Foundations 2 Module 3 Rationale
The nurse is preparing to administer medication to a postoperative client. Which health care provider prescription is written correctly on the chart?Hydromorphone 5 mg PO every 3 hours as needed for pain
Hydromorphone 5 mg PO every 3 hours as needed for pain
A nurse is caring for a client who is going to have a bone marrow biopsy under conscious sedation. The client expresses fear about the procedure and asks the nurse if the biopsy will hurt. Which response should the nurse make?
"The biopsy can be uncomfortable, but I will try to keep you as comfortable as possible."
After completing client teaching on the use of patient-controlled analgesia (PCA), what statement by the client will help the nurse determine that the client understands the use of the PCA?
"The machine will only give me the prescribed amount of pain medication even if I push the button too soon."
A client scheduled for a hysterectomy paces the floor, repeatedly saying, "I just want this over." What should the nurse say to promote a positive surgical outcome for the client?
"What are your specific concerns about the surgery today"
The nurse is to administer midazolam 2.5 mg. The medication is available in a 5 mg/mL vial. How many mL should the nurse administer? Calculate to the nearest tenth.
0.5
Blood administration is prescribed for a client receiving chemotherapy. The nurse is obtaining all supplies needed for the infusion. Which intravenous solution is obtained? Click on the correct picture.
0.9% sodium Chloride
2 out of 2 points A nurse is caring for a client who reports nausea and vomiting 1 day postoperative following left shoulder surgery. Which action should the nurse perform?
Administer antiemetic medication or Assess bowel sounds in all 4 quadrants
A client who had a gastrectomy has been in the postanesthesia recovery room for 30 minutes when the vital signs suddenly change. The nurse checks the recovery room record (see chart below). In addition to notifying the health care provider, what other action should the nurse take immediately?
Administer dantrolene
Immediately following pelvic surgery, a client has an indwelling urinary catheter. Which intervention would be helpful to prevent catheter-related urinary tract infection?
Advocate for limited use of indwellling urinary catheter
A client arrives from surgery to the postanesthesia care unit (PACU). Which respiratory assessment should the nurse complete first?
Airway flow
The client has just returned to bed following the first ambulation since abdominal surgery. The client's heart rate and blood pressure are slightly elevated; oxygen saturation is 91% on room air, but the client reports being "a little short of breath," but does not have dizziness or pain. What intervention should the nurse perform?
Allow the client to rest, then reassess
Upon the admission assessment of a Hispanic patient being prepped for surgery, the nurse realizes that the patient does not speak English. Which action is appropriate by the nurse to prepare the patient for surgery?
Arrange hospital translator's presence during informed consent
Following surgery, a client is receiving 1,000 mL Normal Saline intravenously (IV) with 40 mEq KCL, which has been prescribed to be infused at 125 mL/h. The client states, "My IV hurts." What should the nurse do first?
Assess the IV site for signs of phlebitis
A client has been unable to void since having abdominal surgery 8 hours ago. What intervention should the nurse perform?
Assist client to bedside toilet
The nurse is caring for a client receiving a continuous infusion of narcotics for relief of postoperative pain. On assessment, the client's vital signs are as follows: HR 84, RR 11, BP 104/56 and oxygen saturation of 88%, on room air. Which intervention should the nurse perform?
Assist the client to sit up, cough, and deep breath OR stop the infusion
On the first day after surgery, a client has been breathing room air. The vital signs are normal, and the oxygen saturation is 88%. What should the nurse do first?
Assist with incentive spirometry
On the day of surgery, a client with diabetes who takes insulin on a sliding scale is to have nothing by mouth and all medications withheld. The client's 6 am glucose level is 300 mg/dL. What should the nurse do?
Call surgeon for further instruction
2 out of 2 points A nurse enters a room and finds a client not responding to verbal stimuli. After notifying the rapid response team, which action should the nurse take?
Check for a coratid pulse
Which nursing intervention is most important in preventing postoperative complications?
Early ambulation
A client who is scheduled for an open cholecystectomy has a 20-pack-year history of smoking. Which postoperative complication is the client most at risk?
Collapse of a lung
Which safety measures by the nurse would be most important to implement when caring for a client who is receiving 2 units of packed red blood cells (PRBCs)? Select all that apply.
Compare information on the identification bracelet with the tag on the blood bag Infuse a unit of PRBCs in less than 4 hours Stop the transfusion if a reaction occurs, but keep the line open Inspect the blood bag for leaks, abnormal color, and clots
The nurse is removing the client's staples from an abdominal incision when the client sneezes and the incision splits open, exposing the intestines. Which action should the nurse take?
Cover the abdominal organs with sterile saline-soaked dressings
A nurse is assessing a client returning from same day surgery. The nurse checks preoperative vital signs at 8:30 am to compare them with the current vital signs at 10:30 pm (see chart below). What nursing intervention is needed at this time?
Cover the client with warmed blankets
When receiving a client from the postoperative care unit after right above the knee amputation, which should the nurse assess next after obtaining vital signs?
