EAQS - Med Surg

A patient with diabetes is admitted for a prostatectomy. The patient will receive an antibiotic 60 minutes prior to the surgery, their usual dose of insulin, and etomidate IV for anesthesia. Considering the patient's diabetes, the nurse expects that which component of the preoperative plan will be revised?

The dosage of insulin used to regulate the patient's glucose levels Etomidate is an intravenous anesthetic agent. It is a nonbarbiturate hypnotic and can cause hypoglycemia. Therefore the nurse should consider revising the dosage of insulin with the surgeon to prevent hypoglycemia. It is not appropriate to change the route of administration of etomidate, because it is an IV drug. Changing the drug or omitting administration of the antibiotic is not advised. Antibiotics are administered 30 to 60 minutes prior to surgery to reduce the incidence of postoperative infections.

A patient has been admitted to the postanesthesia care unit (PACU). Which of these assessment findings require the nurse's immediate action?

The patient is restless, agitated, and hypotensive. Assessment in the PACU begins with evaluation of the airway, breathing, and circulation (ABC) status of the patient. Restlessness, agitation, and hypotension are clinical manifestations of inadequate oxygenation. Identification of inadequate oxygenation and ventilation or respiratory compromise requires prompt intervention. Pain, sedation, and draining serosanguinous fluid are expected findings.

A patient with an abdominal mass is scheduled for surgery today. Before the patient is admitted to the operating room, which preoperative documentation must be attached to the chart?

a complete physical exam It is essential that a physical examination report be attached to the chart of a patient going into surgery. This document explains in detail the overall status of the patient for the surgeon and other members of the surgical team. Laboratory test findings, SOAP notes, and electrocardiograms also may be included in the chart; however, the physical examination must always be completed and in the chart before surgery.

The nurse is assessing the fluid balance of a patient being treated for heart failure. Which indicator is the best measure of fluid volume status?

daily weighing Measuring body weight daily is the most accurate measure of fluid volume status. Skin turgor, intake and output, and BUN, sodium, and hematocrit levels are also indicators of fluid volume status, but these are not as accurate or helpful in gaining information as is daily weighing.

A patient is admitted with alcohol abuse. Laboratory data reveals a phosphate level of 1.8 mg/dL. Which assessment finding is consistent with this data?

weakness Signs of hypophosphatemia include weakness, confusion, coma, and diminished reflexes. Seizure activity, diarrhea, and tetany are not associated with this electrolyte imbalance.

The nurse is caring for a patient admitted with an exacerbation of asthma. After several treatments, the arterial blood gas (ABG) results are pH 7.40, PaCO 2 40 mm Hg, HCO 3 24 mEq/L, PaO 2 92 mm Hg, and O 2 saturation 99%. What does the nurse interpret these findings to indicate?

within normal limits The normal pH is 7.35 to 7.45. Normal PaCO 2 levels are 35 to 45 mm Hg, and normal HCO 3 levels are 22 to 26 mEq/L. A normal PaO 2 level is greater than 80 mm Hg. Normal oxygen saturation is greater than 95%. Because the patient's results all fall within these normal ranges, the nurse can conclude that the patient's blood gas results are within normal limits.

A patient has a prescription to receive 0.9% sodium chloride (normal saline) intravenously (IV) at a rate of 100 mL per hour. The current bag of 1000 mL was hung at 1000. When making rounds at 1300, the nurse notes that the IV bag contains 900 mL of normal saline. How would the nurse document this incident report?

wrong rate After three hours of infusion time, 300 mL of IV solution should have infused, but the patient has received 100 mL. Therefore the patient has received the wrong rate. The solution, route, and documentation are correct.

A nurse is completing an assessment on a patient with suspected fluid volume excess. Which cardiovascular changes would support this diagnosis?

-Full, bounding pulse - Distended neck veins - Presence of an S3 heart sound Fluid volume excess results in a full, bounding pulse, presence of an S3 heart sound, and jugular venous distention (distended neck veins). Orthostatic hypotension and an increased heart rate are clinical manifestations of deficient, not excess, fluid volume.

A patient has difficulty passing urine after surgery for the correction of rectal prolapse. How should the nurse help this patient void?

-Pour warm water over perineum. -Reassure the patient of the ability to void. -Help the patient to attain a normal voiding position. Following pelvic surgeries, the patient may experience difficulty voiding. Pouring warm water over the perineum stimulates micturition. Reassuring the patient of his ability to void helps him relax and promotes voiding. Patients feel comfortable voiding in a natural voiding position, so the nurse should help the patient attain that position. Early catheterization should be avoided because of the risk of urinary infection. Immobility and rest impair the voiding ability.

A patient with a history of venous thrombosis had major abdominal surgery. Which nursing interventions are helpful in preventing the development of venous thrombosis?

-Use of dalteparin -Sequential compression devices Dalteparin is an anticoagulant that may be used as prophylactic agent to prevent development of venous thrombosis. Sequential compression devices also help prevent development of venous thrombosis by promoting venous return. Diuretics help remove excess fluid from the body; however, they do not help prevent thromboembolism. Corticosteroids suppress the immune response but have no effect on blood clotting. Late ambulation is a risk factor for venous thrombosis.

The patient had surgery at an ambulatory surgery center. Which criteria support that this patient is ready for discharge?

-Vital signs baseline or stable - Minimal nausea and vomiting -Responsible adult taking patient home Ambulatory surgery discharge criteria include meeting Phase I postanesthesia care unit (PACU) discharge criteria, which include vital signs baseline or stable and minimal nausea and vomiting. Phase II criteria include a responsible adult driving patient, no IV opioid drugs for the last 30 minutes, ability to void, ability to ambulate if not contraindicated, and receiving written discharge instruction, with patient understanding confirmed.

A patient's blood pressure increases from 110/76 mm Hg to 160/90 mm Hg two hours after a cholecystectomy. What action should the nurse take first?

Assess pain level. Treatment for hypertension focuses on the source of the problem. Pain often causes a rise in blood pressure. If a patient becomes hypertensive, the nurse should begin with assessing and treating the pain. Repositioning will not lower the blood pressure. Per prescription of the primary health care provider, decreasing the IV fluid and administering an antihypertensive medication may be appropriate but are not the first nursing interventions.

The nurse has received a patient from surgery in the postanesthesia care unit (PACU). What is the best way for the nurse to ensure that this patient has a patent airway?

By putting in an artificial airway By tilting the head and thrusting the jaw The physical repositioning of a patient to reestablish the patency of the airway involves tilting the head and thrusting the jaw. If the physical repositioning does not help, the patient may need an artificial airway to assist in breathing. Suctioning is helpful for patients with increased secretions; it may not help a patient with an airway obstruction. Oxygen therapy does not help unless the airway is patent. Sedatives would worsen the airway prolapse.

The nurse is preparing to administer a dose of potassium phosphate. What laboratory finding would indicate that the nurse should withhold the medication?

Calcium 6.4 mg/dL Phosphorus and calcium have inverse or reciprocal relationships, meaning that when calcium levels are high, phosphorus levels tend to be low. Therefore administration of phosphorus will reduce a patient's already abnormally low calcium level, which can result in life-threatening complications. Potassium phosphate will not have any effect on sodium, magnesium, or potassium levels.

Which member of the intraoperative team remains in the unsterile field?

Circulating nurse The circulating nurse is not gowned and gloved and handles unsterile activities in the unsterile field during the intraoperative period. The scrub nurse is gowned and gloved and remains in the sterile field. The surgeon's assistant and registered nurse first assistant may handle and prepare surgical instruments and therefore remain in the sterile field during the intraoperative period.

The nurse is educating a patient that had a coronary bypass graft (CABG) about the risk of venous thromboembolism (VTE). What should the nurse be sure to include in the education to the patient?

Early ambulation Activity has proven vital in helping to prevent postoperative VTEs. Other forms of treatment include anticoagulants and sequential compression devices (SCDs). Splinting the chest while coughing, taking pain medication, and turning every 2 hours are important for the recovery of the coronary bypass patient but have little impact on preventing VTE. p. 337

The nurse is caring for a patient after having an exploratory laparotomy that is experiencing postoperative nausea and vomiting. What medication does the nurse prepare to administer to the patient to alleviate these symptoms?

Ondansetron Ondansetron is an antiemetic, whereas midazolam is a benzodiazepine, and fentanyl and meperidine are opioid analgesics.

The nurse is monitoring a patient who is about to be transferred to the clinical unit from the postanesthesia care unit (PACU). Which assessment data require the most immediate attention?

Pulse rate 128 beats/minute The most important aspect of the cardiovascular assessment is frequent monitoring of vital signs. They usually are monitored every 15 minutes in Phase I, or more often until stabilized, and then at less frequent intervals in Phase II. Notify the anesthesia care provider (ACP) or the health care provider if the pulse rate is less than 60 beats/minute or greater than 120 beats/minute. The oxygen saturation should be above 90%, so 94% is good. A respiratory rate of 13 is normal. A temperature of 99.8 is expected.

The nurse is monitoring a patient with hyperkalemia. Which conditions should the nurse conclude may cause this condition?

Renal failure Adrenal Insufficiency Hyperkalemia is a condition in which there is an abnormal increase of potassium in the blood. Renal failure may cause hyperkalemia, because the kidneys cannot remove potassium from the body. Adrenal insufficiency causes aldosterone deficiency, which leads to the retention of potassium ions and also may result in hyperkalemia. Alkalosis is seen in hypocalcemia. Low blood volume and a large urine volume can result in hypokalemia.

