345 Test 1 Practice Questions
Which is considered an isotonic solution?
0.9% normal saline
A client recovering from hip surgery is receiving morphine through a patient-controlled analgesia (PCA) infusion pump with a set basal rate. What action is most important for the nurse to implement? Ask the client about pain status Obtain consent for PCA by proxy Assess the client's respiratory status Instruct the client about bolus doses
Assess the client's respiratory status
The nurse is assessing a 78-year-old woman and suspects that the patient may have age-related macular degeneration. Which assessment finding would most likely support this suspicion?
Diminished color perception
Which is a correct route of administration for potassium? Intramuscular Subcutaneous Oral IV (intravenous) push
Oral
The nurse recognizes that the client who takes hydrochlorothiazide to manage hypertension is predisposed for which interaction with anesthesia? Increased risk of bleeding Respiratory depression Seizures Hypotension
Respiratory depression
The circulating nurse is responsible for monitoring the surgical team
True
At what point does the preoperative period end? When the client signs the consent form When the decision is made to proceed with surgery When the client is admitted to the PACU When the client is transferred onto the operating table
When the client is transferred onto the operating table
A client is preparing for a surgical procedure is taking corticosteroids for Crohn's disease. What is most important for the nurse to monitor during the operative experience with the client? obstruction surgical site infection adrenal insufficiency hypoglycemia
adrenal insufficiency
Which electrolyte is a major cation in body fluid?
potassium
A client is at postoperative day 1 after abdominal surgery. The client is receiving 0.9% normal saline at 75 mL/h, has a nasogastric tube to low wall suction with 200 mL every 8 hours of light yellow fluid, and a wound drain with 50 mL of dark red drainage every 8 hours. The 24-hour urine output total is 2430 mL. What action by the nurse is most appropriate? Discontinue the nasogastric tube suctioning. Assess for signs and symptoms of fluid volume deficit. Document the findings and reassess in 24 hours. Assess for edema.
Assess for signs and symptoms of fluid volume deficit.
When the nurse observes that a postoperative client demonstrates a constant low level of oxygen saturation via the O2 saturation monitor despite the client's breathing appearing normal, what action should the nurse take first? Notify the physician. Document the findings. Apply oxygen. Assess the client's heart rhythm and nail beds.
Assess the client's heart rhythm and nail beds.
A client is postoperative day 3 after surgical repair of an open abdominal wound and traumatic amputation of the right lower leg following a motorcycle crash. What is the highest priority nursing intervention? Obtaining dietary consultation for improved wound healing Administering pain medications within 1 hour of the client's request Educating the client on safe bed-to-chair transfer procedures Assessing WBC count, temperature, and wound appearance
Assessing WBC count, temperature, and wound appearance
A 54-year-old client on a fixed income has had an electrocardiogram (ECG) as part of an annual physical examination. What legislation supports the focus on chronic disease prevention, health promotion, and quality, affordable health care for everyone? A New Health System for the 21st Century Bill Building a Safer Health System Act Healthcare Research and Quality Improvement Bill Patient Protection and Affordable Care Act
Patient Protection and Affordable Care Act
The nurse positions the client in the lithotomy position in preparation for Renal surgery Pelvic surgery Abdominal surgery Perineal surgery
Perineal surgery
A client is experiencing anorexia related to the adverse effects of cancer treatment. Using Maslow's hierarchy, the nurse identifies this as a reflection of which need? Safety and security Belongingness and affection Esteem and self-respect Physiologic needs
Physiologic needs
The nurse is caring for the postoperative client in the postanesthesia care unit. Which of the following is the priority nursing action? Monitor vital signs for early detection of shock. Position the client to maintain a patent airway. Assess the incisional dressing to detect hemorrhage. Administer antiemetics to prevent nausea and vomiting.
Position the client to maintain a patent airway.
A client with a suspected overdose of an unknown drug is admitted to the emergency department. Arterial blood gas values indicate respiratory acidosis. What should the nurse do first? Prepare to assist with ventilation. Prepare for gastric lavage. Monitor the client's heart rhythm. Obtain a urine specimen for drug screening.
Prepare to assist with ventilation.
A patient who has received general anesthesia has reached stage II. Which of the following would the nurse expect the patient to exhibit? Unconsciousness and regular respirations Dizziness and a feeling of detachment Weak, thready pulse and cyanosis Pupillary dilation and rapid pulse
Pupillary dilation and rapid pulse
The circulating nurse is unsure whether proper technique was followed when an object was placed in the sterile field during a surgical procedure. What is the best action by the nurse? Remove the entire sterile field from use. Mark the client's chart for future review of infections. Remove the item from the sterile field. Ask another nurse to review the technique used.
