Med Surg Exam 1 prep u
The nurse documents the presence of granulation tissue in a healing wound. How should the nurse describe the tissue?
Pink to red and soft, bleeding easily
While doing a health history, a client tells the nurse that her mother, grandmother, and sister died of cancer. The client wants to know what she can do to keep from getting cancer. What would be the nurse's best response?
"You can't prevent cancer, but you can have your blood analyzed for tumor markers to see what your risk level is."
A client is scheduled for a surgical procedure. When planning the client's care, the nurse should consider that which of the following conditions will increase the client's risk of complications after surgery?
A history of diabetes
The nurse is concerned that a postoperative patient may have a paralytic ileus. What assessment data may indicate that the patient does have a paralytic ileus?
Absence of peristalsis
A client is undergoing chemotherapy treatment for prostate cancer and has lost considerable weight due to nausea and vomiting. Which nursing intervention is appropriate for the client?
Adjusting the client's meal plan before and after chemotherapy
You are caring for a client preoperatively who is very anxious and fearful about their surgery. You know that this client's anxiety can cause problems with the surgical experience. What type of problems can this client have because of their anxiety and fear?
Anxious clients have a poor response to surgery and are prone to complications.
A client is postoperative day 3 after surgical repair of an open abdominal wound and traumatic amputation of the right lower leg following a motorcycle crash. What is the highest priority nursing intervention?
Assessing WBC count, temperature, and wound appearance
Informed consent from the surgical client is essential in all of the following categories of surgery except:
Emergent Surgery
A nurse is caring for a client after a bone marrow transplant. What is the nurse's priority in caring for the client?
Monitor the client to prevent sepsis.
A nurse is caring for a client receiving chemotherapy. Which nursing action is most appropriate for handling chemotherapeutic agents?
Wear disposable gloves and protective clothing.
A client had a nephrectomy 2 days ago and is now complaining of abdominal pressure and nausea. The first nursing action should be to:
auscultate bowel sounds.
According to the TNM classification system, T0 means there is
no evidence of primary tumor.
After cancer chemotherapy, a client experiences nausea and vomiting. The nurse should assign highest priority to which intervention?
Administering metoclopramide and dexamethasone as ordered
In preparing the client for transfer to the operating room, which of the following actions by the nurse is inappropriate?
Allow the client to wear dentures.
A client refuses to remove her wedding band when preparing for surgery. What is the best action for the nurse to take?
Allow the client to wear the ring and cover it with tape.
A client diagnosed with cancer makes the following statement to the nurse: "I guess I will tell my health care provider to forego the chemotherapy. I do not want to be throwing up all the time. I would rather die." Which of the following facts supports the use of chemotherapy for this client?
Chemotherapy treatment can be adjusted to optimize effects while limiting adverse effects.
A patient with uterine cancer is being treated with internal radiation therapy. What would the nurse's priority responsibility be for this patient?
Explain to the patient that she will continue to emit radiation while the implant is in place
A nurse is administering daunorubicin through a peripheral I.V. line when the client complains of burning at the insertion site. The nurse notes no blood return from the catheter and redness at the I.V. site. The client is most likely experiencing which complication?
Extravasation
The client is receiving a vesicant antineoplastic for treatment of cancer. Which assessment finding would require the nurse to take immediate action?
Extravasation
The nursing assessment of the postoperative client reveals an incision that is well-approximated with sutures intact, minimal redness and edema, and absence of drainage. The nurse recognizes the wound is healing by:
First intention
The nurse working on a bone marrow unit knows that it is a priority to monitor which of the following in a client who has just undergone a stem cell transplant?
Monitor the client closely to prevent infection.
A nurse is teaching a community class about how to decrease the risk of cancer. Which food should the nurse recommend?
Oranges
You are physically preparing a client for surgery and instruct the person to remove any jewelry. The client refuses to remove a wedding band. What should you do in this situation with approval from your facility?
Place gauze under and over the ring and apply adhesive tape over it.
A nurse is receiving a client with a radioactive implant for the treatment of cervical cancer. What is the nurse's best action?
Place the client in a private room.
A nurse is caring for a client in the PACU after surgery requiring general anesthesia. The client tells the nurse, "I think I'm going to be sick." What is the primary action taken by the nurse?
Position the client in the side-lying position.
A client is scheduled for elective surgery. To prevent the complications of hypotension and cardiovascular collapse, the nurse should report the use of which medication?
Prednisone
A nurse is witnessing a client sign the consent form for surgery. After signing the consent form, the client starts asking questions regarding the risks and benefits of a surgical procedure. What action by the nurse is most appropriate?
Request that the surgeon come and answer the questions.
The nurse is providing client teaching for a client undergoing chemotherapy. What dietary modifications should the nurse advise?
avoid spicy and fatty foods
A PACU nurse is caring for an older adult who presents with clinical manifestations of delirium. What short-term outcome would be most important for this client?
experiences pain within tolerable limits.