The nurse is teaching a caregiver for an older adult patient with dementia about fluid balance maintenance at home. Which statement made by the caregiver indicates that he or she requires further education?

"I should provide fluids when the patient feels thirsty." Mental status alterations are a common problem in old age and may lead to decreased ability to express thirst and obtain fluids. Therefore older patients are always encouraged to drink fluids and also to decrease dietary sodium in the diet. Musculoskeletal changes such as stiffness of the hands and fingers may lead to an inability to hold containers. The patient should make a habit of urinating before bed to decrease the chance of nocturia.

Which phosphate level would the nurse be likely to find in the patient who has alcohol withdrawal symptoms?

1.4 mg/dL Alcohol withdrawal can result in hypophosphatemia. Phosphate levels of less than 2.4 mg/dL indicate hypophosphatemia. The nurse would be likely to find the patient's phosphate level at 1.4 mg/dL. Phosphate levels of 2.4, 3.8, and 4.8 mg/dL indicate hyperphosphatemia. The patient with symptoms of alcohol withdrawal does not have hyperphosphatemia.

The nurse is preparing to administer cefazolin 2 gm in 100 mL of normal saline to a postoperative patient. What infusion rate on the infusion pump will infuse this medication over 20 minutes? Record your answer using a whole number. mL/hr

300 mL/hr Volume ÷ time in hours = rate in mL/hr. Therefore, 100 mL ÷ 0.33 hr (20 min) = 300 mL/hr.

When caring for older patients, the nurse should watch for signs of dehydration due to decreased fluid intake. Which factors contribute to dehydration in older patients?

Disorientation and confusion Inability to hold a cup or glass Decrease in thirst mechanisms Some older adults experience mental changes including confusion and disorientation, which may lead to a decrease in fluid intake. In addition, older adults may also have musculoskeletal disabilities, such as stiffness of the hands, which make it difficult for them to hold a cup or glass. Older adults may have decreased thirst mechanisms; therefore they may not feel like drinking water even if they dehydrated and have increased osmolality and serum sodium levels. Fear of bloating and decreased taste sensation do not affect intake of fluid.

The nurse is administering regular insulin intravenously to a patient with moderate hyperkalemia. Which additional intravenous medication will the nurse administer to the patient?

Glucose While administering regular insulin intravenously to a hyperkalemic patient to help force potassium from extracellular fluid to intracellular fluid, the nurse also administers glucose to prevent hypoglycemia. Furosemide is administered if the patient has hypermagnesemia. Pamidronate is administered if the patient has hypercalcemia. Calcium gluconate is administered to treat hypocalcemia.

A patient is having elective cosmetic surgery performed on the face. The patient will remain at the surgery center for 24 hours after surgery. What is the nurse's postoperative priority for this patient?

Manage oxygenatation status The nurse's priority is to manage the patient's oxygenation status by maintaining an airway and ventilation. With surgery on the face, there may be swelling that could compromise the patient's ability to breathe. Pain, bleeding, and fluid imbalance from the surgery may increase the risk for upper airway edema, causing airway obstruction and respiratory suppression, which also indicate managing oxygenation status as the priority.

When reviewing the preoperative forms, the nurse notices that the informed consent form is not signed. What is the best action for the nurse to take?

Notify the health care provider to obtain consent for surgery. The informed consent for the surgery must be obtained by the health care provider. The nurse can witness the signature on the consent form and verify that the patient (or caregiver if patient is a minor, unconscious, or mentally incompetent to sign) understands the informed consent. Verbal consents are not enough. The state's nurse practice act and agency policies must be followed.

Upon assessment of laboratory data, the nurse notes a calcium level of 6.4 mg/dL. Which physical assessment finding is consistent with this data?

Paresthesias Signs of hypocalcemia include paresthesias, tetany, and muscle weakness. Bone pain, diminished reflexes, and polyuria are signs of hypercalcemia.

The nurse caring for a postoperative patient assesses clinical manifestations of early pulmonary edema secondary to heart failure. What manifestations does the nurse determine correlates with this disorder?

Paroxysmal nocturnal dyspnea The most common cause of pulmonary edema is left-sided congestive heart failure, which commonly manifests as shortness of breath and crackles in the lungs. Between the two, shortness of breath in the form of paroxysmal nocturnal dyspnea is the earlier symptom, although crackles are more common. An early-morning cough may be seen with respiratory infection or chronic obstructive pulmonary disease but is not usually a symptom of pulmonary edema. In pulmonary edema, urine output is typically decreased due to fluid retention. Crackles heard on auscultation of the lungs are one of the more common symptoms of pulmonary edema, along with coughing of frothy pink-tinged sputum.

The nurse is caring for four patients. Based upon the patient charts, which patient would the nurse suspect has developed a fluid volume deficit?

Patient A DI restlessness, decreased skin turgor & cap refill, urine specific gravity of 1.037 The clinical manifestations of fluid volume depletion include restlessness, decreased skin turgor, decreased capillary refill, and concentrated urine and can be caused by diabetes insipidus, so Patient A is correct. Heart failure - as in Patient B - can be a cause of fluid volume excess, not deficit. Heatstroke - as in Patient C - can be a cause of fluid volume deficit, however in this case the urine specific gravity is within normal limits, and flushed skin, nausea, and vomiting are signs of heatstroke. SIADH - as in Patient D - can be a cause of fluid volume excess, not deficit.

A patient has been admitted for dehydration. What is a priority nursing intervention?

Perform daily weights. Measuring weight is the most reliable means of detecting changes in fluid balance. Weight loss would indicate that the dehydration is worsening, whereas weight gain would indicate restoration of fluid volume. The nurse would recall that a 1-kg weight gain indicates a gain of approximately 1000 mL of body water. This patient is not disoriented, and that is not a common assessment finding in the patient with dehydration. Continuous oxygen saturation monitoring is not indicated. Sodium intake does not need to be restricted.

The nurse is documenting a patient's skin turgor assessment. After pinching a fold of skin over the sternum, it takes approximately 22 seconds for the pinched skin to return to normal after being released. How would the nurse most accurately document this finding?

Poor Poor skin turgor is characterized by skin that takes 20 to 30 seconds to return to normal after being pinched. "Lagged" is not a term used to describe skin turgor. With normal skin turgor, the skin resumes shape within seconds of being released. "Decreased" skin turgor is too vague a description of the finding.

An unconscious patient needs to undergo emergency surgery. There are no family members or friends available. What action should the nurse take regarding obtaining consent for the surgery?

Proceed with plans for surgery; consent is not required for a true medical emergency. A true medical emergency may override the need to obtain consent. When immediate medical treatment is needed to preserve life and the patient is incapable of giving consent, the next of kin may give consent. If reaching the next of kin is not possible, the physician may begin treatment without written consent. Calling the local magistrate to get consent for the surgery is not necessary. Treatment should not be avoided; the priority should be to save the life of the patient. If a patient is unconscious, a legally appointed representative or responsible family member may give written permission, but in this case, no one is available.

The nurse reviews the arterial blood gases for a patient that has taken an overdose of barbiturates. The results are: pH 7.32; PaCO 2 52; HCO 3- 24. What does the nurse interpret these results to mean?

Respiratory acidosis Normal pH is 7.35 to 7.45. Values less than 7.35 indicate acidosis. Normal value for PaCO 2 is 35 to 45 mm Hg. Because the HCO 3- is normal and the PaCO 2 is elevated, the source of the acidosis is respiratory. The patient is in respiratory acidosis.

The family of a patient being treated for acute pancreatitis hears the nurse referring to "third spacing" during the assessment and asks the nurse what that means. Which explanation provides the best description for the family?

"The fluid normally in the cells becomes trapped in between the cells and has difficulty moving back into the cells." Third spacing refers to the collection of excess fluid in the nonfunctional areas between the cells. The fluid becomes trapped and has difficulty moving back into the cells. First spacing describes the normal distribution of fluids in the intracellular fluid and extracellular fluid compartments. Second spacing refers to edema. "Extracellular" and "intracellular" are terms that describe places where fluids can be found in the cells, blood vessels, and lymph system.

A patient is given dexamethasone to counteract emetic effects of morphine. The nurse should monitor for which medication side effects?

-Insomnia -abdominal distention Dexamethasone is usually used to counteract the emetic effects of opioid drugs and inhalation agents. The nurse should monitor for side effects like insomnia, nervousness, and abdominal distension. Dexamethasone does not cause dizziness, tachycardia, or dysrhythmia.

The nurse is monitoring a postoperative patient in the Phase I postanesthesia care unit (PACU). What criteria must the patient meet in order to be discharged from this phase?

-No respiratory depression -Oxygen saturation above 90% -Patient reports pain level of 4 on a 1 to 10 scale Discharge criteria from Phase I are listed in Table 20-8 and include oxygen saturation above 90%; no respiratory depression; and pain controlled or tolerable. Nausea and vomiting should be minimal. Understanding written discharge instructions are part of Phase II discharge criteria. https://eolscontent.elsevier.com/105WLB4FDG8/image/248_Table19.8.png

A nurse discusses pain medications when providing preoperative teaching to a patient. The patient asks the nurse about the effects of opioid medications. What should the nurse include in the explanation?