Remove the entire sterile field from use.
A client is placed on the operating room table for the surgical procedure. Which surgical team member is responsible for handing sterile instruments to the surgeon and assistants? First assistant Circulating nurse Certified registered nurse anesthetist Scrub nurse
Scrub nurse
Which condition is a heightened response that occurs after exposure to a noxious stimulus? Pain threshold Pain tolerance Sensitization Dependence
Sensitization
The nurse is working at an institution that uses a collaborative practice model. Which of the following would most likely be reflected at this institution? Isolated participation from the patient Centralized organizational structure Physician as the primary decision-maker Shared accountability for care
Shared accountability for care
A client at risk for malignant hyperthermia returns to the surgical unit. For what time period will the nurse monitor the client for development of malignant hyperthermia? A client can develop malignant hyperthermia only with intravenous anesthesia after surgery. Malignant hyperthermia occurs in the operating room only. The client can develop malignant hyperthermia up to 24 hours after surgery. The client will need to be discharged with special instructions.
The client can develop malignant hyperthermia up to 24 hours after surgery.
The nurse asks a preoperative patient to sign a surgical consent form as specified by the surgeon and signs the form after the patient. What is the use doing by performing this action? Witnessing the patient's signature Obtaining informed consent from the patient for surgery Verifying that the consent for surgery is truly voluntary and informed Ensuring that the patient is mentally competent to sign the consent form
Witnessing the patient's signature
Nociception includes four specific processes: transduction, transmission, perception, and modulation. Which action illustrates the nociception process of pain transmission? A mother in labor utilizing imagery to reduce pain A surgeon making an incision to perform surgery A child quickly removing a hand when touching a hot object A patient taking tramadol to enhance pain management
A child quickly removing a hand when touching a hot object
A client undergoing coronary artery bypass surgery is subjected to intentional hypothermia. The client is ready for rewarming procedures. Which action by the nurse is appropriate? Place warm damp drapes on the client, replacing them every 5 minutes. Apply a warm air blanket, gradually increasing body temperature. Temporarily set the OR temperature to 30°C. Administer IV fluids warmed to room temperature.
Apply a warm air blanket, gradually increasing body temperature.
Although nurse practice acts may vary state by state, all recognize several basic principles supporting the legal parameters for all registered nurses. Select the activity that falls under the scope of nursing practice. Diagnosing pathology based on the patient's response to treatment Changing a patient's health care treatment plan Appraising and enhancing an individual's health-seeking perspective Prescribing a physical therapy program to treat a flare-up of a chronic condition
Appraising and enhancing an individual's health-seeking perspective
Which of the following manifestations should the nurse assess for when developing a plan of care for a patient with hyponatremia? Muscle weakness Moist mucous membranes Subnormal temperature Complaints of thirst and agitation
Complaints of thirst and agitation
What would you give in a patient with a positive chovstek sign Calcitonin Vitamin D Loop diuretics Calium glulconate
Calium glulconate
A post op client reports severe abdominal pain. The nurse cannot auscultate bowel sounds and notes the client's abdomen is rigid. What is the nurse's priority action? Re-attempt to auscultate bowel sounds. Call the health care provider. Prepare to administer a stool softener. Prepare to insert a nasogastric tube.
Call the health care provider.
The nurse is working in a long-term care facility. When assessing her patients, what body system dysfunction should the nurse look for as the leading cause of morbidity and mortality in the older adult population?
Cardiovascular
The nurse is completing a postoperative assessment for a patient who has received a depolarizing neuromuscular blocking agent. The nursing assessment includes careful monitoring of which body system? Gastrointestinal system Cardiovascular system Endocrine system Genitourinary system
Cardiovascular system
The nurse is assessing a patient complaining of severe pain. What physiologic indicator does the nurse recognize as significant of acute pain? Decreased respiratory rate Bradycardia Hypotension Diaphoresis
Diaphoresis
Which of the following is the appropriate intervention to avoid physical withdrawal on drugs in a client? Administer subtherapeutic doses. Increase dosage of the drug. Discontinue drugs gradually. Administer adjuvant drugs along with the prescribed drug.
Discontinue drugs gradually.