The nurse is working with a client who has had an allo-hematopoietic stem cell transplant (HSCT). The nurse notices a diffuse rash and diarrhea. The nurse contacts the physician to report that the client has symptoms of
graft-versus-host disease.
A client, 66 years old, has just been diagnosed with multiple myeloma (a cancer of the plasma) and will be initiating chemotherapy. The nurse, in an outpatient clinic, reviews the medications the client has been taking at home. The medications include pantoprazole for gastroesophageal reflux disease (GERD) and an over-the-counter calcium supplement to prevent osteoporosis. What interventions should the nurse take? Select all that apply.
instructs the client to discontinue calcium asks about nausea and vomiting teaches the client to report abdominal or bone pain
Which type of vaccine uses the client's own cancer cells, which are killed and prepared for injection back into the client?
Autologous
Clients who have received corticosteroids preoperatively are at risk for which type of insufficiency?
Adrenal
What would the instructor tell the students purulent fluid indicates?
Infection
When is the ideal time to discuss preoperative teaching
Preadmission visit
It is important for the nurse to assist a postsurgical client to sit up and turn the head to one side when vomiting in order to
avoid aspiration
A client is on a ventilator. Alarms are sounding, indicating an increase in peak airway pressure. The nurse assesses first for
A kink in the ventilator tubing
A client with chronic bronchitis is admitted to the health facility. Auscultation of the lungs reveals low-pitched, rumbling sounds. Which term should the nurse document?
Rhonchi
The nurse enters the room of a client who is being monitored with pulse oximetry. Which of the following factors may alter the oximetry results?
Diagnosis of peripheral vascular disease
The nurse recognizes that the client most at risk for mortality associated with surgery is the:
Client with chronic alcoholism
The clinic nurse is caring for a client who has just been diagnosed with a tumor. The client says to the nurse "The doctor says my tumor is benign. What does that mean?" What is the nurse's best response?
"Benign tumors don't usually cause death."
While doing a health history, a client tells the nurse that her mother, her grandmother, and her sister died of breast cancer. The client asks what she can do to keep from getting cancer. What is the best response by the nurse?
"Cancer prevention and detection can be done with blood analysis for tumor markers to measure your risk level."
A nurse is caring for a client who is receiving chemotherapy and has a platelet count of 30,000/mm3. Which statement by the client indicates a need for additional teaching?
"I floss my teeth every morning."
The nurse is preparing a client for surgery. The nurse would notify the surgeon if the client made which of the following statements? Select all that apply.
"I took my Coumadin as usual last evening." "I took two aspirins for joint pain this morning."
A nurse is teaching a client about pain management after surgery. Which client statement indicates the teaching was effective?
"I will support my incision with my hands when I cough and do my deep breathing exercises."
A client receiving chemotherapy has a nursing diagnosis of Deficient diversional activity related to decreased energy. Which client statement indicates an accurate understanding of appropriate ways to deal with this deficit?
"I'll play card games with my friends."
Which statement by a client undergoing external radiation therapy indicates the need for further teaching?
"I'm worried I'll expose my family members to radiation."
A client asks why a drain is in place to pull fluid from the surgical wound. What is the best response by the nurse?
"It assists in preventing infection."
You are the nurse working in an ambulatory surgery center. A teenage son of your clients ask you why so many people have surgery. What would be your best reply?
"Many people have diagnostic or short therapeutic surgical procedures."
The nurse is caring for a client who is scheduled for chemotherapy. Which is the best statement the nurse can make about the client experiencing chemotherapy-induced alopecia?
"The hair loss is usually temporary."
The nurse has provided preoperative instructions to a client scheduled for surgery at an ambulatory care center. Which statement, made by the client, would indicate that further instruction is needed?
"The nurse will explain the details of the surgery before I sign a consent."
A patient is scheduled for cryoablation for cervical cancer and tells the nurse, "I am not exactly sure what the surgeon is going to do." What is the best response by the nurse?
"The surgeon is going to use liquid nitrogen to freeze the area."
The nurse is completing a preoperative assessment. The nurse notices the client is tearful and constantly wringing their hands. The client states, "I'm really nervous about this surgery. Do you think it will be ok?" What is the nurse's best response?
"What are your concerns?"
A patient who wears contact lenses is to be placed on rifampin for tuberculosis therapy. What should the nurse tell the patient?
"You should switch to wearing your glasses while taking this medication."
The nurse is providing preoperative care to a client who is anxious about total hip replacement surgery. "What if I can never walk again? I don't want to end up like my father!" What are some ways the nurse might help alleviate the client's anxiety? Select all that apply.
-Make sure the client understands what will happen during surgery. -Listen empathetically to the client's concerns about the procedure. -Review the client's postoperative goals following the procedure. -Ask the client if he would like to speak with a clergyperson.
