for surgery. Which contents of the informed consent are required? Select all that apply. Personnel present Explanation of procedure Estimated time of procedure Description of alternatives Benefits of surgery Potential risks
Explanation of procedure Potential risks Benefits of surgery Description of alternatives
A nurse is caring for an adult client with numerous draining wounds from gunshots. The client's pulse rate has increased from 100 to 130 beats per minute over the last hour. The nurse should further assess the client for which of the following? Extracellular fluid volume deficit Metabolic alkalosis Altered blood urea nitrogen (BUN) value Respiratory acidosis
Extracellular fluid volume deficit
Which factor increases blood urea nitrogen (BUN)? Gastrointestinal bleeding Overhydration Decreased protein intake Hypothermia
Gastrointestinal bleeding
A client who has developed a painless penile ulcer is diagnosed with syphilis. What treatment would physician prescribe? IV penicillin G; single dose IV penicillin G; multiple dosing oral penicillin G; single dose IV tetracycline
IV penicillin G; single dose
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. Maintain an aseptic environment. Provide oral fluids to the patient. Review the medical records. Verify the surgical site and mark it appropriately. Apply grounding devices to the client.
Identify the client using two identifiers. Verify the surgical site and mark it appropriately. Review the medical records.
The nurse applies a transdermal patch of fentanyl for a client with pain due to cancer of the pancreas. The client puts the call light on 1 hour later and tells the nurse that it has not helped. What is the best response by the nurse? "It will take approximately 12 to 18 hours for the medication to begin to work, so I will give you something else now to relieve the pain." "It should have begun working 30 minutes ago. I will call the doctor and let the doctor know you need something stronger." "You have probably developed a tolerance to the medication." "It will take about 24 hours for the medication to work. I can't give you anything else or you will overdose."
It will take approximately 12 to 18 hours for the medication to begin to work, so I will give you something else now to relieve the pain."
Which sign suggests that a client with the syndrome of inappropriate antidiuretic hormone (SIADH) secretion is experiencing complications? Tetanic contractions Jugular vein distention Weight loss Polyuria
JVD
The nurse is providing preoperative care to a client who is anxious about total hip replacement surgery. "What if I can never walk again? I don't want to end up like my father!" What are some ways the nurse might help alleviate the client's anxiety? Select all that apply. Make sure the client understands what will happen during surgery. Listen empathetically to the client's concerns about the procedure. Ask the client if he would like to speak with a clergyperson. Remind the client that the chances of something going wrong are statistically low. Offer a sedative to help the client relax and feel more comfortable. Review the client's postoperative goals following the procedure.
Make sure the client understands what will happen during surgery. Listen empathetically to the client's concerns about the procedure. Review the client's postoperative goals following the procedure. Ask the client if he would like to speak with a clergyperson.
During surgery a patient develops hypothermia. The circulating nurse would monitor the patient closely for which of the following? Rebound hyperthermia Metabolic acidosis Anaphylaxis Hypoxia
Metabolic acidosis
The nurse is caring for a client with severe diarrhea. The nurse recognizes that the client is at risk for developing which acid-base imbalance? Metabolic acidosis Respiratory acidosis Metabolic alkalosis Respiratory alkalosis
Metabolic acidosis
During the preoperative assessment, the client mentions allergies to avocados, bananas, and hydrocodone. What is the priority action by the nurse? Notify the surgical team to remove all latex-based items. Notify the dietary department. Notify the physician regarding postoperative pain medications. Notify the nurse manager to follow up on the procedure.
Notify the surgical team to remove all latex-based items.
An elderly client is preparing to undergo surgery. The nurse participates in preoperative care knowing that which of the following is the underlying principle that guides preoperative assessment, surgical care, and postoperative care for older adults? Aging processes reduce the chances that surgery will be successful for these clients. Older adults have less physiologic reserve (or ability to regain physical equilibrium) than younger clients. Neurologic and musculoskeletal complications are the leading cause of postoperative morbidity and mortality for older adults. All older people face similar risks when undergoing surgeries.
Older adults have less physiologic reserve (or ability to regain physical equilibrium) than younger clients.
A nurse would implement droplet precautions for a client with which condition? Select all that apply. Ebola virus Pertussis Mumps Scabies Parvovirus B 19
Pertussis Mumps Parvovirus B 19
A nurse implements aseptic technique as a means to break the chain of infection at which element? Reservoir Portal of exit Means of transmission Portal of entry
Portal of entry
The nurse is caring for a client needing emergency surgery. Which preoperative teaching is least important to prepare the client for surgery? Effective coughing and deep breathing Types of postoperative pain medication Post-discharge diet Knowledge of surgical procedure
Post-discharge diet
A patient who has received general anesthesia has reached stage II. Which of the following would the nurse expect the patient to exhibit? Dizziness and a feeling of detachment Pupillary dilation and rapid pulse Unconsciousness and regular respirations Weak, thready pulse and cyanosis
Pupillary dilation and rapid pulse During stage II, or the excitement stage, of general anesthesia, the pupils dilate and the pulse rate is rapid. During stage I, warmth, dizziness, and a feeling of detachment may be experienced. During stage III, the patient is unconscious, respirations are regular, and the pulse rate and volume are normal. During stage IV, respirations become shallow, the pulse is weak and thready, the pupils become widely dilated, and cyanosis develops. Reference:
When assessing a client with infectious diarrhea, which of the following would lead the nurse to suspect that the client is experiencing severe dehydration? Dry oral mucous membranes Increased thirst Rapid, thready pulse Sunken eyes
Rapid, thready pulse
The nurse is providing an education program to reduce the incidence of infection currently on the rise in the community. What areas should the nurse focus on when presenting this program? (Select all that apply.) Regulated health practices Sanitation techniques The use of antibiotics to prevent infections Immunization programs Swimming in the community pool
Regulated health practices Sanitation techniques Immunization programs
The client is postoperative for a right total-knee arthroplasty, and medications include lidocaine 5% (Lidoderm). Past history includes a left mastectomy and herpes zoster following treatment with chemotherapy. The best nursing action is to: Question the use of lidocaine 5%. Apply the patch to the right thigh. Remove the patch after 12 hours. Withhold opioids during lidocaine use.