-Opioids decrease intraoperative pain. -Opioids relieve pain during preoperative procedures. -Opioids decrease intraoperative anesthetic requirements. Opioid drugs are often used before surgery to decrease intraoperative pain and anesthetic requirements. They also help relieve pain during preoperative procedures. Opioids do not have amnestic or sedative actions. Opioids have no effect on the risk of postoperative infections.

An older adult patient is admitted to the hospital for hip replacement surgery. What special considerations should be followed during the surgery to prevent complications?

-Take greater care in preparing and positioning the patient. -Maintain clear and concise communication with the patient. -Use warming devices to prevent perioperative hypothermia. Some older adults are at a greater risk of perioperative hypothermia, and warming devices should be considered. The care and vigilance of the entire surgical team are needed in preparing and positioning the older patient. Some older adults may have difficulty communicating and following directions as a result of alterations in hearing or vision. These factors increase the need for clear and concise communication in the operating room. Asking the patient about a family history and teaching postoperative care are not appropriate activities to be done in the operating room. These activities should be done during the preoperative assessment.

When planning the care of a patient with dehydration, what would the nurse instruct the unlicensed assistive personnel (UAP) to report?

20 mL urine output for two consecutive hours The minimal urine output necessary to maintain kidney function is 30 mL/hr. If the output is less than this for two consecutive hours, the nurse should be notified so that additional fluid volume replacement therapy can be instituted.

A patient had 5 liters of fluid removed during a paracentesis. What intravenous (IV) solution may be used to pull fluid into the intravascular space after the paracentesis?

25% albumin solution After a paracentesis of 5 L or greater of ascites fluid, 25% albumin solution may be used as a volume expander. Normal saline, lactated Ringer's, and 5% dextrose in 0.45% saline will not be effective for this action.

The patient is presently in respiratory acidosis. What concentration of bicarbonate ion in blood is an indicator of a compensatory response in this patient?

27 mEq/L The bicarbonate ion concentration in blood increases as a compensatory response in patients with respiratory acidosis. The normal range of bicarbonate ion is 22 to 26 mEq/L. Therefore, 27 mEq/L indicates a compensatory response.

The patient has a prescription for lactated Ringers intravenously (IV) at a rate of 200 mL/hour. An IV pump is not available. The IV tubing has a drop factor of 10 drops/mL. The nurse will administer the lactated Ringers solution at drops per minute. Record your answer using a whole number.

33 drops/mL Use the following formula to calculate the rate of IV solutions: Volume multiplied by drop factor divided by time (in minutes). Multiply 200 by 10 to yield 2000 and divide this by 60 to yield 33.3 or 33 gtt/minute (because the nurse cannot count a fraction of a drop).

What is the normal range of partial pressure of carbon dioxide (PaCO 2) in arterial blood?

35 to 45 mm Hg The normal value of partial pressure of carbon dioxide (PaCO 2) in arterial blood lies between 35 and 45 mmHg.

The patient has a one-time prescription for potassium chloride 20 mEq in 250 mL of normal saline intravenous (IV) to be given immediately. The nurse would seek clarification for this prescription if the patient's more recent potassium level is at what level?

4.5 mEq/L The normal range for serum potassium is 3.5 to 5 mEq/L. The IV prescription provides a substantial amount of potassium, so the patient's potassium level must be low. A level of 4.5 mEq/L would not warrant this medication.

The nurse is caring for a patient with sickle cell anemia. What common electrolyte imbalance should the nurse carefully assess the patient for that is commonly associated with this disease?

Increased phosphate levels Sickle cell anemia leads to increased concentration of phosphates in the body, thus causing hyperphosphatemia. Hypercalcemia, or increased calcium levels, is associated with hyperparathyroidism. Hyperkalemia, or increased potassium levels, is associated with tumor-lysis syndrome. Hypermagnesemia, or increased magnesium levels, is associated with diabetic ketoacidosis.

A patient is about to have a surgical procedure with general anesthesia. What does the nurse anticipate will be the initial stage?

Induction is performed with an intravenous (IV) agent. Routine general anesthesia usually begins with an IV induction agent, which may be a hypnotic, anxiolytic, or dissociative agent. When used during the initial period of anesthesia, these agents induce a pleasant sleep with a rapid onset of action that patients find desirable. The patient is immediately intubated. An oral tablet would be contraindicated before surgery. Agents delivered via face mask are used, but not during initial stage.

The nurse is admitting a patient to the same-day surgery unit and informs the nurse that they took kava last night to help them sleep. Which nursing action would be most appropriate?

Inform the anesthesiologist of the patient's recent use of kava. Kava may prolong the effects of certain anesthetics. Thus the anesthesiologist needs to be informed of recent ingestion of this herbal supplement. Patients should not take anything before surgery without the health care provider's knowledge.

A patient who is being prepared for surgery tells the nurse: "I am afraid I may die during surgery without being able to confess my sins. I don't want to die without receiving absolution." Which action by the nurse would best meet this patients needs?

Inform the surgeon of the patient's fears and contact the appropriate religious leader to talk with the patient before surgery if possible. The nurse must acknowledge the patient's fears, inform the surgeon, and make efforts to have the appropriate spiritual leader speak with the patient to allay his or her fears before surgery. Assuring the patient that the risk of death is minor ignores the patient's fears. Informing the surgeon that the surgery is canceled would not be appropriate at this point in time; the patient may be able to have his or her fears allayed without unduly delaying the surgery. Informing the patient that it is too late is an inappropriate response that dismisses his or her fears.

The arterial blood gas (ABG) analysis of a patient with diabetes shows a partial pressure of carbon dioxide (PaCO 2) of 43 mm Hg and pH of 5.1. What would be the nurse's interpretation of these ABG results?

Metabolic acidosis Metabolic acidosisis characterized by increased levels of acid in the blood. As a result, pH of the blood decreases. The normal range of pH of blood is 7.35 to 7.45, and the normal value of partial pressure of carbon dioxide (PaCO 2) lies between 35 and 45 mm Hg. The patient's numbers indicate metabolic acidosis. Metabolic alkalosis is manifested by an increased pH. A decreased pH and elevated PaCO 2 indicate respiratory acidosis. Respiratory alkalosis is manifested by increased plasma pH and decreased PaCO 2.

A patient is diagnosed with Cushing syndrome. What manifestation does the nurse anticipate while assessing this patient?

dyspnea Excess extracellular volume may result from fluid retention during Cushing syndrome. This shift of fluid into the interstitial spaces leads to blockage of air spaces (pulmonary edema) resulting in dyspnea, crackles, and peripheral edema. Dry mouth, weight loss, and restlessness are the common manifestations resulting from extracellular fluid depletion.

A patient with a history of psychosis has newly developed anxiety and is combative with the nurse. What does the nurse know may be causes of this change in behavior?

electrolyte imbalances The nurse knows electrolyte imbalances can cause an acute change in a patient's behavior. A new onset of anxiety and combativeness may cause delirium rather than the other way around. Sleep deprivation, not excessive sleep, would cause anxiety and aggression. Hyperoxygenation would not cause such behavior changes; hypoxemia does.

A patient is admitted to the emergency room with second-degree (partial-thickness) burns over 30% of the total body surface area with poor skin turgor, a urine output of less than 50 mL over the past two hours, a rapid and thready pulse, and restlessness. The nurse determines that these symptoms might indicate which type of imbalance?

extracellular fluid volume deficit Patients with burns are susceptible to third-space shifts, resulting in extracellular fluid volume deficit. Extracellular fluid volume deficit is characterized by poor skin turgor, decreased urine output, a rapid and thready pulse, and restlessness. Hyperkalemia is characterized by weakness, irregular pulse, and paresthesias. Hyperphosphatemia is characterized by numbness and tingling, hyperreflexia, tetany, and seizures. Metabolic acidosis is characterized by drowsiness, confusion, decreased blood pressure, dysrhythmias, nausea, and vomiting.

A nurse is caring for an older adult patient, who had a knee replacement the previous day. The patient denies any pain. Which response by the nurse would be most appropriate?

"Almost everyone has pain after this surgery. Are you certain that you are not experiencing pain?" Thoroughly assessing the presence of pain is imperative, especially for those who deny any pain after surgery, especially the elderly. Gerontology patients may hesitate about reporting pain because of the belief that pain should be tolerated and is inevitable postsurgery. It is not appropriate to compliment the patient on being able to handle pain. The patient will not develop an addiction to pain medication, so it is not appropriate to tell the patient he or she should only take it when necessary. The nurse should not tell the patient that pain medication will help him or her recover quicker, because that could give the patient false reassurance.

The nursing student is discussing anesthetic agents with the nursing instructor. Which statement by the nursing student indicates a need for further teaching? "Brevital can be used for short procedures and has minimal postoperative effects." "Propofol has a very quick impact and can cause a slow heart rate and low blood pressure." "Volatile inhalation agents all cause respiratory depression, and I should monitor the breathing of patients on such drugs." "Although nitrous oxide is an old anesthetic agent, it is the best choice for patients who have problems with nausea and vomiting."