A nurse prepares to suction a client's tracheostomy tube. Place the procedure steps in correct order.
1.Position the client in Fowlers position. 2. Don sterile gloves. 3. Lubricate the sterile suction catheter. 4. Insert suction catheter into the lumen of the tube. 5. Apply intermittent suction while withdrawing the catheter.
When performing endotracheal suctioning, the nurse applies suctioning while withdrawing and gently rotating the catheter 360 degrees for how long?
10 to 15 seconds
After diagnosing a client with pulmonary tuberculosis, the physician tells family members that they must receive isoniazid (INH [Laniazid]) as prophylaxis against tuberculosis. The client's daughter asks the nurse how long the drug must be taken. What is the usual duration of prophylactic isoniazid therapy?
6 to 12 months
For the client who is taking aspirin, it is important to stop taking this medication at least how many day(s) before surgery?
7
The nurse is preparing to discharge a client from the PACU using a PACU room scoring guide. With what score can the client be transferred out of the recovery room?
7
A client having a surgical procedure takes aspirin 325 mg daily for prevention of platelet aggregation. When should the client stop taking the aspirin before the surgery?
7 to 10 days
What is the blood glucose level goal for a diabetic client who will be having a surgical procedure?
80 to 110 mg/dL
What abnormal postoperative urinary output should the nurse report to the physician for a 2-hour period?
<30 mL
What dietary recommendations should a nurse provide a client with a lung abscess?
A diet rich in protein
Which statement describes emphysema?
A disease of the airways characterized by destruction of the walls of overdistended alveoli
The nurse expects informed consent to be obtained for insertion of:
A gastrostomy tube
The nurse assesses an older adult patient who complains of dimmed vision. What does this alert the nurse to plan for?
A safe environment
Which of the following is accurate regarding status asthmaticus?
A severe asthma episode that is refractory to initial therapy
Constant bubbling in the water seal of a chest drainage system indicates which problem?
Air leak
A client with asthma is prescribed a short acting beta-adrenergic (SABA) for quick relief. Which of the following is the most likely drug to be prescribed?
Albuterol
In which statements regarding medications taken by a client diagnosed with COPD do the drug name and the drug category correctly match? Select all that apply.
Albuterol is a bronchodilator. Ciprofloxacin is an antibiotic. Prednisone is a corticosteroid.
Which is a sign or symptom of septic shock?
Altered mental status
While conducting the physical examination during assessment of the respiratory system, which conditions does the nurse assess by inspecting and palpating the trachea?
Deviation from the midline
A patient is scheduled for a surgical procedure. For which surgical procedure should the nurse prepare an informed consent form for the surgeon to sign?
An open reduction of a fracture
A client is diagnosed with a chronic respiratory disorder. After assessing the client's knowledge of the disorder, the nurse prepares a teaching plan. This teaching plan is most likely to include which nursing diagnosis?
Anxiety
When should the nurse encourage the postoperative patient to get out of bed?
As soon as it is indicated
The nurse is caring for a client with recurrent hemoptysis who has undergone a bronchoscopy. Immediately following the procedure, the nurse should complete which action?
Assess the client for a cough reflex.
A new ICU nurse is observed by her preceptor entering a patient's room to suction the tracheostomy after performing the task 15 minutes before. What should the preceptor educate the new nurse to do to ensure that the patient needs to be suctioned?
Auscultate the lung for adventitious sounds.
For a client with an endotracheal (ET) tube, which nursing action is the most important?
Auscultating the lungs for bilateral breath sounds
What assessment method would the nurse use to determine the areas of the lungs that need draining?
Auscultation
A client receiving external radiation to the left thorax to treat lung cancer has a nursing diagnosis of Risk for impaired skin integrity. Which intervention should be part of this client's care plan?
Avoiding using soap on the irradiated areas
If concern exists about fluid accumulation in a client's lungs, what area of the lungs will the nurse focus on during assessment?
Bilateral lower lobes
A victim has sustained a blunt force trauma to the chest. A pulmonary contusion is suspected. Which of the following clinical manifestations correlate with a moderate pulmonary contusion?
Blood-tinged sputum
Which occurs when fluid accumulates in the pericardial space and compresses the heart?
Cardiac tamponade
Which oncologic emergency involves the accumulation of fluid in the pericardial space?
Cardiac tamponade
The nurse is evaluating the client's understanding of diet teaching aimed at promoting wound healing following surgery. The nurse would conclude teaching was ineffective if the client selects which of the following?
Cheeseburger, french fries, coleslaw, and ice cream
The nurse assesses a patient with a heart rate of 42 and a blood pressure of 70/46. What type of hypoxia does the nurse determine this patient is displaying?
Circulatory hypoxia
The nurse is collaborating with a community group to develop plans to reduce the incidence of lung cancer in the community. Which of the following would be most effective?