Dressing
Which intervention should the nurse encourage the unlicensed assistive personnel (UAP) to assist with in the care of postoperative clients? Select all that apply.
Empty and measure indwelling urinary catheter collection bag Reposition clients for pain relief Tell the nurse if clients report they are having pain
Following abdominal surgery, a client refuses to deep breathe and cough every 2 hours as prescribed. What should the nurse do first?
Explain risks of not performing activities
When the nurse administers IV midazolam, the client oxygen saturation drops from 94% to 86% and begin to go into respiratory arrest. What action should the nurse perform?
Give intravenous flumazenil OR Ventilate with a bag-valve mask
The nurse is preparing to administer a preoperative medication. Which actions should the nurse take?
Have the client empty the bladder
Which intervention should the nurse implement for pulmonary emboli prophylaxis?
Have the patient to do leg exercises every hour while awake
A nurse is caring for a client immediately following a procedure that required spinal anesthesia. Which finding indicates the client is experiencing a complication of the anesthia?
Headache
A client has been in the position shown in the figure for surgery. The nurse should document that the client has been in which position?
High lithotomy
What is the expected therapeutic effect of metoclopramide prescribed as a premedication for a client about to undergo a gastroduodenoscopy?
Increased gastric emptying
The nurse is evaluating a client who is using a incentive spirometer following abdominal surgery 1 day ago. The client is performing the procedure correctly when the client does which interventions? Select all that apply.
Inhales for 3-5 seconds following fully expanding the lungs Coughs after using the spirometer Is sitting upright
The nurse observes the client with an intermittent compression device in place after hip surgery (see figure below). What should the nurse do?
Make sure the client is comfortable in the device
A nurse is observing a client's postoperative vital signs. Which nursing intervention should be done? Select all that apply. - BP drops quickly & HR increases rapidly
Monitor vital signs frequently Increase IV fluid rate Elevate the lower extremities Administer oxygen Notify the health care provider
A client has had a nasogastric tube connected to low intermittent suction. "The client is a risk for which complication?
Muscle cramping
The nurse assesses a client who has just received morphine sulfate. The client's blood pressure is 90/50 mm Hg; pulse rate, 58 bpm; respiration rate, 4 breaths/min. The nurse should check the client's chart for which prescription to administer?
Naloxone
When the nurse asks the client who is to have abdominal surgery today if the client understands the procedure, the client replies, "No, not really; I talked about several different things with my surgeon, and I am just not sure." What should the nurse do?
Notify the surgeon of the client's expressed lack of understanding
During a preoperative physical exam, the nurse is alerted to the possibility of compromised respiratory function after surgery in a patient with which problem?
Obesity
A client is admitted to the postanesthesia care unit (PACU) following a left hip replacement. The initial nursing assessment is: T 97.0 F, Pulse 90, RR 14, and BP 128/80. The client only responds with moaning when spoken to. What action should the nurse take?
Place client on right side
A client is to receive a blood transfusion of packed red blood cells (RBCs) for severe anemia. Place the steps in the order a nurse would follow to administer this product. All options must be used.
Record baseline vital signs. Check the packed cells for abnormal color, clumping, gas bubbles, and expiration date. Verify the blood bag identification, ABO group, and Rh compatibility against the client information. Put on gloves, a gown, and a face shield. Flush the intravenous tubing with normal saline solution. Begin blood transfusion. Remain with the client and watch for signs of a transfusion reaction.
During a preoperative review of systems,the client reveals a history of renal disease. Which preoperative diagnostic study should the health care provider prescribe?
Serum Creatinine
The nurse is reviewing the laboratory results for a preoperative patient. Which study result should be brought to the attention of the surgeon immediately?
Serum K level of 2.0 mEq/L
A patient scheduled for hip replacement surgery in the early afternoon is NPO but receives and eats a breakfast tray with clear liquids on the morning of surgery. What response does the nurse expect when the surgeon is notified?
Surgery will be done as scheduled
A client is to be discharged from same-day surgery 7 hours after his inguinal hernia repair. Which of the following indicates this client is ready to be discharged?
The client voids 500 mL of urine
Which intervention is appropriate for the nurse to delegate to the unlicensed assistive personnel (UAP) when caring for the client experiencing acute pain? Select all that apply.
Turn the television to the guided imagery channel Provide soothing music Reposition the client
The initial postoperative assessment is completed on a client who had an arthroscopy of the knee. Assessment of which parameter is not necessary every 15 minutes during the first postoperative hour?
Urine output
While in the postoperative acute care unit (PACU), the patient's blood pressure drops from an admission pressure of 126/82 to 100/62 with a pulse change of 68 to 94. The nurse administers oxygen. What other intervention should the nurse perform?
Use a cardiac monitor to assess heart rhythm or Increase the rate of IV fluids
A nurse is providing preoperative teaching for a client who is scheduled for a gastrectomy. Which information regarding prevention of postoperative complications should the nurse include in the teaching?
instruct use of incentive spirometer