"Although nitrous oxide is an old anesthetic agent, it is the best choice for patients who have problems with nausea and vomiting." Nitrous oxide is a weak anesthetic that is rarely used alone and should not be used for patients with a history of nausea and vomiting. Thus this statement indicates a need for further education. Brevital has an immediate impact and a brief duration of less than five minutes; this drug causes few postoperative effects. Propofol is a nonbarbiturate hypnotic with a rapid onset; side effects include bradycardia and hypotension. All volatile inhalation agents can cause respiratory depression; nurses should monitor for these effects.

A nurse working in the emergency department is taking care of a patient with respiratory alkalosis. Which statements would be appropriate for the nurse to give as an explanation of the cause of this imbalance to the patient and family? .

"Hyperventilation can occur without any physiologic need from pain or anxiety." "This imbalance can be caused by hyperventilation, which can occur from fevers." "The primary cause is hypoxemia from acute pulmonary disorders, such as pneumonia." Respiratory alkalosis is primarily caused by hypoxemia related to pulmonary disorders that prevent appropriate gas exchange. Such examples of pulmonary disorders include pulmonary embolism or pneumonia. Hyperventilation decreases the level of CO 2 in the blood; this condition can lead to respiratory alkalosis. Hyperventilation can occur with or without physiologic need from fevers, pain, or anxiety. Hypercarbia is an increase in CO 2 in the blood, which is not associated with hyperventilation or hypoxemia. Some central nervous system disorders can cause hyperventilation without physiologic need, which can lead to respiratory alkalosis.

An older adult patient with dementia arrives in the emergency department with a family member; the patient is found to be hypercarbic. The patient has an advanced directive and does not want any invasive procedure. The family member asks if this issue will resolve by itself. Which is the nurse's most appropriate response?

"Older adults have a harder time compensating because they have decreased respiratory and kidney functions." Hypercarbia is an increased level of CO 2 in the blood, which is a hallmark of respiratory acidosis. Older adults have difficulty compensating for acid-base imbalances because of decreased functional capacity in the respiratory and renal systems. Hyperventilation is a normal physiologic response to hypercarbia; hyperventilation may not be possible with decreased functional respiratory reserves. Normal kidneys can sense hypercarbia and begin to reabsorb buffer to normalize pH; however, older adults may lack the functional capacity or have some degree of kidney disease. Normal renal compensation is slow and will often begin in 24 hours, if kidney function is normal.

The nurse is performing a preoperative assessment for a patient scheduled for surgery. What does the nurse explain to the patient is the reason for obtaining accurate documentation of the current medications being taken?

"Some medications may interact with anesthetics, altering the potency and effect of the drugs." Drug interactions may occur between prescribed medications and anesthetic agents used during surgery. For this reason, it is important to take a careful medication history and check that they have been communicated to the anesthesia care provider. Medications generally do not alter the patient's perceptions about surgery. The anesthetics may interact with the other medications, but they are not likely to alter renal and hepatic function. Routine medications are not always held during surgery, and dosage and schedule adjustments are not always necessary. Routine medications may or may not be prescribed for use the day of surgery.

To ensure patient safety and reduce risks associated with surgical procedures, the circulating nurse calls a surgical timeout prior to surgery. Which activities should be included in the timeout?

- Verify patient identification. - Complete a fire risk assessment. - Verify surgical site and procedure. - Ensure that consent for the specific procedure was obtained Just before a surgical procedure, all surgical team members complete a surgical timeout to prevent risk of fire, wrong patient, wrong site, and wrong procedure. The team must also ensure that consent was obtained. Although a significant other may be present for a consultation if needed, this action is not an aspect of the surgical timeout process.

The nurse places an abdominal binder on a patient after colon surgery. After approximately an hour, the nurse assesses the patient has shallow respirations, is hypoxemic, and hypercapnic. How should the nurse promote optimal breathing in this patient?

- Loosen the binder - Reposition the patient - Raise the head end of the bed The hypoventilation observed in this patient is due to mechanical restriction caused by the abdominal binder. Therefore the patient should be repositioned to improve comfort and the binder should be loosened to relieve the constriction. Raising the head end of the bed would promote lung expansion and facilitate breathing. Music therapy may relax the patient but would not relieve the mechanical restriction. Elevating the foot end of the bed would further aggravate the patient's condition.

An older adult postoperative patient has difficulty with memory and the ability to concentrate. What should the nurse do to help this patient?

- Provide adequate nutrition. -Provide bowel and bladder care. -Monitor fluid and electrolyte disturbance. The patient suffers from postoperative cognitive dysfunction, which dissipates over a few weeks. The nurse should provide supportive care during this period, such as bowel and bladder care, adequate nutrition, and fluid and electrolyte monitoring. Early mobilization should be encouraged to prevent pulmonary complications. Sedatives should not be used because they further add to cognitive dysfunction.

A postoperative patient who has been transferred from surgery to the postanesthesia care unit is cold and shivering. The patient's plan of care includes a prescription for morphine to be administered for pain relief. When managing this patient, which interventions should the nurse perform?

- Use forced air warmers. - Administer oxygen therapy. - Administer warmed IV fluids. - Use warmed cotton blankets. Administering warm liquids and using forced air warmers are active warming methods. Using warmed cotton blankets is a passive warming measure. Oxygen therapy is needed to meet the increased oxygen demand during shivering. Opioids are used to treat shivering in the immediate postoperative period, so the nurse should not withhold the morphine dose.

A nurse is caring for a patient with a central venous access device. The patient is experiencing chest pain, dyspnea, hypotension, and tachycardia. What nursing actions are essential in the care of this patient?

- administer oxygen -Clamp the central venous access catheter. - Place the patient on the left side with the head down. Pulmonary embolism is a complication of central venous access devices. The nurse should start oxygen therapy to relieve dyspnea. The catheter should be clamped to prevent further formation of emboli. Because the signs suggest air embolism, the patient is placed on the left side with the head down. Administering anticoagulants and normal saline are required if the catheter is occluded, and they do not help in relieving a pulmonary embolus.

An older adult postoperative patient wakes up and becomes restless and agitated and starts thrashing and shouting. The nurse finds that the patient was administered benzodiazepines during surgery. What would be important to have on the patient's plan of care?

- ensure patient safety - use drugs to reverse benzodiazepines The patient's presentation of restlessness, agitation, thrashing, and shouting indicates emergence delirium. It is due to the prolonged action of opioids and benzodiazepines during the surgery. The use of opioid and benzodiazepine antagonists may reverse the effect and alleviate agitation in the patient. Until the patient is fully conscious, the nurse should ensure the patient's safety by raising the side rails of the bed and securing the equipment, such as the IV line. Antianxiety drugs are less helpful in managing emergence delirium. Emergence delirium is not a psychotic condition; therefore antipsychotic drugs are not useful. Narcotic analgesics would further enhance the action of opioids that were used during surgery.

The scrub nurse is performing a surgical scrub before a procedure. Which of these actions should the nurse be sure to use to promote infection control?

- scrub fingers and hands first - hold hands higher than the elbows To perform a surgical scrub, the fingers and hands should be scrubbed first, progressing to the forearms and elbows. The hands should be held away from surgical attire and higher than the elbows at all times to prevent contamination from clothing or from detergent suds and water draining from the unclean area above the elbows to the clean and previously scrubbed areas of the hands and fingers. Scrubbing from the elbows to the hands, without mechanical friction, and for a minimum of 10 minutes are not correct actions.

The circulating nurse is preparing the surgical team for a time out. Which activities should the circulating nurse perform during this time?

-Ask the patient to confirm name and date of birth. -Compare the hospital identity (ID) number with the patient's own ID band. -Ask the patient to confirm the operative procedure and site and to give consent. During a surgical time-out all members of the surgical team stop what they are doing, just before the procedure starts, to verify patient identification, surgical procedure, and surgical site. The patient is asked to confirm the name and date of birth, operative procedure site, and consent. The hospital ID number is compared with the patient's own ID band. Helping with surgical attire and teaching patients how to do deep-breathing exercises are important activities, but they do not occur during a surgical time-out.

The nurse is caring for a patient in the postanesthesia care unit (PACU), when the blood pressure drops from 110/60 mm HG to 92/58 mm Hg. What actions should the nurse take?

-Assess ECG tracing. -Inspect the surgical site. -Have the patient take deep breaths. -Administer intravenous (IV) fluid bolus per protocol. Have the patient take deep breaths; hypoxemia can cause hypotension. Hypotension in the postoperative patient can be due to various reasons, but the nurse should begin by treating hypoxemia. Inspect the surgical site; hypotension can be caused by hemorrhage. Therefore it is important to inspect the surgical site for evidence of bleeding. Administer IV fluid boluses per protocol; fluid shifts during and after surgery can cause a drop in blood pressure. Fluid boluses often are needed to correct for these shifts. Assess ECG tracing; a change in the heart rhythm can cause a decrease in blood pressure. Some of these rhythms include supraventricular tachycardia, sinus bradycardia, atrial fibrillation, and atrial flutter. Hypertension, not hypotension, is indicative of pain. A side effect of many pain medications is hypotension, which would exacerbate the patient's present hypotensive state. Metoprolol causes a decrease in blood pressure. If the patient is hypotensive, the prudent nurse should hold the metoprolol and notify the primary health care provider.

A nurse educator discusses career options with a group of nursing students and describes the intraoperative activities of the perioperative nurses. What are the duties of a scrub nurse?