Classes at community centers to teach about smoking cessation strategies
Upon assessment, the nurse suspects that a client with COPD may have bronchospasm. What manifestations validate the nurse's concern? Select all that apply.
Compromised gas exchange Wheezes Decreased airflow
Which primary cancer treatment goal is prolonged survival and containment of cancer cell growth?
Control
A nurse is caring for a client who has just been diagnosed with lung cancer. What is a cardinal sign of lung cancer?
Cough or change in chronic cough
The nurse is having an information session with a women's group at the YMCA about lung cancer. What frequent and commonly experienced symptom should the nurse be sure to include in the session?
Coughing
The nurse is assessing the lungs of a patient diagnosed with pulmonary edema. Which of the following would be expected upon auscultation?
Crackles at lung bases
A son brings his father into the clinic, stating that his father's color has changed to bluish around the mouth. The father is confused, with a respiratory rate of 28 breaths per minute and scattered crackles throughout. The son states this condition just occurred within the last hour. Which of the following factors indicates that the client's condition has lasted for more than 1 hour?
Cyanosis
The nurse hears the patient's ventilator alarm sound and attempts to find the cause. What is the priority action of the nurse when the cause of the alarm is not able to be determined?
Disconnect the patient from the ventilator and manually ventilate the patient with a manual resuscitation bag until the problem is resolved.
While administering cisplatin to a client, the nurse assesses swelling at the insertion site. What is the nurse's first action?
Discontinue the intravenous medication.
At which time does the nurse realize that it is best to begin teaching about care needed during the postoperative period?
During the preoperative period
A client has suspected fluid accumulation in the pleural space of the lungs and is scheduled for a thoracentesis. The nurse will implement which of the following for this procedure? Select all that apply.
Educate the client about the need to cleanse the thoracic area. Apply pressure to the puncture site after the procedure. Complete a respiratory assessment after the procedure.
What action by the nurse best encompasses the preoperative phase?
Educating clients on signs and symptoms of infection
A fractured skull would be classified under which category of surgery based on urgency?
Emergent
A gunshot wound would be classified under which category of surgery based on urgency?
Emergent
A junior-level nursing class has just finished learning about the management of clients with chronic pulmonary diseases. They learned that a new definition of COPD leaves only one disorder within its classification. Which of the following is that disorder?
Emphysema
Which intervention does a nurse implement for clients with empyema?
Encourage breathing exercises
A nurse is caring for a patient diagnosed with empyema. Which of the following interventions does a nurse implement for patients with empyema?
Encourage breathing exercises.
You are caring for a client who has been diagnosed with viral pneumonia. You are making a plan of care for this client. What nursing interventions would you put into the plan of care for a client with pneumonia?
Encourage increased fluid intake.
A nurse asks a client who had abdominal surgery 1 day ago if he has moved his bowels since surgery. The client states, "I haven't moved my bowels, but I am passing gas." How should the nurse intervene?
Encourage the client to ambulate as soon as possible after surgery.
The nurse is caring for a client postoperatively. What nursing interventions help prevent venous stasis and other circulatory complications in a client who has undergone surgery?
Encourage the client to move legs frequently and do leg exercises.
A patient is being educated in the use of incentive spirometry prior to having a surgical procedure. What should the nurse be sure to include in the education?
Encourage the patient to take approximately 10 breaths per hour, while awake
A client hospitalized with pneumonia has thick, tenacious secretions. Which intervention should the nurse include when planning this client's care?
Encouraging increased fluid intake
A nurse assesses a postoperative client as having abdominal organs protruding through the surgical incision. Which term best describes this assessment finding?
Evisceration
Which term refers to the protrusion of abdominal organs through the surgical incision?
Evisceration
The nurse is reviewing a preoperative informed consent when preparing the client for surgery. Which contents of the informed consent are required? Select all that apply.
Explanation of procedure Potential risks Benefits of surgery Description of alternatives
Which exposure accounts for most cases of COPD?
Exposure to tobacco smoke
Which exposure acts as a risk factor for and accounts for the majority of cases of chronic obstructive pulmonary disease (COPD)?
Exposure to tobacco smoke
The occupational nurse is completing routine assessments on the employees where you work. What might be revealed by a chest radiograph for a client with occupational lung diseases?
Fibrotic changes in lungs
Which type of healing occurs when granulation tissue is not visible and scar formation is minimal?
First intention
You are an occupational health nurse in a large ceramic manufacturing company. How would you intervene to prevent occupational lung disease in the employees of the company?
Fit all employees with protective masks.
A nurse is reviewing with a client the use of a patient-controlled anesthesia device and is explaining the benefits. Which of the following would the nurse correctly emphasize? Select all that apply.
