Adult 1 Final: Test 1
"The nurse is caring for a 78-year-old female patient who is scheduled for surgery to remove her brain tumor. The patient is very apprehensive and keeps asking when she will get her preoperative medicine. The medicine is ordered to be given on call to OR. When would be the best time to give this medication?"
"After being notified by the OR and before any other preoperative preparations"
"The nurse is admitting a patient to the medical surgical unit from the PACU. What should the nurse do to help the patient clear secretions and help prevent pneumonia?"
"Encourage the patient to use the incentive spirometer every 2 hours."
"One day after a patient is admitted to the medical unit, you note that the patient is oliguric. You notify the acute-care nurse practitioner who orders a fluid challenge of 200 mL of normal saline solution over 15 minutes. This intervention will achieve which of the following?"
"Help distinguish reduced renal blood flow from decreased renal function" Test kidney function, give fluid (100-200 mL NS) to see if there is increased U/O, BP and CVP (normal kidney function)
"The nurse admits a patient to the PACU with a blood pressure of 132/90 mm Hg and a pulse of 68 beats per minute. After 30 minutes, the patients blood pressure is 94/47 mm Hg, and the pulse is 110. The nurse documents that the patients skin is cold, moist, and pale. Of what is the patient showing signs?"
"Hypovolemic shock"
"A nurse is caring for a patient following knee surgery that was performed under a spinal anesthetic. What intervention should the nurse implement to prevent a spinal headache?"
"Keep the patient positioned supine"
"A patient has questioned the nurses administration of IV normal saline, asking whether sterile water would be a more appropriate choice than saltwater. Under what circumstances would the nurse administer electrolyte-free water intravenously?"
"Never, because it rapidly enters red blood cells, causing them to rupture"
"The nurse is caring for a patient on the medical surgical unit postoperative day 5. During each patient assessment, the nurse evaluates the patient for infection. Which of the following would be most indicative of infection?"
"Red, warm, tender incision"
"The ED nurse is caring for an 11-year-old brought in my ambulance after having been hit by a car. The childs parents are thought to be en route to the hospital but have not yet arrived. No other family members are present and attempts to contact the parents have been unsuccessful. The child needs emergency surgery to save her life. How should the need for informed consent be addressed?"
"Surgery should be done without informed consent."
"The OR nurse is taking the patient into the OR when the patient informs the operating nurse that his grandmother spiked a 104F temp in the OR and nearly died 15 years ago. What relevance does this information have regarding the patient?"
"The patient may be at risk for malignant hyperthermia"
"The nurse in the ED is caring for a man who has returned to the ED 4 days after receiving stitches for a knife wound is now infected, so the stitches were removed, and the wound is cleaned and packed with gauze. The ED doctor plans to have the man return tomorrow to remove the packing and restore the wound. You are aware that the wound will now heal by what means?"
"Third intention"
"The PACU nurse is caring for a patient who has arrived from the OR. During the initial assessment, the nurse observes that the patients skin has become blue and dusky. The nurse looks, listens, and feels for breathing, and determines the patient is not breathing. What is the priority intervention?"
"Treat the possible airway obstruction by tilting the head back and pushing forward on the angle of the lower jaw."
"A patient is admitted to the ED complaining of severe abdominal pain, stating that he has been vomiting coffee-ground like emesis. The patient is diagnosed with a perforated gastric ulcer and is informed that he needs surgery. When can the patient most likely anticipate that the surgery will be scheduled?"
"Without delay because the bleed is emergent"
Hypoxemia, blood loss, and electrolyte imbalances can look like confusion and restlessness
All other possibilities must be ruled out before old people are diagnosed with confusion
I think was a test question: A gerontologic nurse is teaching students about the high incidence and prevalence of dehydration in older adults. What factors contribute to this phenomenon? Select all that apply
Decreased kidney mass Decreased renal blood flow Decreased excretion of potassium
Family is using pushing pump
Don't let them
The nurse is doing a preoperative assessment of an 87-year-old man who is slated to have a right lung lobe resection to treat lung cancer. What underlying principle should guide the nurses preoperative assessment of an elderly patient?
Elderly patients have less physiologic reserve than younger patients
Venous stasis
Encourage exercise to prevent after surgery
"The OR nurse is participating in the appendectomy of a 20 year-old female who has a dangerously low body mass index. The nurse recognizes the patients consequent risk for hypothermia. What action should the nurse implement to prevent the development of hypothermia?"
Ensure that IV fluids are warmed to the patients body temperature
" Not sure if a test question You are the nurse caring for a patient who is to receive IV daunorubicin, a chemotherapeutic agent. You start the infusion and check the insertion site as per protocol. During your most recent check, you note that the IV has infiltrated so you stop the infusion. What is your main concern with this infiltration?"
Extravasation of the medication
You are caring for a patient who has a diagnosis of syndrome of inappropriate antidiuretic hormone secretion (SIADH). Your parents plan of care includes assessment of specific gravity every 4 hours. The results of this test will allow the nurse to assess what aspect of the patients health?
Fluid volume status Causes fluid retention
Kidneys excrete/retain ?; lungs retain/excrete ?
H+; C02
Urine specific gravity Is 1.010-1.025
High is dehydrated Measures kidney's ability to excrete/conserve H20
The nurse is assessing the patient for presence of a Chvostek's sign. What electrolyte imbalance would a positive Chvostek's sign indicate?