Remove the patch after 12 hours.
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.
A client reports nausea, vomiting, and diarrhea for 5 days. The nurse assesses the mucous membranes as pale and dry. The client has sunken eyes with the following vital signs: pulse 122 and thready, respirations 23, blood pressure 78/55, temperature 101.8°F oral. Which is the prioritynursing intervention? Initiate oral rehydration therapy at 100 mL/kg of oral rehydration solution over 4 hours. Request an order from the physician for IV rehydration therapy. Assess vital signs every 15 minutes. Obtain stool specimen for analysis.
Request an order from the physician for IV rehydration therapy.
A nurse is working as part of the surgical team in the semi-restricted area. Which of the following would be appropriate to wear? Select all that apply. Street clothes Scrub clothes Caps Shoe covers Masks
Scrub clothes Caps
A client is being prepared for a same-day surgical procedure and is discussing with the nurse what potential ramifications this type of surgery has. Which of the following would the nurse correctly identify? Select all that apply. The client will leave the hospital sooner than in the past. Need for teaching is increased. The client must be prepared to take on more self-care than he or she may have done in the past. Discharge planning is minimal because the stay is so short. Home care and other referrals are unlikely because same-day surgeries are usually minor.
The client will leave the hospital sooner than in the past. Need for teaching is increased. The client must be prepared to take on more self-care than he or she may have done in the past
How does the nurse determine that the patient may have hidden fears about the impending surgical procedure? (Select all that apply.) The patient tells the nurse of concerns with the outcome of the procedure. The patient informs the nurse of problems with postoperative nausea in the past and that it was a bad experience. The patient avoids communication with the nurse. The patient repeatedly asks questions that have previously been answered. The patient talks incessantly.
The patient avoids communication with the nurse. The patient repeatedly asks questions that have previously been answered. The patient talks incessantly.
The nurse is caring for a postsurgical client who speaks very little English. How should the nurse most accurately assess this client's pain? Use a chart with English on one side of the page and the client's native language on the other so he can rate his pain. Ask the client to write down a number according to the 0-to-10 point pain scale. Use the Visual Analog Scale (VAS). Use the services of a translator each time you assess the client so you can document the client's pain rating.
Use a chart with English on one side of the page and the client's native language on the other so he can rate his pain.
The perioperative nurse has a number of major responsibilities when a patient is admitted to a surgical unit or center. Which of the following is the most important function? Completes preoperative assessment Develops a plan of care Verifies that operative consent is signed Provides psychological support
Verifies that operative consent is signed
Which intervention should the nurse implement during the intraoperative period to protect the client from injury? Select all that apply. Verify scheduled procedure with client. Administer anti-anxiety medication. Cover the client with warm blankets. Assess the client for allergies. Confirm the consent form is signed.
Verify scheduled procedure with client. Assess the client for allergies. Confirm the consent form is signed.
A nurse is caring for a client in acute renal failure. The nurse should expect hypertonic glucose, insulin infusions, and sodium bicarbonate to be used to treat: hypernatremia. hypokalemia. hyperkalemia. hypercalcemia.
hyperkalemia.
Oncotic pressure refers to the number of dissolved particles contained in a unit of fluid. osmotic pressure exerted by proteins. amount of pressure needed to stop the flow of water by osmosis. excretion of substances such as glucose through increased urine output.
osmotic pressure exerted by proteins.
Which arterial blood gas (ABG) result would the nurse anticipate for a client with a 3-day history of vomiting? pH: 7.55, PaCO2: 60 mm Hg, HCO3-: 28 pH: 7.45, PaCO2: 32 mm Hg, HCO3-: 21 pH: 7.28, PaCO2: 25 mm Hg, HCO3: 15 pH: 7.34, PaCO2: 60 mm Hg, HCO3: 34
pH: 7.55, PaCO2: 60 mm Hg, HCO3-: 28
A client presents with fatigue, nausea, vomiting, muscle weakness, and leg cramps. The laboratory values are as follows:sodium 147 mEq/L (147 mmol/L)potassium 3.0 mEq/L (3.0 mmol/L)chloride 112 mEq/L (112 mmol/L)Magnesium 2.3 mg/dL (0.95 mmol/L)What laboratory value is consistent with the client's symptoms?
potassium 3.0 mEq/L (3.0 mmol/L)
Which route of medication administration should the nurse consider first after IV removal in a postoperative client with an NPO (nothing by mouth) order? Rectal Topical Intrathecal Subcutaneous
rectal
The nurse recognizes that the client who takes hydrochlorothiazide to manage hypertension is predisposed for which interaction with anesthesia? Respiratory depression Hypotension Increased risk of bleeding Seizures
resp depression
The patient is NPO prior to having a colonoscopy. The patient is to take a daily blood pressure pill prior to the procedure. Until when may water be given prior to the procedure? Up to 8 hours before surgery Up to 6 hours before surgery Up to 4 hours before surgery Up to 2 hours before surgery
up to 2 hours
x A circulating nurse is preparing a client for a surgical procedure. What are the primary responsibilities of the circulating nurse in the perioperative experience? Select all that apply. verifying informed consent ensuring proper lighting coordinating the efforts of the surgical team marking the surgical site passing the surgical instruments
verifying informed consent ensuring proper lighting coordinating the efforts of the surgical team