-Assist in the draping procedure. -Assist in preparing the operating room. A scrub nurse always remains in a sterile environment. The scrub nurse has many duties, some of which include assisting in the draping procedure, assisting in preparing the operating room, and passing instruments to surgeons and assistants by anticipating their needs. Preparing the instrument table and maintaining a sterile environment are also the responsibilities of a scrub nurse. Assisting in induction of anesthesia, monitoring the draping procedure, and providing a hand-off report to the PACU nurse are the duties of a circulating nurse.

An older adult patient is being prepared for a cholecystectomy. What assessment data need to be included for this patient?

-Fluid balance history -Current mobility problems -Current cognitive function Preoperative fluid balance history is especially critical for older adults because they have reduced adaptive capacity that puts them at greater risk for overhydration and underhydration. Mobility problems must be assessed to assist with intraoperative and postoperative positioning and ambulation. Preoperative assessment of the older person's baseline cognitive function is especially crucial for intraoperative and postoperative evaluation, because the older patient is more prone to adverse outcomes during and after surgery from the stressors of the surgery, dehydration, hypothermia, and anesthesia. Foods the patient dislikes are not important unless the patient is allergic to them, but this is no more important for older patients than it is for all patients.

A patient is scheduled for laparoscopic cholecystectomy. When educating regarding the advantages of minimally invasive surgery over conventional surgery to the patient, what information should the nurse include?

-Incisions are smaller. -Blood loss is reduced. -Postoperative pain is decreased. In a minimally invasive surgery such as laparoscopic cholecystectomy, incisions are smaller, there is less blood loss, and postoperative pain is lesser than in traditional surgeries. The recovery time is also shortened. Robotics is used in robotic-assisted surgeries.

The nurse is caring for a patient undergoing surgery for a below-the-knee amputation. What is critical to the patient's safety before and during the procedure?

-The patient's allergies are conveyed to the surgical team. -The surgeon marks the surgical site with the patient's involvement. -The surgical team confirms the patient's identity before anesthesia is administered. Intraoperative nursing care includes determining the patient's allergy status in response to food, drugs, and latex. Preventing wrong site, wrong procedure, and wrong surgery has become known as the Universal Protocol. The Universal Protocol is part of a global patient safety initiative. A surgical time-out is performed before the induction of anesthesia during which the patient is asked to confirm name, birth date, operative procedure and site, and consent, and the patient's hospital ID number is compared with the patient's own ID band and chart. Determining if the patient has health coverage and identifying that the anesthesia care provider is an anesthesiologist does not apply to patient safety.

The nurse is preparing to remove a patient's central venous access device (CVAD). What actions are important for the nurse to perform prior to removal?

-Understand the scope of nursing practice -Review the health care provider's prescription -Review the health care organization's policy on the procedure Not all health care agencies allow a nurse to perform this procedure. Prior to removing a patient's CVAD, the nurse should know the health care organization's policy, confirm that the removal is in the scope of a registered nurse's practice to perform, and review the health care provider's prescription. It is not necessary to have another nurse assist with the removal of a CVAD or to routinely medicate the patient.

A patient has provided an informed consent for an elective tubal ligation under general anesthesia. The nurse recalls that the patient can revoke the consent for the surgery at what stage?

-When the patient is partially informed -Just before the scheduled surgery time -After the patient has signed the consent form -When the patient is in the preoperative holding area The patient can revoke the consent at any time before the scheduled surgery. The patient can refuse the surgery even when she is in the preoperative holding room, assuming she is conscious and able to make the decision for herself. The informed consent can be revoked whether she has received full or partial information, even at the very last minute. Once the surgery has started and the patient is under general anesthesia, obviously she will not be able to revoke the consent.

A patient admitted with dehydration is receiving a hypertonic solution. What assessments must be done to avoid risk factors of these solutions?

-lung sounds -BP -serum sodium level BP, lung sounds, and serum sodium levels must be monitored frequently because of the risk for excess intravascular volume with hypertonic solutions. Bowel sounds and serum potassium level do not need to be monitored frequently.

A patient's laboratory reports reveal a sodium concentration of 143 mmol/L and the sum of chloride and bicarbonate ion concentration as 132 mmol/L. What is the anion gap of the patient? Record your answer using a whole number.

11 mol/L The anion gap is calculated by subtracting the concentration of anions from the concentration of cations in the blood. The sum of chloride and bicarbonate ions yields an anion concentration of 132 mmol/L. The cation concentration is the sodium concentration: 143 mmol/L. Simply subtract 132 from 143 to get 11 mmol/L.

The nurse is preparing to give a dose of cefazolin 1.5 g intravenous piggyback (IVPB) to a patient before surgery. The vials available on the unit contain 500 mg in powder form. The instructions state to "dilute each 500 mg with 5 mL of sterile water." After reconstituting the medication, the nurse should draw up ________________ total milliliters of solution for dosage preparation? Record your answer using a whole number.

15 mL Because the dose is 1.5 g and each vial contains 500 mg, the nurse needs to first convert grams to milligrams. 1.5 grams is equal to 1500 mg. Dividing 1500 by 500, the nurse needs to use a total of three vials. The nurse then adds 5 mL of sterile water to each vial of powder on the basis of the direction to "add 5 mL of sterile water per 500 mg of medication." Once all vials are reconstituted, the concentration of each solution is 500 mg/5 mL. The nurse then needs to draw up the contents of all three vials, making the total volume 15 mL.

A patient has a prescription to receive D5W with 20 mEq KCl/L at 100 mL/hour. The nurse should select which solution from the intravenous supply cart?

5% dextrose in water with 20 mEq of KCl D5W stands for 5% dextrose in water, which is different than normal saline, half normal saline, or lactated Ringer's.

The charge nurse is reviewing the electrolyte laboratory study results for the unit's assigned patients. Which patient would be at greatest risk for the potential development of hypomagnesemia?

65-year-old homeless woman with a history of chronic alcoholism Causes of hypomagnesemia include chronic alcoholism, diarrhea, vomiting, malabsorption syndromes, prolonged malnutrition, and nasogastric (NG) suction. Lung cancer, hypertension, eclampsia, BPH, and UTIs are not causes of hypomagnesemia.

The nurse is developing a care plan for the postoperative patient in order to prevent complications and promote ambulation, coughing, deep breathing, and turning. What actions can the nurse provide to achieve desired outcomes?

Administer enough analgesics to promote relative freedom from pain. Even when a patient understands the importance of postoperative activities, it is unlikely that the best outcome will occur unless the patient has sufficient pain relief to cooperate. Warning the patient about pneumonia and clotting will not enhance proper activities if pain is not managed. Family encouragement and understanding of the rationale for completing these actions are important; however, pain control is the most helpful way to ensure ambulation, coughing, deep breathing, and turning can be performed.

The nurse finds that the patient with renal disease is irritable and has an irregular pulse. ECG changes suggest severe hyperkalemia. What is the first nursing action?

Administer intravenous calcium gluconate In the case of severe hyperkalemia, manifested by irritation, irregular pulse, and changes in ECG findings, the nurse should act immediately to prevent cardiac arrest. The nurse should administer intravenous calcium gluconate to reverse the membrane potential effects of extracellular fluid (ECF) potassium. Administering ion-exchange resins (to increase elimination of potassium) and intravenous insulin with glucose (to force potassium from ECF to intracellular fluid [ICF]) can be done once the patient is stable. Stopping all sources of dietary potassium is an important measure when hyperkalemia is mild.

A nurse finds that a patient has severe diarrhea and may be at risk of fluid volume deficit. What does the nurse anticipate administering to this patient to treat the fluid volume deficit?

Administer lactated Ringer's solution To correct fluid deficit in the patient the nurse would administer lactated Ringer's solution to replace both water and any needed electrolytes. Isotonic normal saline is used when rapid volume replacement is needed. If the fluid deficit has been identified as due to blood loss, then blood can be transfused. Sodium intake should be restricted in case of fluid excess.

A nurse is preparing a patient for an appendectomy. Shortly after the patient receives fentanyl for anesthesia, the patient experiences severe respiratory depression. What should be the next primary action?

Administer naloxone to the patient. Fentanyl is an opioid drug, which can cause respiratory depression. Naloxone is the antidote for opioid drugs, and it can reverse respiratory depression. Therefore it should be given to this patient. Increasing or decreasing the dose of fentanyl will not help. Oxygen can be administered once naloxone is administered. Artificial ventilation may be needed if the respiratory depression is severe.

The nurse is assessing a patient's surgical dressing on the first postoperative day and notes new, bright-red drainage about 5 cm in diameter. In response to this finding, what should the nurse do first?

Assess the patient's blood pressure and heart rate The first action by the nurse is to gather additional assessment data to form a more complete clinical picture. The nurse then can report all of the findings. Continued reassessment will be done. Agency policy determines whether the nurse may change the dressing for the first time or simply reinforce it.

The nurse is caring for a patient diagnosed with heat stroke and with a urine output of 4000 mL per day. What is the most appropriate nursing action?

Administrating lactated Ringer's solution Heat stroke and an increased amount of urine output of about 4000 mL leads to a deficit in extracellular fluid volume, causing dehydration. Administering lactated Ringer's solution to maintain fluid and electrolyte balance is beneficial. Blood transfusions are performed only when the fluid loss is due to blood loss. Moisturizers are applied to patients with dry skin to prevent the fluid loss.Tube feeding is preferred in the patient with severe extracellular fluid loss. The patient on tube feeding must be thereby supplemented with water added to the enteric formula.