While interviewing a patient, the nurse notices that the patient is wearing a medallion around his neck. The patient tells the nurse, "It's a medal that everyone in my family wears to protect against cancer." The nurse interprets this statement as most likely reflecting which of the following? Morality Religion Race Culture
Culture
Which medication classification must be assessed during the preoperative period because it can cause an electrolyte imbalance during surgery? Corticosteroids Diuretics Phenothiazines Insulin
Diuretics
Which route of administration of medication is preferred in the most acute care situations? Intravenous Intramuscular Epidural Subcutaneous
Intravenous
A nurse is providing client teaching about the body's plasma pH and the client asks the nurse what is the major chemical regulator of plasma pH. What is the best response by the nurse? renin-angiotensin-aldosterone system bicarbonate-carbonic acid buffer system sodium-potassium pump ADH-ANP buffer system
bicarbonate-carbonic acid buffer system
A client presents with anorexia, nausea and vomiting, deep bone pain, and constipation. The following are the client's laboratory values. sodium 137 mEq/L (137 mmol/L)potassium 4.6 mEq/L (4.6 mmol/L)chloride 94 mEq/L (94 mmol/L)calcium 12.9 mg/dL (3.2 mmol/L) What laboratory value is of highest concern to the nurse? sodium 137 mEq/L (137 mmol/L) chloride 94 mEq/L (94 mmol/L) potassium 4.6 mEq/L (4.6 mmol/L) calcium 12.9 mg/dL (3.2 mmol/L)
calcium 12.9 mg/dL (3.2 mmol/L)
The nurse assesses the patient notes a bounding pulse quality, neck vein distention when supine, presence of crackles in the lungs and increasing peripheral edema. What condition Fluid excess Fluid deficit Electrolyte imbalance Serum protein increase
Fluid excess
A client is complaining of pain 1 day after a colostomy. The nurse gives meperidine (demerol) I.M. and 30 minutes later finds the client's respiratory rate of 8 breaths/min, with the nasal cannula on the floor. ABG results are pH 7.23, PaO2 58 mmHg, PaCo 61 mmHg, HCO3 24 meq. Which group of factors contributes most to the clients ABG results? Colostomy, pain, and demerol Demerol, the nasal cannula on the floor, and the colostomy Demerol, RR of 8 per min, and nasal cannula on the floor Pain, RR of 8, and the nasal cannula on the floor
Respiratory acidosis Demerol, RR of 8 per min, and nasal cannula on the floor
A nurse is completing the intake record for a client with chronic pancreatitis. The client has. Had the following intake during the previous 8 hours. How many milliliters should the nurse record as the client's intake? 4 oz apple juice 1/2 cup fruit flavored gelatin 6 oz water 500 mL of .45% sodium chloride
920 mL
Your patient has hypercalcemia. Which of the following interventions would you include in the care plan? Monitoring for trousseau and chvsteks signs Auscultating lung sounds every 4 hours Encouraging fluid intake up to 4,000 mL every day Maintaining the patient in bed rest
Encouraging fluid intake up to 4,000 mL every day. Make sure they don't get renal stones
Your patient is receiving a 3% NaCl solution to correct hyponatremia. Which of the following assessments is the most important for the nurse doing the administration of this solution? Urinary output Lung sounds Peripheral pulses Peripheral edema
Lung sounds — crackles
Your patient has massive fluid loss. Which of the following is the greatest concern? Urine output is 30 mL over the last hour The blood pressure is 90/40 mmHg There is prolonged skin tenting over the sternum Oral fluid intake is 100 mL for the last 8 hours
The blood pressure is 90/40 mmHg
Which nursing intervention should a nurse perform when caring for a client who is prescribed opiate therapy for pain? Monitor blood counts and liver function tests Do not administer if respirations are less than 12 breaths per minute Avoid caffeine or other stimulants, such as decongestants Monitor weight, vital signs, and serum glucose concentration
Do not administer if respirations are less than 12 breaths per minute
Nursing assessment findings reveal a temperature of 96.2°F, pulse oximetry 90%, shivering, and client complains of chilling. The findings are indicative of which nursing diagnosis? Ineffective airway clearance Ineffective thermoregulation Decreased cardiac output Acute incisional pain
Ineffective thermoregulation
About which issue should the nurse inform clients who use pain medications on a regular basis? Inform the primary health care provider about the use of salicylates before any procedure, and avoid over-the-counter analgesics consistently without consulting a physician. Consume the medications just before or along with meals. Minimize fiber intake during the therapy. Avoid harsh sunlight for 2 hours after administering analgesic agents or salicylates.