Fosters client participation in care Facilitates reduction of postoperative pulmonary complications
A nurse has established a nursing diagnosis of ineffective airway clearance. The datum that best supports this diagnosis is that the client
Has wheezes in the right lung lobes
Which domain of perioperative nursing practice focuses on clinical processes and outcomes?
Health care system
A nurse consulting with a nutrition specialist knows it's important to consider a special diet for a client with chronic obstructive pulmonary disease (COPD). Which diet is appropriate for this client?
High-protein
A patient with uncontrolled diabetes is scheduled for a surgical procedure. What chief life-threatening hazard should the nurse monitor for?
Hypoglycemia
What complication in the immediate postoperative period should the nurse understand requires early intervention to prevent?
Hypoxemia and hypercapnia
An anxious client being prepared for surgery is encouraged to concentrate on a pleasant experience or restful scene. What cognitive coping strategy would the nurse document as being used?
Imagery
The nurse has instructed a client on how to perform pursed-lip breathing. The nurse recognizes the purpose of this type of breathing is to accomplish which result?
Improve oxygen transport; induce a slow, deep breathing pattern; and assist the client to control breathing
A nurse has agreed to draft a medication teaching plan for a patient who is taking the hormonal agent, Aromasin, an aromatase inhibitor for postmenopausal women with breast cancer. The nurse knows that a major teaching point is to tell the patient to:
Increase her intake of calcium-rich foods.
Nursing assessment findings reveal a temperature of 96.2°F, pulse oximetry 90%, shivering, and client complains of chilling. The findings are indicative of which nursing diagnosis?
Ineffective thermoregulation
A client who underwent surgery 12 hours ago has difficulty breathing. He has petechiae over his chest and complains of acute chest pain. What action should the nurse take first?
Initiate oxygen therapy.
For a client newly diagnosed with radiation-induced thrombocytopenia, the nurse should include which intervention in the care plan?
Inspecting the skin for petechiae once every shift
A nurse is teaching a client about the rationale for administering allopurinol with chemotherapy. Which example would be the best teaching by the nurse?
It lowers serum and uric acid levels.
The nurse is caring for a client undergoing an incisional biopsy. Which statement does the nurse understand to be true about an incisional biopsy?
It removes a wedge of tissue for diagnosis.
What disadvantages of chemotherapy should the patient be informed about prior to starting the regimen?
It targets normal body cells as well as cancer cells.
A client suffers acute respiratory distress syndrome as a consequence of shock. The client's condition deteriorates rapidly, and endotracheal (ET) intubation and mechanical ventilation are initiated. When the high-pressure alarm on the mechanical ventilator sounds, the nurse starts to check for the cause. Which condition triggers the high-pressure alarm?
Kinking of the ventilator tubing
A decrease in circulating white blood cells (WBCs) is referred to as
Leukopenia
The client asks the nurse about ways to control pain other than taking pain medication. Which strategy should the nurse include when responding to the client? Select all that apply.
Listening to music Watching television Changing position
A physician has ordered that a client with suspected lung cancer undergo magnetic resonance imaging (MRI). The nurse explains the benefits of this study to the client. What is the reason the client with suspected lung cancer would undergo magnetic resonance imaging (MRI)?
MRI can view soft tissues and can help stage cancers.
A client with chronic obstructive pulmonary disease (COPD) is intubated and placed on continuous mechanical ventilation. Which equipment is most important for the nurse to keep at this client's bedside?
Manual resuscitation bag
For a client who has a chest tube connected to a closed water-seal drainage system, the nurse should include which action in the care plan?
Measuring and documenting the drainage in the collection chamber
In which phase of the cell cycle does cell division occur?
Mitosis
An inappropriate nursing action implemented to keep the client safe includes:
Moving the client swiftly
According to the tumor-node-metastasis (TNM) classification system, T0 means there is
No evidence of primary tumor
A client is at postoperative hour 8 after an appendectomy and is anxious, stating "Something is not right. My pain is worse than ever and my stomach is swollen." Blood pressure is 88/50, pulse is 115, and respirations are 24 and labored. The abdomen is soft and distended. No obvious bleeding is noted. What action by the nurse is most appropriate?
Notify the physician.
A client is undergoing preoperative assessment. During admission paperwork, the client reports having enjoyed a hearty breakfast this morning to be ready for the procedure. What is the nurse's next action?
Notify the surgeon.
A nurse practitioner diagnosed a patient with an infection in the maxillary sinuses. Select the area that the nurse palpated to make that diagnosis.
On the cheeks below the eyes
The nurse has medicated a postoperative client who reported nausea. Which medication would the nurse document as having been given?
Ondansetron
Which term will the nurse use to document the inability of a client to breathe easily unless positioned upright?
Orthopnea
A client is scheduled for a cholecystectomy. Which finding by the nurse is least likely to contribute to surgical complications?