In the regulation of water balance, which system has a primarily antiinflammatory effect and increases serum glucose levels?

Adrenal-cortical The adrenal-cortical system secretes glucocorticoids and mineralocorticoids to regulate water and electrolyte balance. Glucocorticoids have an antiinflammatory effect and increase serum glucose levels. The renal system regulates water balance through urine volume changes and excretion of electrolytes. The cardiac system produces natriuretic peptides that promote the excretion of sodium and water. The hypothalamic-pituitary system releases antidiuretic hormone, which results in increased water reabsorption into the blood and decreased excretion in the urine.

A nurse cares for a patient with acute pulmonary edema. What findings would the nurse expect to assess?

Anxiety and distended neck veins The patient experiencing acute pulmonary edema would most likely experience anxiety related to hypoxia. Distended neck veins would be present because of decreased cardiac output resulting in right-sided heart congestion, causing blood to back up into the neck veins. Vertigo and headaches, and palpitations and nausea, may be present but are not as distinct and common as anxiety, distended neck veins, and shortness of breath. The cough associated with pulmonary edema will be moist and productive. In severe cases, this may present as pink and frothy sputum. Chest pain may also be present.

A patient is being evaluated for acid-base imbalances. Which health information should the nurse assess?

Ask about the patient's exercise routines. Ask the patient about any special dietary practices. Ask about any deviations from usual bowel and bladder habits. Any alterations in elimination (such as diarrhea or oliguria) can cause metabolic acid-base derangements. Weight reduction, fad diets, or eating disorders can all lead to acid-base problems. Vigorous exercise can increase metabolic demands and cause fluid and electrolyte losses that may alter acid-base balance. Vaccination status is an important part of health maintenance, but it will not provide information regarding acid-base deviations. Smoking status is also an important part of health promotion; however, this information is unlikely to help assess for acute acid-base imbalances.

In caring for the postoperative patient on the clinical unit after transfer from the postanesthesia care unit (PACU), which care can be delegated to the unlicensed assistive personnel (UAP)?

Assist the patient to take deep breaths and cough The UAP can encourage and assist the patient to do deep breathing and coughing exercises and report complaints of pain to the nurse caring for the patient. The registered nurse (RN) should do the admission vital signs for the patient transferring to the clinical unit from the PACU. The licensed practical nurse (LPN) or RN will monitor and treat the patient's pain and change the dressings.

The perioperative nurse is assisting with the induction of anesthesia. What is an appropriate nursing action during the induction stage?

Assist with the application of monitors. General anesthesia has four different phases, including preinduction, induction, maintenance, and emergence phases. In each stage the anesthesia care provider and perioperative nurse have different roles. In the induction stage, the duty of the perioperative nurse is to assist with the application of monitors. Securing the airway, administering appropriate drugs, and positioning the patient for the surgical procedure are the duties of the anesthesia care provider.

Shortly after having a central IV catheter inserted into the subclavian vein, the patient experiences shortness of breath, anxiety, and restlessness. What is the highest priority for the nurse? a) Administering a sedative b) Advising the patient to relax c) Auscultating the breath sounds d) Obtaining an arterial blood gas analysis

Auscultate the breath sounds. Because this is an acute episode, the nurse should first listen to the patient's lungs to see whether anything has changed. In this situation the probability is high that the patient sustained a pneumothorax during the subclavian IV catheter insertion procedure. The patient will need oxygen, and the care provider should be notified of the findings. Administering a sedative is not appropriate. Advising the patient to relax does provide reassurance, but the anxiety and restlessness are probably due to hypoxia. Obtaining an arterial blood gas analysis would likely be the next nursing action.

The nurse is caring for a patient receiving epidural anesthesia. The patient reports nausea. Upon assessment, the nurse notes a blood pressure of 80/60 mm Hg and a heart rate of 52. Which condition does the nurse expect the patient is experiencing?

Autonomic nervous system blockade

The nurse is to administer ranitidine to a patient scheduled for a cholecystectomy. What would be the best time for the nurse to administer the drug?

Before surgery Ranitidine is an H 2 receptor blocker used for aspiration prophylaxis. It should be given in the preinduction stage to avoid aspiration of secretions during anesthesia. Therefore the nurse should clarify the order from the primary health care provider and administer it before surgery. Administration of ranitidine after surgery, during surgery, and just after surgery does not serve the purpose of preventing aspiration of secretions during anesthesia.

The nurse is reviewing magnesium levels for a patient. What does the nurse recognize is the importance of assessing this level for a patient?

Can affect neuromuscular excitability and contractility. Alterations in serum magnesium levels profoundly affect neuromuscular excitability and contractility because magnesium directly acts on the myoneural junction. A decrease in blood magnesium levels increases the blood pressure. Magnesium is the second most abundant intracellular cation. The majority of the body's magnesium is present in the bones. Causing extracellular fluid overload, being the most abundant intracellular cation, and the patient being at risk for hypotension are not relevant to this situation.

A patient who is scheduled for thyroid surgery reports amenorrhea that began two months ago. How should the nurse ensure the patient is not pregnant?

By checking human chorionic gonadotropin level Human chorionic gonadotropin (hCG) levels are measured to check for pregnancy status. X-rays of the abdomen are harmful to a fetus, so they should always be avoided in women of reproductive age if pregnancy is suspected. Hematocrit levels indicate the hemoglobin level in the blood. International normalized ratio (INR) is used to check for coagulation status.

A patient is admitted to the postanesthesia care unit (PACU) with a blood pressure of 100/60 mm Hg. Which action should the nurse take first?

Check the medical record for the patient's baseline blood pressure. The first action of the nurse is to identify what the patient's normal blood pressure is. Interventions are dependent on the baseline variation. Rousing the patient is an intervention that can increase the blood pressure, but would be done after determining the baseline blood pressure. Placing the patient in Trendelenburg is not an appropriate action in this situation. Before notifying the anesthesiologist of the blood pressure, the nurse needs to check the baseline blood pressure.

Which medical diagnosis would cause the nurse to include nursing interventions appropriate for hyponatremia in the plan of care?

Congestive heart failure Congestive heart failure increases the patient's risk for developing hyponatremia; therefore this diagnosis would cause the nurse to include interventions specific to hyponatremia in the plan of care. Diabetes insipidus, Cushing syndrome, and uncontrolled diabetes mellitus increase the patient's risk for hypernatremia, not hyponatremia.

A patient undergoing a surgical procedure with general anesthesia exhibits muscle rigidity, temperature of 103° F (39.4° C), pulse 100 beats per minute (beats/minute), and a respiratory rate of 26 breaths per minute. The symptoms subside with the administration of dantrolene. What should the nurse include in the patient's postoperative instructions?

Consider getting genetic testing for malignant hyperthermia. Hyperthermia, tachycardia, and tachypnea, along with skeletal muscle rigidity induced by general anesthesia, are indications of malignant hyperthermia. The patient should undergo genetic testing to confirm the condition. These tests can help in taking preventive action in the future. Antipyretics may not help in bringing the body temperature down, because the temperature is increased because of an imbalance in intracellular calcium in the skeletal muscles. The patient can receive general anesthesia with appropriate precautions in future surgeries. The manifestations of latex allergy may range from urticaria to anaphylactic reaction, but that is not a factor for this patient.

As the nurse is preparing a patient for outpatient surgery, the patient wants to give the patient's hearing aid to the spouse so it will not be lost during surgery. Which action by the nurse should be taken in this situation?

Encourage the patient to wear it for the surgery. Although jewelry is removed before surgery, hearing aids should be left in place to allow the patient to better follow instructions given in the surgical suite and the postanesthesia care unit (PACU), as well as the dismissal instructions that will be given before the patient returns home for recovery. Removing the hearing aid could cause issues for the patient in following instructions in the surgical suite and PACU. Taping the hearing aid to the patient's ear is not necessary to prevent loss.

When planning care for a patient with dehydration related to nausea and vomiting, the nurse would anticipate which fluid shift to occur because of the fluid volume deficit?

Fluid movement from the interstitial space into the blood vessels In dehydration, fluid is lost first from the blood vessels. To compensate, fluid moves out of the interstitial spaces into the blood vessels to restore circulating volume in that compartment. As the interstitial spaces then become volume depleted, fluid moves out of the cells into the interstitial spaces.

A patient is admitted to the hospital for elective surgery. The patient is taking nonsteroidal antiinflammatory drugs (NSAIDs) for knee pain. The nurse recognizes that NSAID use will have what effect on a postoperative patient?

It may increase risk of postoperative bleeding. Although analgesics are required for surgical patients, the use of NSAIDS should be stopped before surgery because these drugs are associated with increased postoperative bleeding. NSAIDS do not increase the risk of infections. NSAIDS do not cause atelectasis postoperatively. NSAIDS do not increase blood clotting.

A nurse is assisting a postoperative patient with ambulation. What benefits of early ambulation should the nurse explain to the patient?

It stimulates circulation. It improves muscle tone. It prevents thrombus embolism. Early ambulation is the most significant general nursing measure to prevent postoperative complications. Early ambulation increases muscle tone and strength and promotes venous return. This is turn improves circulation, which prevents formation of thrombus in the blood vessels. Early ambulation increases vital capacity by promoting lung expansion, and prevents venous stasis.