Inform the primary health care provider about the use of salicylates before any procedure, and avoid over-the-counter analgesics consistently without consulting a physician.
A nursing student is preparing for a class presentation addressing the collaborative practice model. Which of the following would the student expect to include? A discussion of a centralized organizational structure Nurses and physicians playing major roles in clinical decisions Accountability that is primarily attributed to the patient Participation in decision making that is shared by all involved
Participation in decision making that is shared by all involved
A nursing student is preparing for a class presentation addressing the collaborative practice model. Which of the following would the student expect to include? Nurses and physicians playing major roles in clinical decisions Participation in decision making that is shared by all involved Accountability that is primarily attributed to the patient A discussion of a centralized organizational structure
Participation in decision making that is shared by all involved
Which of the following techniques least exhibits surgical asepsis? Suctioning the nasopharyngeal cavity of a client Keeping sterile gloved hands above the waist Placing the sterile field at least one foot away from personnel Adding only sterile items to a sterile field
Suctioning the nasopharyngeal cavity of a client
The nurse asks the client about a reddened area on the left arm. The client states that he was bitten by an insect, and it burned briefly. What type of pain does the nurse document this as? Superficial somatic pain Neuropathic pain Visceral pain Deeper somatic pain
Superficial somatic pain
A client was admitted to the hospital unit after 2 days of vomiting and diarrhea. The client's spouse became alarmed when the client demonstrated confusion and elevated temperature, and reported "dry mouth." The nurse suspects the client is experiencing which condition? hyperkalemia hypercalcemia dehydration hypervolemia
dehydration
A PACU nurse is caring for an older adult who presents with clinical manifestations of delirium. What short-term outcome would be most important for this client? experiences pain within tolerable limits. exhibits wound healing without complications. maintains adequate fluid status. resumes usual urinary elimination pattern.
experiences pain within tolerable limits.
A family of a patient with Alzheimer's disease asks the nurse what causes this condition? Which response by the nurse would be most appropriate? "Evidence shows that there are changes in nerve cells and brain chemicals." "This condition is most likely due to a stroke that the patient didn't realize he had." "The numerous drugs that he was taking contributed to his current confusion." "A specific gene is involved in the development of this disorder."
"Evidence shows that there are changes in nerve cells and brain chemicals."
An older adult female client tells the nurse, "I have lost an inch [2.5 cm] of height and have a hump on my back. What can I do about this?" What is the best response by the nurse? "In order to prevent further bone loss, eat a diet high in calcium and low in phosphorus." "You can reverse the shape of your spine with surgical intervention." "Supplement your diet with a multivitamin." "In order to prevent further bone loss, eat a diet high in magnesium and high in phosphorus."
"In order to prevent further bone loss, eat a diet high in calcium and low in phosphorus."
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." "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 should have begun working 30 minutes ago. I will call the doctor and let the doctor know you need something stronger."
"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."
A client with Alzheimer's disease is prescribed donepezil hydrochloride. When teaching the client and family about this drug, which of the following would the nurse include? "Once it becomes effective, you can stop the drug." "This drug will help to stop the disease from getting worse." "The drug helps to control the symptoms of the disease." "The client need to take this drug for the rest of his or her life."
"The drug helps to control the symptoms of the disease."
A nurse is caring for a client with dementia. A family member of the client asks what the most common cause of dementia is. Which response by the nurse is most appropriate? "Drug interactions are the most common cause of dementia in the elderly." "The most common cause of dementia in the elderly is Alzheimer's disease." "Dementia is a terrible disease of the elderly." "Depression may manifest as dementia in elderly clients."
"The most common cause of dementia in the elderly is Alzheimer's disease."
Which question is most important for the nurse to ask the client when obtaining the preoperative admission history? "Did you bring a copy of your health care power of attorney?" "Did you bring any valuables with you?" "Who is here with you?" "When is the last time you ate or drank?"
"When is the last time you ate or drank?"
A client is undergoing a lumbar puncture. The nurse educates the client about surgical positioning. Which statement by the nurse is appropriate? "You will be flat on your back with the table slanted so your head is below your feet." "You will be on your back with the head of the bed at 30 degrees." "You will be lying on your side with your knees to your chest." "You will be placed flat on the table, face down."
"You will be lying on your side with your knees to your chest."
The World Health Organization defines health as: "a state of complete physical, mental, and social well-being and not merely the absence of disease and infirmity." "reflecting an individual's location along a wellness--illness continuum." "a condition of homeostasis and adaptation." "a fluid, ever-changing balance reflected through physical, mental, and social behavior."