Osteoporosis
Following admission of the postoperative client to the clinical unit, which of the following assessment data requires the most immediate attention?
Oxygen saturation of 82%
The nurse is admitting a patient with COPD. The decrease of what substance in the blood gas analysis would indicate to the nurse that the patient is experiencing hypoxemia?
PaO2
After being seen in the oncology clinic, a client with severe bone marrow suppression is admitted to the hospital. The client's cancer therapy consisted of radiation and chemotherapy. When developing the care plan for this client, which nursing diagnosis takes priority?
Risk for infection
The nurse recognizes that written informed consent is required for insertion of a(n):
Peripherally-inserted central catheter.
Which health care profession has the ultimate responsibility to provide appropriate information regarding a nonemergent surgery?
Physician
A patient comes to the emergency department complaining of a knifelike pain when taking a deep breath. What does this type of pain likely indicate to the nurse?
Pleurisy
What does the nurse recognize as one of the most common postoperative respiratory complications in elderly clients?
Pneumonia
The nurse is caring for a client needing emergency surgery. Which preoperative teaching is least important to prepare the client for surgery?
Post-discharge diet
During which step of cellular carcinogenesis do cellular changes exhibit increased malignant behavior?
Progression
The nurse at the clinic explains to the patient that the surgeon will be removing a mole on the patient's back that has the potential to develop into cancer. The nurse informs the patient that this is what type of procedure?
Prophylactic
You are a clinic nurse. One of your clients has found she is at high risk for breast cancer. She asks you what can be done to reduce her risk. What is a means of reducing the risk for breast cancer?
Prophylactic surgery
A patient is admitted for an excisional biopsy of a breast lesion. What intervention should the nurse provide for the care of this patient?
Provide time for the patient to discuss her concerns.
Which should a nurse encourage in clients who are at the risk of pneumococcal and influenza infections?
Receiving vaccinations
The nurse is attempting to ambulate a client who underwent shoulder surgery earlier in the day, but the client is refusing to do so. What action by the nurse is most appropriate?
Reinforce the importance of early mobility in preventing complications.
Which action should a nurse perform to prevent deep vein thrombosis when caring for a postsurgical client?
Reinforce the need to perform leg exercises every hour when awake.
The nurse observes that a postsurgical client has hemorrhaged and is in hypovolemic shock. Which nursing intervention will manage and minimize hemorrhage and shock?
Reinforcing dressings or applying pressure if bleeding is frank
A nurse is teaching a client about deep venous thrombosis (DVT) prevention. What teaching would the nurse include about DVT prevention?
Report early calf pain.
In chronic obstructive pulmonary disease (COPD), decreased carbon dioxide elimination results in increased carbon dioxide tension in arterial blood, leading to which of the following acid-base imbalances?
Respiratory acidosis
A nurse administers albuterol (Proventil), as ordered, to a client with emphysema. Which finding indicates that the drug is producing a therapeutic effect?
Respiratory rate of 22 breaths/minute
Once the operating team has assembled in the room, the circulating nurse calls for a "time out." What action should the nurse take during the time out?
Review the scheduled procedure, site, and client.
The nurse is caring for a client with an endotracheal tube (ET). Which nursing intervention is contraindicated?
Routinely deflating the cuff
The nurse is preparing to assess a client whose chart documents that the client experienced extravasation when receiving the vesicant vincristine during the previous shift. The documentation also notes that an antidote was administered immediately. The nurse prepares to assess for which conditions? Select all that apply.
Sloughing tissue Tissue necrosis Effectiveness of the antidote
A client is undergoing thoracic surgery. What priority education should the nurse provide to assist in preventing respiratory complications?
Splint the incision site using a pillow during deep breathing and coughing exercises.
A patient comes to the clinic for the third time in 2 months with chronic bronchitis. What clinical symptoms does the nurse anticipate assessing for this patient?
Sputum and a productive cough
A nurse is caring for a client receiving chemotherapy. Which assessment finding places the client at the greatest risk for an infection?
Stage 3 pressure Ulcer
A nurse is teaching the client about use of the pictured item with a metered-dose inhaler (MDI). What instructions should the nurse include in the teaching? Select all that apply.
Take a slow, deep inhalation from the device. Activate the MDI once. The device may increase delivery of the MDI medication.
A nurse is developing a teaching plan for a client with asthma. Which teaching point has the highest priority?
Take ordered medications as scheduled.
A nurse is administering a chemotherapeutic medication to a client, who reports generalized itching and then chest tightness and shortness of breath. The nurse immediately
Stops the chemotherapeutic infusion
To help prevent infections in clients with COPD, the nurse should recommend vaccinations against two bacterial organisms. Which of the following are the two vaccinations?
Streptococcus pneumonia and Hemophilus influenzae
A patient comes to the clinic with fever, cough, and chest discomfort. The nurse auscultates crackles in the left lower base of the lung and suspects that the patient may have pneumonia. What does the nurse know is the most common organism that causes community-acquired pneumonia?