The nurse is caring for a patient who requires emergency surgery following a motor vehicle crash. Which anesthetic drug combination is most appropriate for this patient?

Ketamine and midazolam Ketamine is the preferred anesthetic drug used in trauma patients requiring surgery because it increases the heart rate and helps in improving cardiac output. When used alone it can cause hallucinations, and therefore, it is used with midazolam. Midazolam can reduce or eliminate hallucinations associated with ketamine. Fentanyl is an opioid and has no advantages over ketamine. Midazolam and fentanyl should not be administered together because they may precipitate respiratory depression. Metaclopramide and ondansetron are antiemetics.

The nurse is caring for a patient admitted with heart failure. The morning laboratory results reveal a serum potassium level of 2.9 mEq/L. What classification of medications should be withheld until consulting with the health care provider?

Loop diuretics Loop diuretics are contraindicated during episodes of hypokalemia because these medications cause the kidneys to excrete sodium and potassium. Thus administration of this type of medication at this time would worsen the hypokalemia, putting the patient at risk for dysrhythmias. The prescribing health care provider should be consulted for potassium replacement therapy, and the drug should be withheld until the potassium has returned to normal range. Antibiotics, bronchodilators, and antihypertensives are not an issue in this case.

A nurse is caring for a patient three days after abdominal surgery who continues to have poorly controlled abdominal pain with green bilious nasogastric output. The patient's respiratory rate is 32 and heart rate is 128. Which acid-base imbalance does the nurse suspect is occurring?

Mixed alkalosis Mixed alkalosis can occur in a patient who is losing CO 2 via hyperventilation (possibly related to pain) while also losing acid by another method, such as prolonged suctioning with a nasogastric tube. Respiratory acidosis occurs when the primary loss of acid is via a respiratory "blow off" of CO 2. Metabolic alkalosis occurs with a systemic loss of acid via a metabolic process such as vomiting or suctioning with a nasogastric tube. Mixed acidosis occurs when acid is retained by both respiratory and metabolic systems, such as in a critically ill patient in shock with hypoperfusion and hypoventilation, and will often cause a more profoundly acidotic pH than either condition could independently create.

A patient is recovering from a surgical procedure with pain rating at a 10 on a scale of 0-10 and has a nasogastric (NG) tube draining copious amounts of contents. The patient's respiratory rate is 32. What condition is this patient at greatest risk for?

Mixed respiratory and metabolic alkalosis A mixed acid-base disorder is a condition in which two or more disorders that affect the acid-base balance are present at the same time. Septicemia causes respiratory alkalosis, which causes acid-base imbalance. Metabolic alkalosis also affects the acid-base balance. Thus septicemia and metabolic alkalosis are examples of a mixed acid-base disorder. Hypoxia causes respiratory alkalosis. Overdose of sedatives causes respiratory acidosis. Diabetic ketoacidosis results in metabolic acidosis. An example of a mixed acidosis is a patient in severe shock with poor perfusion and hypoventilation. Mixed alkalosis can occur in a patient hyperventilating because of postoperative pain and losing acid secondary to NG suctioning.

A patient on the postoperative unit was given a large dose of opioids during a surgical procedure and is now hypoxemic. What would the nurse expect to be prescribed to manage hypoxemia in this patient?

Naloxone Shallow respiration associated with hypoxemia and reduced respiratory rate in a patient who received large doses of opioids indicates hypoventilation due to medullary depression. Drugs that reverse the effect of opioids should be administered to stimulate the medullary respiratory center such as naloxone. Opioids and benzodiazepines should be avoided because they further aggravate medullary depression. In severe medullary depression, the patient may need mechanical ventilation.

The nurse is preparing the patient for a colonoscopy. Which type of anesthesia should the nurse expect to be used?

Monitored anesthesia care The nurse should expect monitored anesthesia care to be used for the patient having a colonoscopy because it can match the sedation level to the patient needs and procedural requirements. Local anesthesia would not be used because the area affected by a colonoscopy is larger than loss of sensation could be provided for with topical, intracutaneous, or subcutaneous application. Moderate sedation is used for procedures performed outside the operating room and the patient remains responsive. General anesthesia is not needed for a colonoscopy, and it requires advanced airway management.

A patient has been administered pancuronium during a surgical procedure. The nurse determines that what medication is administered at the end of surgery to reverse the action of pancuronium?

Neostigmine Pancuronium is a neuromuscular blocking agent that causes muscle paralysis. To reverse its action towards the end of surgery, an anticholinergic drug like neostigmine is administered. Methadone and remifentanil are opioid drugs. Dolasetron is an antiemetic.

Five minutes after the patient receives preoperative sedative medication by intramuscular (IM) injection, they ask to get up to go to the bathroom to urinate. What is the most appropriate action by the nurse?

Offer the patient a urinal and provide privacy. The prime issue after administration of a sedative or opioid analgesic medication is safety. Providing the patient with a urinal and providing privacy allows the patient to stay in bed, but also allows the patient to void. Because these medications affect the central nervous system, the patient is at risk for falls and should not be allowed out of bed, even with assistance. A Foley catheter is not indicated at this time, and it is not reasonable to ask the patient to wait until the surgery is underway.

A school-age child is scheduled for a tonsillectomy. In the preoperative area, the child is crying and shaking. Which is the best nursing intervention by the nurse to decrease the child's preoperative anxiety?

Permit the parent to remain with the child until the child is taken to the operation suite. The nurse should permit the parent to remain with the child until the child is taken to the operating suite. The presence of a parent or loved one helps to decrease anxiety without use of sedation. The child should not be given anything by mouth prior to a surgical procedure. Nonpharmacologic measures should be tried before sedation is given in this situation. Notifying the surgeon will not address the child's anxiety.

The patient has chronic kidney disease and ate a lot of nuts, bananas, peanut butter, and chocolate. The patient is admitted with loss of deep tendon reflexes, somnolence, and altered respiratory status. What treatment should the nurse expect for this patient?

Renal Dialysis Renal dialysis will need to be administered to remove the excess magnesium that is in the blood from the increased intake of foods high in magnesium. If renal function was adequate, IV potassium chloride would oppose the effects of magnesium on the cardiac muscle. IV furosemide and increased fluid would increase urinary output, which is the major route of excretion for magnesium.

A patient has the following arterial blood gas results: pH 7.32; PaCO 2 56 mm Hg; HCO 3 - 24 mEq/L. What does the nurse determine these results will indicate for the patient?

Respiratory acidosis The normal ranges are as follows: pH 7.35-7.45; PaCO2 35-45 mm Hg; HCO3- 22-26 mEq/L. Respiratory acidosis (carbonic acid excess) occurs whenever a person experiences hypoventilation. Hypoventilation leads to a buildup of CO2, resulting in an accumulation of carbonic acid in the blood. Carbonic acid dissociates, liberating H+, and there is a decrease in pH. The patient is not experiencing metabolic acidosis. These results are not indicative of metabolic alkalosis or respiratory alkalosis (because the pH is high).

While caring for a patient with chronic obstructive pulmonary disease, the nurse finds that the patient's arterial blood gas results show a blood pH of 7.29, partial pressure of carbon dioxide (PaCO 2) of 49 mm Hg, and a bicarbonate ion (HCO 3) level of 25 mEq/L. Which condition does the nurse suspect?

Respiratory acidosis The normal ranges of blood pH, partial pressure of carbon dioxide, and bicarbonate ion levels are 7.35 to 7.45, 75 to 100 mm Hg, and 22 to 26 mEq/L, respectively. Patients with chronic obstructive pulmonary disease (COPD) have difficulty breathing, which leads to hypoventilation. This causes a buildup of carbon dioxide in the blood, which increases the concentration of carbonic acid, leading to a decrease in blood pH. Thus the patient is expected to have respiratory acidosis. In respiratory alkalosis, partial pressure of carbon dioxide decreases. Metabolic acidosis is manifested by decreased concentration of bicarbonate in blood. Respiratory alkalosis is manifested by decreased carbonic acid concentration in blood and decreased PaCO 2.

A patient had an estimated blood loss of 400 mL during abdominal surgery. The patient received 300 mL of 0.9% saline during surgery and now is experiencing hypotension postoperatively. What should the nurse anticipate for this patient?

Restoring circulating volume The nurse should anticipate restoring circulating volume with intravenous (IV) infusion. Although blood could be used to restore circulating volume, there are no manifestations in this patient indicating a need for blood administration. The nurse will need to do more than monitor pulse and blood pressure. An ECG may be done if there is no response to the fluid administration or there is a past history of cardiac disease or cardiac problems were noted during surgery. Returning to surgery to check for internal bleeding would only be done if the patient's level of consciousness changes or the abdomen becomes firm and distended.

A patient inadvertently received a large amount of intravenous fluid. The nurse assesses that the patient has reduced oxygen saturation, crackles on auscultation, and infiltrates on chest x-ray. How should the nurse relieve the patient's breathing discomfort and promote oxygen saturation?