"a state of complete physical, mental, and social well-being and not merely the absence of disease and infirmity."
Two days after a colectomy, a patient's breath sounds are diminished and the vital signs are: T 100.2 F, respirations 24, pulse 104, and BP 136/84. Which nursing actions prevent post-operative complications? Select all The application of TED hose Encouraging the use of the incentive spirometer Increasing IV and oral fluids Encouraging the patient to turn, cough, and deep breathe Assisting the patient with all activities of daily living
- The application of TED hose - Encouraging the use of the incentive spirometer - Encouraging the client to turn, cough, and deep breath
For the client who is taking aspirin, it is important to stop taking this medication at least how many day(s) before surgery? 1 3 7 5
7
The nurse is preparing to discharge a client from the PACU using a PACU room scoring guide. With what score can the client be transferred out of the recovery room? 7 4 5 6
7
What is the blood glucose level goal for a diabetic client who will be having a surgical procedure? 300 to 350 mg/dL 80 to 110 mg/dL 150 to 240 mg/dL 250 to 300 mg/dL
80 to 110 mg/dL
The nurse expects informed consent to be obtained for insertion of: A nasogastric tube A gastrostomy tube An indwelling urinary catheter An intravenous catheter
A gastrostomy tube
A client is scheduled for a surgical procedure. When planning the client's care, the nurse should consider that which of the following conditions will increase the client's risk of complications after surgery? A history of chronic low back pain A history of sensitivity to aspirin A history of osteoarthritis A history of diabetes
A history of diabetes
Which of the following best describes the health-illness continuum? A person with high-level wellness is free of any disease or infirmity. A person on the continuum remains at the point based on his or her initial state of health. A person may be considered neither completely healthy or completely ill. A person with chronic illness is at the far end of the continuum reflecting illness.
A person may be considered neither completely healthy or completely ill.
A preoperative nurse prepares a patient for surgery, which nursing interventions are necessary actions that should be included in the plan of care (select all that apply) Maintain NPO status to prevent aspiration Verify the patient's signature on the consent prior to surgery Remove dentures and contact lenses prior to surgery Check the patient's allergy and blood bands for accuracy Verify the patient's mobility in all extremities prior to surgery A, B, C, D
A, B, C, D
Which of the following occurs during the inflammatory stage of wound healing? A.Blood clot forms B.Granulation tissue forms C.Fibroblasts leave wound D.Tensile strength increases
A.Blood clot forms
Acute pain can be distinguished from chronic pain by assessing which characteristic? Acute pain responds poorly to drug therapy. Chronic pain is symptomatic of primary injury. Chronic pain diminishes with healing. Acute pain is specific and localized.
Acute pain is specific and localized.
During an admission assessment, the nurse suspects that an older patient may be depressed. What should be the next action by the nurse? Ask the patient, "Are you depressed?" Document on the assessment, "The patient is depressed." Administer the Geriatric Depression Scale—Short Form. Notify the patient's physician as soon as possible.
Administer the Geriatric Depression Scale—Short Form.
A client is postoperative and has not taken her pain medication. The nurse is performing an assessment at the beginning of her shift and determines that sensitization has occurred. The first nursing intervention is to Provide alternative measures, such as a back rub, for pain relief. Medicate with naloxone (Narcan) for reversal of sensitization. Administer the prescribed intravenous opioid. Educate the client about notifying the nurse about pain before the pain becomes intense.
Administer the prescribed intravenous opioid.
A client refuses to remove her wedding band when preparing for surgery. What is the bestaction for the nurse to take? Discuss the risk for infection caused by wearing the ring. Allow the client to wear the ring and cover it with tape. Notify the surgeon to cancel surgery. Remove the ring once the client is sedated.
Allow the client to wear the ring and cover it with tape.
A patient is scheduled for a surgical procedure. For which surgical procedure should the nurse prepare an informed consent form for the surgeon to sign? Urethral catheterization Irrigation of the external ear canal An insertion of an intravenous catheter An open reduction of a fracture
An open reduction of a fracture
A chronic, unpleasant sensation that occurs due to disease affecting one or more body systems. An unpleasant sensation of physical hurt or discomfort that can be caused by disease, injury, or surgery. An unpleasant sensation that occurs due to malfunctioning of the nervous system. An unpleasant sensation created by emotional states such as fear, frustration, anger, or depression.
An unpleasant sensation of physical hurt or discomfort that can be caused by disease, injury, or surgery.