Streptococcus pneumoniae
The nurse is invited to present a teaching program to parents of school-age children. Which topic would be of greatest value for decreasing cancer risks?
Sun safety and use of sunscreen
Nursing assessment findings reveal that the client is afraid of dying during the surgical procedure. Which surgical team member would be most helpful in addressing the client's concern?
Surgeon
The nurse is assisting a physician with endotracheal intubation for a client in respiratory failure. It is most important for the nurse to assess for:
Symmetry of the client's chest expansion
Which oncologic emergency involves the failure in the negative feedback mechanism that normally regulates the release of antidiuretic hormone (ADH)?
Syndrome of inappropriate antidiuretic hormone release (SIADH)
At what point does the preoperative period end?
When the client is transferred onto the operating table
The patient with a chest tube is being transported to X-ray. Which complication may occur if the chest tube is clamped during transportation?
Tension pneumothorax
Which client would the nurse recognize as having the greatest risk for complications during the intraoperative or postoperative period?
The 35-year-old client with non-insulin dependent diabetes.
A physician calls the nurse for an update on his client who underwent abdominal surgery 5 hours ago. The physician asks the nurse for the total amount of drainage collected in the Hemovac since surgery. The nurse reports that according to documentation, no drainage has been recorded. When the nurse finishes on the telephone, she goes to assess the client. Which assessment finding explains the absence of drainage?
The Hemovac drain isn't compressed; instead it's fully expanded.
The nurse is caring for the client in the preoperative period and documenting rationale for a palliative surgical procedure. Which rationale is most appropriate?
The client and physician are focusing on symptom relief not a cure.
A nurse is teaching a client about diaphragmatic breathing. What client action indicates that further teaching is needed?
The client exhales forcefully with a short expiration.
The nurse suctions a patient through the endotracheal tube for 20 seconds and observes dysrhythmias on the monitor. What does the nurse determine is occurring with the patient?
The patient is hypoxic from suctioning.
When does the nurse understand the patient is knowledgeable about the impending surgical procedure?
The patient participates willingly in the preoperative preparation.
A 36-year-old man is receiving three different chemotherapeutic agents for Hodgkin's disease. The nurse explains to the client that the three drugs are given over an extended period because:
The three drugs have a synergistic effect and act on the cancer cells with different mechanisms
The nurse is caring for a client diagnosed with asthma. While performing the shift assessment, the nurse auscultates breath sounds including sibilant wheezes, which are continuous musical sounds. What characteristics describe sibilant wheezes?
They can be heard during inspiration and expiration.
A client with metastatic pancreatic cancer underwent surgery to remove a malignant tumor in the pancreas. Despite the tumor being removed, the physician informs the client that chemotherapy must be started. Why might the physician opt for chemotherapy?
To prevent metastasis
The nurse is educating a community group about types of surgery. A member of the group asks the nurse to describe a type of surgery that is curative. What response by the nurse is true?
Tumor excision
A recently extubated postoperative client starts to gag and make vomiting sounds. What action should the nurse perform first?
Turn patient on their side
A client vomits postoperatively. What is the most important nursing intervention?
Turn the client's head completely to one side to prevent aspiration of vomitus into the lungs.
A nurse is discussing squamous epithelial cells lining each alveolus, which consist of different types of cells. Which type of alveolar cells produce surfactant?
Type II cells
A client is receiving radiation therapy and asks the nurse about oral hygiene. What teaching specific to the client's situation should the nurse include?
Use a soft toothbrush and allow it to air dry before storing.
A nurse is teaching a client with chronic bronchitis about breathing exercises. Which instruction should the nurse include in the teaching?
Use diaphragmatic breathing.
A nurse assesses a client's respiratory status. Which observation indicates that the client is having difficulty breathing?
Use of accessory muscles
For a client with advanced chronic obstructive pulmonary disease (COPD), which nursing action best promotes adequate gas exchange?
Using a Venturi mask to deliver oxygen as ordered
The nurse caring for a client with tuberculosis anticipates administering which vitamin with isoniazid (INH) to prevent INH-associated peripheral neuropathy?
Vitamin B6
Which vitamin is usually administered with isoniazid (INH) to prevent INH-associated peripheral neuropathy?
Vitamin B6
Which nutrient plays an important role in normal blood clotting?
Vitamin K
Which type of ventilator has a preset volume of air to be delivered with each inspiration?
Volume cycled
After lobectomy for lung cancer, a client receives a chest tube connected to a disposable chest drainage system. The nurse observes that the drainage system is functioning correctly when she notes tidal movements or fluctuations in which compartment of the system as the client breathes?
Water-seal chamber
The nurse is caring for a client during the immediate postoperative period. What signs and symptoms indicate that the client may be in shock?