Restrict fluids. Administer diuretics. Administer oxygen therapy. The breathing difficulty in the patient is due to the development of pulmonary edema caused by the infusion of a large volume of fluids. The patient would be relieved of pulmonary edema by fluid restriction. Use of diuretics would reduce the volume load. Oxygen therapy would help maintain adequate oxygenation saturation levels. Bronchodilators may help patients with constriction of the bronchi, but that is not the case with this patient. Anticoagulant therapy prevents the blood from clotting but may not be helpful in relieving pulmonary edema.

The nurse is to administer preoperative medications for a patient who is scheduled for surgery at 7:30: cefazolin intravenously (IV) to be infused 30 minutes before surgery, midazolam IV before surgery, and a scopolamine patch behind the ear. Which medication should the nurse administer first?

Scopolamine The scopolamine patch will be administered first to allow enough time for the serum level to become therapeutic. The cefazolin will be given at 7 to allow infusion 30 minutes before surgery. Fentanyl is a narcotic and was not prescribed preoperatively. The midazolam, a short-acting benzodiazepine, is used as a sedative.

A patient transferred to the medical-surgical unit from the postanesthesia care unit (PACU) has regained consciousness. In which position should the nurse place the patient in order to prevent respiratory problems?

Supine position with head elevated If the patient is conscious, the patient should be positioned in supine position with the head elevated. This position helps to maximize the expansion of the thorax by decreasing the pressure of abdominal contents on the diaphragm. Lateral recovery position is usually used in unconscious patients to keep the airway open and reduce the risk of aspiration if vomiting occurs. Prone and lithotomy positions are not used in postsurgery patients.

A patient is being discharged after having a laparoscopic cholecystectomy. The nurse should instruct the patient to notify the surgeon immediately if which condition develops?

Temperature of 103° F The primary health care provider should be notified immediately if the patient experiences an increase in temperature higher than 101° F because this may be indicative of an infectious process that will require immediate interventions to resolve. Right shoulder pain is expected after a laparoscopic surgery and is resolved within 48 to 72 hours. Constipation and decreased appetite may occur. If these do not resolve after discharge, the patient should be instructed to contact the primary health care provider.

The nurse is caring for a group of patients. Which patient should the nurse closely monitor for the development of respiratory acidosis?

The patient being treated for severe pneumonia Pneumonia is an inflammatory condition that causes hypoventilation, which results in increased concentration of carbon dioxide in blood and precipitates respiratory acidosis. Severe vomiting may cause loss of strong acids from the body, resulting in metabolic alkalosis. A pulmonary embolism causes hyperventilation, resulting in respiratory alkalosis. Diabetic ketoacidosis causes accumulation of ketone bodies in the body, resulting in metabolic acidosis.

The nurse suspects which possible conditions in a patient whose serum potassium level is 6.8 mEq/L on admission?

The patient is taking amiloride daily. The patient suffers from renal disease. Potassium levels greater than 5.0 mEq/mL indicated hyperkalemia. Potassium-sparing diuretics, such as amiloride, increase the potassium levels. Insulin moves potassium into the cell and decreases serum potassium values. The kidneys excrete potassium, so renal disease can lead to increased potassium levels. Hyperkalemia is manifested on an electrocardiogram as tall, peaked T waves. Potassium should not be added to IV fluids if the patient suffers from hyperkalemia.

A patient's arterial blood gas results indicate the presence of metabolic alkalosis. Which clinical manifestations assessed by the nurse confirm this interpretation?

Tremors Vomiting Tachycardia Tremors, vomiting, and tachycardia are signs of metabolic alkalosis. Epigastric pain and numbness of limbs are signs of respiratory alkalosis.

A patient's insensible water loss is estimated at 900 mL per day. The nurse understands that this fluid is lost via which mechanism?

Vaporized by the lungs and skin Approximately 600-900 mL of water is lost each day via insensible water loss, which is vaporization by the lungs and skin. Approximately 1,500 mL is excreted in the urine and 100 mL in the feces. Approximately 8,000 mL of digestive fluids are secreted daily, but most is reabsorbed in the gastrointestinal tract.

A patient gives consent for surgery to the surgeon and a nurse witnesses the consent. The patient then states they do not want to have the surgery. The patient has one adult child but no other immediate family. What action should the nurse take next?

inform the surgeon The patient has the right to revoke the consent at any time; however, this should be reported to the concerned medical staff who obtained the consent, because knowing this would help in planning the next steps. The information need not be given to the patient's son if he did not witness the informed consent. The nurse should not try to persuade the patient to change his or her mind; all the pertinent information should already have been provided to the patient earlier. The senior nurse need not be notified.

Which term is used to describe the fact that extracellular fluid and intracellular fluid have the same osmolality?

isotonic Extracellular fluid and intracellular fluid have the same osmolality; this characteristic is termed isotonic, meaning that there is no net movement of fluids. Hypotonic refers to fluids with a lower osmolality, which results in water moving into the cell when the cell is surrounded by a hypotonic fluid. Hypertonic refers to fluids with a higher osmolality, which results in water moving out of the cells when they are surrounded by a hypertonic solution. Oncotic pressure refers to the pressure of plasma colloids in a solution.

The nurse provides care for a patient with respiratory alkalosis. What arterial blood gas results correspond to this condition?

pH 7.52, pCO 2 24 mm Hg, PO 2 85 mm Hg, and HCO 3 - 24 mEq/L explanation: The patient is experiencing alkalosis because the pH is greater than 7.45. The alkalosis is of a respiratory origin because the carbon dioxide is below normal (reflecting that there is not enough acid) and the HCO3- is within normal range. Normal arterial blood gas values include pH 7.35 to 7.45, pCO2 35 to 45, HCO3- 22 to 26. A pH of 7.46, pCO2 of 44 mm Hg, pO2 of 95 mm Hg, and HCO3- of 36 mEq/L indicate metabolic alkalosis because pH is increased, the pCO2 is normal, and the HCO3- is increased. A pH of 7.27, pCO2 of 70 mm Hg, pO2 of 80 mm Hg, and HCO3- of 26 mEq/L indicate respiratory acidosis because pH is low, pCO2 is increased, and HCO3- is normal. A pH of 7.30, pCO2 of 35 mm Hg, pO2 of 70 mm Hg, and HCO3- of 20 mEq/L indicate metabolic acidosis because the pH is low, pCO2 is normal, and HCO3- is low.9

While documenting the arterial blood gas values of a group of patients, the nurse suspects a patient to have respiratory alkalosis. Which patient's findings support the nurse's suspicion?

patient B pH 7.62 PaCO2 30 HCO3- 22 Respiratory alkalosis is characterized by an increased pH and decreased carbon dioxide concentration (PaCO 2) in blood. The normal values of blood pH, partial pressure of carbon dioxide (PaCO 2), and bicarbonate ion (HCO 3 -) are between 7.35 and 7.45, 35 and 45 mm Hg, and 22 and 26 mEq/L, respectively. The increased pH and decreased PaCO 2 in patient B are indicators of respiratory alkalosis. tip:Respiratory alkalosis is caused by hyperventilation.

After reviewing the laboratory reports of four patients, the primary health care provider orders the nurse to prepare one of the patients for mechanical ventilation. Which patient's reports indicate the need for this intervention?

patient C ph 7.34 PaCO2 47 A need for mechanical ventilation arises when the patient is not able to breathe properly. This is manifested by decreased oxygen and increased carbon dioxide in blood. The normal partial pressure of carbon dioxide (PaCO 2) value lies between 35 and 45 mm Hg, and the normal range of blood pH is 7.35 to 7.45. Patient C has an increased concentration of carbon dioxide in the blood and a low pH, which indicate that the patient has difficulty breathing and requires mechanical ventilation.

The nurse is administering midazolam to a patient during a closed reduction of a shoulder. What outcome does the nurse anticipate achieving from the administration of the medication?

provided conscious decision Midazolam is a benzodiazepine that is used widely for its ability to induce amnesia and provide moderate sedation (conscious sedation). Nitrous oxide is a gaseous agent that potentiates volatile agents to speed induction and reduce total dosage and side effects. Antiemetics prevent intraoperative vomiting. Neuromuscular blocking agents facilitate endotracheal intubation.

A patient taking warfarin and digoxin for treatment of atrial fibrillation is instructed to discontinue the use prior to surgery. What should the nurse closely monitor this patient for?

pulmonary embolism Warfarin is an anticoagulant that is used to prevent mural thrombi from forming on the walls of the atria during atrial fibrillation. Once the medication is terminated, thrombi could form again. If one or more detach from the atrial wall, they could travel as arterial emboli from the left atrium or as pulmonary emboli from the right atrium. Excessive bleeding would occur from excess warfarin administration, not withholding. Blood pressure and peripheral vascular resistance are not affected by warfarin.

A patient is scheduled for an appendectomy. During the preoperative assessment, the patient states they developed allergic skin rashes when exposured to rubber gloves when admitted to the hospital a few years ago. The nurse should review the patient's medical record for a history of what?

reactions to latex

The nurse finds that a postoperative patient has low oxygen saturation and crackles on auscultation. Which is an appropriate nursing action?

restrict fluid intake Pulmonary edema in a postoperative patient is due to fluid overload. Therefore fluid restriction is the most appropriate intervention. In addition, oxygen therapy and diuretics can be administered. The airway is suctioned if there is any secretion retained in the system. Monitoring of mental status is done in the early postoperative period to determine emergence from anesthesia. Lateral recovery position is used in the early postoperative period to keep the airway patent and prevent aspiration in case the patient vomits.