When applying a fentanyl patch, the last dose of sustained-release morphine should be administered at what point? At the same time the first patch is applied 1 hour before application There are no administration requirements 1 hour after application
At the same time the first patch is applied
A nursing instructor is preparing a class about age-related changes in the cardiovascular system that occur in the older adult. Which of the following would the instructor most likely include? Atrophy of the heart muscle Thinning of the heart valves Increased blood pressure Decreased arterial resistance
Atrophy of the heart muscle
A nurse is assessing an elderly client with senile dementia. Which neurotransmitter condition is most likely to contribute to this client's cognitive changes? Decreased norepinephrine level Increased acetylcholine level Decreased acetylcholine level Increased norepinephrine level
Decreased acetylcholine level
Your patient is admitted with hypovolemia and has multiple draining wounds. What is the most accurate assessment for this patient? Presence of edema Hourly urine output Skin turgor Daily weight
Daily weight
A 70-year-old patient who is to undergo surgery arrives at the operating room (OR). The nurse, when reviewing the patient's medical record, understands that this patient will require a lower dose of anesthetic agent because of which of the following? Impaired thermoregulation Increased tissue elasticity Decreased lean tissue mass Increased anxiety level
Decreased lean tissue mass
The nurse is caring for a 72-year-old client who has been admitted to the unit for a fluid volume imbalance. The nurse knows which of the following is the most common fluid imbalance in older adults? Fluid volume excess Hypovolemia Hypervolemia Dehydration
Dehydration
The nurse is instructing a patient diagnosed with hyperkalemia about foods to avoid. Which indicates a need for further teaching? I should avoid eating a lot of banana It will be nice to be able to eat fresh tomatoes this summer I will use salt substitutes instead of real salt No more avocado sandwhiches for me
I will use salt substitutes instead of real salt
A nurse reviews the results of an electrocardiogram (ECG) for a patient who is being assessed for hypokalemia. Which of the following would the nurse notice as the most significant diagnostic indicator? Peaked T wave Flat P wave Widened QRS wave Elevated U wave
Elevated U wave
Which substance reduces the transmission of pain? Substance P Endorphins Acetylcholine Serotonin
Endorphins
A client is receiving general anesthesia. The nurse anesthetist starts to administer the anesthesia. The client begins giggling and kicking her legs. What stage of anesthesia would the nurse document related to the findings? IV I II III
II
The primary nursing goal in the immediate postoperative period is maintenance of pulmonary function and prevention of laryngospasm
False - first part is true second part should by hypoxia
The most frequent early sign for a patient at risk for malignant hyperthermia is bradycardia. True or false
False - tachycardia
The nursing assessment of the postoperative client reveals an incision that is well-approximated with sutures intact, minimal redness and edema, and absence of drainage. The nurse recognizes the wound is healing by: First intention Second intention Granulation Third intention
First intention
The nurse concludes that a patient understands the side effects of furosemide (lasix) and its relationship to potassium levels when the patient makes which statement? I do not need to take my pulse anymore when I take digoxin I should call my doctor If I have digoxin I should call my doctor if I Feel myself becoming dizzy when I stand up I so not need to eat bananas for breakfast anymore because I am taking this medication
I should call my doctor if I Feel myself becoming dizzy when I stand up
Nursing students are reviewing information about agents used for anesthesia. The students demonstrate understanding when they identify which of the following as an inhalation anesthetic? Succinylcholine Propofol Halothane Fentanyl
Halothane
The nurse is preparing to administer a premedication. Which of the following actions should the nurse take first? Have the family present Ensure that the preoperative shave is complete Have the patient void Make sure the patient is covered with a warm blanket
Have the patient void
Which action should be incorporated into the client teaching plan to prevent deep vein thrombosis? Fluid restriction Use of blanket rolls to elevate the lower extremities Hourly leg exercises Prolonged dangling of the legs over the edge of the bed
Hourly leg exercises
Following a bowel resection surgery, a patient's magnesium level is 1.0 which assessment finding should the nurse report to the physician immediately? Hyperactive reflexes Nausea Anorexia Abdominal pain
Hyperactive reflexes
The patient is talking to the nurse about sodium intake. Which statement by the patient indicates an understanding of high sodium foods? I love bacon and eggs We never eat seafood because of the salt water I love Chinese food but I gave it up because of the soy sauce