Hypocalcemia
There was also a question on the T sign,
Hypocalcemia
"You are working on a burns unit and one of your acutely ill patients is exhibiting signs and symptoms of third spacing. Based on this change in status, you should expect the patient to exhibit signs and symptoms of what imbalance?"
Hypovolemia
ADH
If elevated=hyponatremia
Anesthesia awareness; obvious signs
Increase in BP, rapid HR, pt movement
"The nurse is creating the care plan for a 70-year-old obese patient who has been admitted to the postsurgical unit following a colon resection. This patients age and increased body mass index mean that she is at increased risk for what complication in the postoperative period?"
Infection
The clinic nurse is doing a preoperative assessment of a patient who will be undergoing outpatient cataract surgery with lens implantation in 1 week. While taking the patient's medical history, the nurse notes that this patient had a kidney transplant 8 years ago and that the patient is taking immunosuppressive drugs. For what is this patient at increased risk when having surgery?
Infection
Stomach upset, baking soda
Metabolic alkalosis
Old person comes in w/renal issues, something about K+
Monitor the ECG
"A patient is 2 hours postoperative with a Foley catheter in situ. The last hourly urine output recorded for this patient was 10 mL. The tubing of the Foley is patent. What should the nurse do?"
Notify the physician and continue to monitor the hourly urine output closely
"During the care of a preoperative patient, the nurse has given the patient a preoperative benzodiazepine. The patient is now requesting to void. What action should the nurse take?"
Offer the patient a bedpan or urinal.
Not sure if a test question: The nurse is caring for a hospice patient who is scheduled for a surgical procedure to reduce the size of his spinal tumor in an effort to relieve his pain. The nurse should plan this patient care with the knowledge that his surgical procedure is classified as which of the following?
Palliative
Old people have slower recovery from anesthesia due to reduced kidney function (filtration)
Post op confusion and delirium Fall risk
"The nurse is discharging a patient home from an outpatient surgery center. The nurse has reviewed all of the discharge instructions with the patient and her caregiver. What else should the nurse do before discharging the patient from the facility? Select all that apply."
Provide all discharge instructions in writing Provide the nurses or surgeons contact information Give prescriptions to the patient
"A postoperative patient rapidly present with hypotension; rapid, thread pulse; oliguria, and cold, pale skin. The nurse suspects that the patient is experiencing a hemorrhage. What should be nurses first action?"
Quickly attempt to determine the cause of hemorrhage.
A patient with a longstanding diagnosis of generalized anxiety disorder presents to the emergency room. The triage nurse notes upon assessment that the patient is hyperventilating. The triage nurse is aware that hyperventilation is the most common cause of which acidbase imbalance?
Respiratory Alkalosis: brown paper bag
I think this was a test question: The surgical patient is a 35-year-old woman who has been administered general anesthesia. The nurse recognizes that the patient is in stage II (the excitement stage) of anesthesia. Which intervention would be most appropriate for the nurse to implement during this stage?
Restrain the patient
Not sure if a test question: A 90-year-old female patient is scheduled to undergo a partial mastectomy for the treatment of breast cancer. What nursing diagnosis should the nurse prioritize when planning this patients postoperative care?
Risk for Infection related to reduced immune function
"A surgical patient has been in the PACU for the past 3 hours. What are the determining factors for the patient to be discharged from the PACU? Select all that apply."
Stable blood pressure Sufficient oxygen saturation Adequate respiratory function
The nurse is caring for a 78-year-old man who ahs had an outpatient cholecystectomy. The nurse is getting him up for his first walk postoperatively. To decrease the potential for orthostatic hypotension and consequent falls, what should the nurse have the patient do?
Stand upright for 2 to 3 minutes prior to ambulating
Possibly "pt has SOB w/hypervolemia" Possibly: "overhydrated pt lung sounds"
Stop IV infusion Crackles
Not sure if a test question: The perioperative nurse is constantly assessing the surgical patient for signs and symptoms of complications of surgery. Which symptom should first signal to the nurse the possibility that the patient is developing malignant hyperthermia?
Tachycardia
Not sure if a test question: A medical nurse educator is reviewing a patients recent episode of metabolic acidosis with members of the nursing staff. What should the educator describe about the role of the kidneys in metabolic acidosis?
The kidneys excrete hydrogen ions and conserve bicarbonate ions to help restore balance
The dressing surrounding a mastectomy patients Jackson-Pratt drain has scant drainage on it. The nurse believes that the amount of drainage on the dressing may be increasing. How can the nurse best confirm this suspicion?
Trace the outline of the drainage on the dressing for future comparison
BNP? Pt is hip surgery, why BNP?
Ventricles stretched
Not sure if a test questions: The nurse is caring for a trauma victim in the ED who will require emergency surgery due to injuries. Before the patient leaves the ED for the OR, the patient goes into cardiac arrest. The nurse assists in the successful resuscitation and proceeds to release the patient to the OR staff. When can the ED nurse perform the preoperative assessment?
When assisting with the resuscitation
Hyponatremia
cold clammy skin
ATP is needed for ?
energy, active transport, and requires phosphorus
Organ transplant question
make sure patient is taking immunosuppressants