Weak and rapid pulse rate
Which of the following is not a primary symptom of COPD?
Weight gain
A client is preparing for a surgical procedure is taking corticosteroids for Crohn's disease. What is most important for the nurse to monitor during the operative experience with the client?
adrenal insufficiency
The nurse assessed a 28-year-old woman who was experiencing dyspnea severe enough to make her seek medical attention. The history revealed no prior cardiac problems and the presence of symptoms for 6 months' duration. On assessment, the nurse noted the presence of both inspiratory and expiratory wheezing. Based on this data, which of the following diagnoses is likely?
asthma
During discharge teaching, a nurse is instructing a client about pneumonia. The client demonstrates his understanding of relapse when he states that he must:
continue to take antibiotics for the entire 10 days.
A 17-year-old client is having same-day surgery. Solely during the intraoperative phase of perioperative care, the nurse:
continuously monitors the sedated client.
A physically fit older adult is scheduled for right knee replacement. What factor for the client creates an increased risk for postoperative complications?
current smoking history
A client with an abdominal surgical wound sneezes and then states, "Something doesn't feel right with my wound." The nurse asses the upper half of the wound edges, noticing that they are no longer approximated and the lower half remains well approximated. The nurse would document that following a sneeze, the wound
dehisced.
A nurse is assisting with a subclavian vein central line insertion when the client's oxygen saturation drops rapidly. He complains of shortness of breath and becomes tachypneic. The nurse suspects the client has developed a pneumothorax. Further assessment findings supporting the presence of a pneumothorax include:
diminished or absent breath sounds on the affected side.
The nurse is evaluating the client's risk for cancer. The nurse should recommend the client change which lifestyle choice?
eats red meat such as steaks or hamburgers every day
When the indication for surgery is without delay, the nurse recognizes that the surgery will be classified as
emergency
A client is being seen in the pediatric clinic for a middle ear infection. The client's mother reports that when the client develops an upper respiratory infection, an ear infection seems quick to follow. What contributes to this event?
eustachian tubes
A nurse is caring for a client who underwent a skin biopsy and has three stitches in place. This wound is healing by:
first intention
What foods should the nurse suggest that the patient consume less of in order to reduce nitrate intake because of the possibility of carcinogenic action?
ham and bacon
In advance of a client's scheduled appendectomy, the nurse spends significant time explaining to the client what will happen, both before the procedure and after the procedure is complete. The primary reason the nurse puts so much effort into preoperative teaching is to:
increase the likelihood of a successful recovery.
A decrease in circulating white blood cells is
leukopenia
A client has received several treatments of bleomycin. It is now important for the nurse to assess
lung sounds
What is the highest priority nursing intervention for a client in the immediate postoperative phase?
maintaining patient airway
Which is a growth-based classification of tumors?
malignancy
The nurse assesses a client to determine if there is increased risk for complications intraoperatively or postoperatively. Which are general risk factors? Select all that apply.
nutritional status age physical condition health status
The client is experiencing nausea and vomiting following surgery. What will the nurse expect the surgeon to order?
ondansetron
A nurse is caring for a client with prostate cancer and assesses bleeding gums and hematuria. What serum indicator should the nurse relate the bleeding?
platelet count of 60,000/mm3
The nurse is reviewing the pre-admission laboratory findings of the client scheduled for surgery. Which laboratory value would be of greatest concern to the nurse?
potassium 6.2 mEq/L
A client with a brain tumor is undergoing radiation and chemotherapy for treatment of cancer. The client has recently reported swelling in the gums, tongue, and lips. Which is the most likely cause of these symptoms?
stomatitis
A client experiences a head injury in a motor vehicle accident. The client's level of consciousness is declining, and respirations have become slow and shallow. When monitoring a client's respiratory status, which area of the brain would the nurse realize is responsible for the rate and depth?
the pons
A perioperative nurse is assigned to complete a preoperative assessment on a client who is scheduled for surgery for kidney stones the next day. What category of surgery does this procedure fall into?
urgent
The nurse is caring for a client 6 hours post-surgery. The nurse observes that the client voids urine frequently and in small amounts. The nurse knows that this most probably indicates what?
urine retention
Which of the following would be inconsistent as a common side effect of chemotherapy?
weight gain
The nurse is performing chest auscultation for a patient with asthma. How does the nurse describe the high-pitched, sibilant, musical sounds that are heard?
wheezes
A nurse is assessing a postoperative client with hyperglycemic blood glucose levels. Which client surgical risk factor would decrease if the surgical client maintained strict blood glycemic control?
wound healing
Which question is most important for the nurse to ask the client when obtaining the preoperative admission history?
"When is the last time you ate or drank?"
The nurse recognizes that which of the following clients is at least risk for perioperative complications?
A 65-year-old Caucasian man who has a history of arthritis