I love Chinese food but I gave it up because of the soy sauce
The nurse educator is planning a teaching session for nursing students related to the treatment and management of gestational diabetes. The nurse educator arranges for a dietitian, pharmacist, and physician assistant to participate in the lesson plan. Which professional nurse competency is the nurse educator demonstrating? Interdisciplinary teamwork Patient-centered care Evidence-based practice Quality improvement measures
Interdisciplinary teamwork
The nurse is caring for a geriatric client in the home setting. Due to geriatric changes decreasing thirst, the nurse is likely to see a decrease in which fluid location which contains the most body water? Extracellular fluid Intracellular fluid Interstitial fluid Intravascular fluid
Intracellular fluid
A physician orders an isotonic I.V. solution for a client. Which solution should the nurse plan to administer? 10% dextrose in water 5% dextrose and normal saline solution Lactated Ringer's solution Half-normal saline solution
Lactated Ringer's solution
A client hospitalized for treatment of a pulmonary embolism develops respiratory alkalosis. Which clinical findings commonly accompany respiratory alkalosis? Hallucinations or tinnitus Headache or blurry vision Light-headedness or paresthesia Abdominal pain or diarrhea
Light-headedness or paresthesia
A client is undergoing a perineal surgical procedure. The nurse should place the client in which position? Lithotomy Trendelenburg Sims Dorsal recumbent
Lithotomy
Thirty six hours postoperatively, a patient has a temperature of 100 degrees F. What is the most likely cause of this finding? Dehydration Wound infection Lung congestion and atelectasis The normal surgical stress response
Lung congestion and atelectasis
Through which route are general anesthetics primarily eliminated? Kidneys Liver Lungs Skin
Lungs
The nurse is caring for a client with multiple organ failure and in metabolic acidosis. Which pair of organs is responsible for regulatory processes and compensation? Kidney and liver Lungs and kidney Pancreas and stomach Heart and lungs
Lungs and kidney
During surgery, a patient has a nursing diagnosis of risk for perioperative positioning injury. Which of the following is a common risk factor for this diagnosis? Skin lesions Break in sterile technique Musculoskeletal deformities Electrical or mechanical equipment failure
Musculoskeletal deformities
A client, who had an above the knee amputation of the left leg related to peripheral vascular disease from uncontrolled diabetes, complains of pain in the left lower extremity. What type of pain is the client experiencing? Referred pain Visceral pain Neuropathic pain Breakthrough pain
Neuropathic pain
A client is scheduled for a cholecystectomy. Which finding by the nurse is least likely to contribute to surgical complications? Urinary tract infection Osteoporosis Pregnancy Diabetes
Osteoporosis
A nurse is monitoring a client recovering from moderate sedation that was administered during a colonoscopy. Which finding requires the nurse's immediate attention? Oxygen saturation (SaO2) of 85% Heart rate of 84 beats/minute Blood-tinged stools Decreased cough and gag reflexes
Oxygen saturation (SaO2) of 85%
A client is experiencing anorexia related to the adverse effects of cancer treatment. Using Maslow's hierarchy, the nurse identifies this as a reflection of which need? Physiologic needs Esteem and self-respect Belongingness and affection Safety and security
Physiologic needs
During the surgical procedure, the client's temperature falls to 96.6°F. Which of the following nursing actions is inappropriate? Remove wet gowns and drapes. Place a cooling blanket under the client. Increase the temperature of the OR environment. Warm IV and irrigating fluids.
Place a cooling blanket under the client.
A nurse is caring for a client in the PACU after surgery requiring general anesthesia. The client tells the nurse, "I think I'm going to be sick." What is the primary action taken by the nurse? Position the client in the side-lying position. Obtain an emesis basin. Administer an anti-emetic. Ask the client for more clarification.
Position the client in the side-lying position.
A scrub nurse is diagnosed with a skin infection to the right forearm. What is the priorityaction by the nurse? Request a role change to circulating nurse. Return to work after taking antibiotics for 24 hours. Ensure the infection is covered with a dressing. Report the infection to an immediate supervisor.
Report the infection to an immediate supervisor.
A nurse is preparing a health promotion class for a group of seniors at a local community center. As one part of the presentation, the nurse is planning to address sexuality and sexual function. Which statement would be least appropriate to include? It might take longer to complete sexual intercourse. Response to sexual stimulation may be less intense. Sexual arousal may take longer to occur. Sexual desire typically becomes progressively less.
Sexual desire typically becomes progressively less.
Which of the following electrolytes is the primary determinant of extracellular fluid (ECF) osmolality? Magnesium Calcium Sodium Potassium
Sodium
There are four stages of general anesthesia. Select the stage during which the OR nurse knows not to touch the patient (except for safety reasons) because of possible uncontrolled movements. Stage II: excitement Stage III: surgical anesthesia Stage IV: medullary depression Stage I: beginning anesthesia
Stage II: excitement
Which clinical manifestation is often the earliest sign of malignant hyperthermia? Tachycardia (heart rate >150 beats per minute) Oliguria Hypotension Elevated temperature
Tachycardia (heart rate >150 beats per minute)
A nursing assessment's findings reveal a postoperative client has a temperature of 96.2 °F (35.7 °C), shivering, and reports feeling cold. What does the nurse conclude about the client? The client is experiencing hypothermia. The client is beginning to develop pneumonia. The client is experiencing atelectasis. The client is having pain at the surgical site.
The client is experiencing hypothermia.
A client is scheduled for a prostatectomy, and the anesthesiologist plans to use a spinal (subarachnoid) block during surgery. In the operating room, the nurse positions the client according to the anesthesiologist's instructions. Why does the client require special positioning for this type of anesthesia? To prevent cerebrospinal fluid (CSF) leakage To prevent confusion To prevent cardiac arrhythmias To prevent seizures
To prevent cerebrospinal fluid (CSF) leakage
The primary goal in withholding food before surgery is to prevent aspiration True or false
True
A nurse is teaching a client with chronic bronchitis about breathing exercises. Which instruction should the nurse include in the teaching? Use chest breathing. Make inhalation longer than exhalation. Exhale through an open mouth. Use diaphragmatic breathing.
Use diaphragmatic breathing.
The nurse would identify which vitamin deficiency to prevent hemorrhaging during surgery? Magnesium Vitamin K Vitamin A Zinc
Vitamin K
A nurse is caring for a client with obesity and diabetes after abdominal surgery. What is the client at increased risk for? Phlebitis Contractures Wound dehiscence Hypotension
Wound dehiscence
The nurse's assessment of a postop client reveals a temperature of 103.2°F, tachycardia, and client complaints of increased incisional pain. What does the nurse recognize that this client is experiencing? Uncontrolled pain Hyperthermia Wound infection Atelectasis
Wound infection
An age-related change associated with the cardiovascular system is decreased blood pressure. increased compliance of heart muscle. decreased cardiac output. thinner heart valves.
decreased cardiac output.
The nurse recognizes older adults require lower doses of anesthetic agents due to: decreased bone mass. increased liver mass. increased tissue elasticity. decreased lean tissue mass.
decreased lean tissue mass.
The nurse recognizes that the older adult is at risk for surgical complications due to: increased cardiac output increased skeletal mass decreased adipose tissue decreased renal function
decreased renal function
A nurse is caring for an elderly adult client admitted to the hospital from a nursing home because of a change in behavior. The client has a diagnosis of Alzheimer's disease and has started to experience episodes of incontinence. The hospital staff is having difficulty with toileting because the client wanders around the unit all day. To assist with elimination, a nurse should: ask the physician to order restraints to prevent wandering. ask the physician to order sedation to allow the client to rest. incorporate the client's toileting schedule into the pattern of his wandering. have the client wear two briefs at a time to ensure absorption of incontinent urine.
incorporate the client's toileting schedule into the pattern of his wandering.
The nurse understands that the purpose of the "time out" is to: identify the client's allergies. clarify the roles of the OR personnel. verify all necessary supplies are available. maintain the safety of the client.
maintain the safety of the client.
The primary objective in the immediate postoperative period is controlling nausea and vomiting. maintaining pulmonary ventilation. relieving pain. monitoring for hypotension.
maintaining pulmonary ventilation.
A client has a long history of diabetes mellitus and developed diabetic neuropathy more than 25 years ago. The client is without breakthrough pain at this point in time. How would this client's pain be classified? nociceptive and acute neuropathic and chronic neuropathic and acute nociceptive and chronic
neuropathic and chronic
The client is experiencing nausea and vomiting following surgery. What will the nurse expect the surgeon to order? chlorpromazine ondansetron nizatidine omeprazole
ondansetron
Hypothermia may occur as a result of increased muscle activity. being young. open body wounds. the infusion of warm fluids.
open body wounds.
A client is admitted with generalized abdominal pain, nausea, vomiting, and hypotension. The client has not passed stool in over 1 week and has been in pain for the past 4 days. Which type of pain would you expect the client to be experiencing? chronic deeper somatic visceral neuropathic
visceral