Med Surg Exam 1
A nurse prepares to suction a client's tracheostomy tube. Place the procedure steps in correct order.
Position the client in Fowlers position Don sterile gloves Lubricate the sterile suction catheter Insert suction catheter into the lumen of the tube Apply intermittent suction while withdrawing the catheter
Adequate hourly urine output for a client with an indwelling urinary catheter is
2.0 mL/kg/h
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 patient from the PACU using a PACU room scoring guide. With what score can the patient be transferred out of the recovery room?
8
What is the blood glucose level goal for a diabetic client who will be having a surgical procedure?
80 to 110 mg/dL
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
A patient with renal failure is scheduled for a surgical procedure. When would surgery be contraindicated for this patient due to laboratory results?
A blood urea nitrogen level of 42 mg/dL The kidneys are involved in excreting anesthetic medications and their metabolites; therefore, surgery is contraindicated if a patient has acute nephritis, acute renal insufficiency with oliguria or anuria, or other acute renal problems (see Chapter 54). A blood urea nitrogen level of 42 mg/dL (significantly elevated) is an indicator of renal failure. The other levels are normal.
The nurse expects informed consent to be obtained for insertion of:
A gastrostomy tube
A client is scheduled for a surgical procedure. When planning the client's care, the nurse should consider that which of the following conditions will increase the client's risk of complications after surgery?
A history of diabetes
The nurse assesses an older adult patient who complains of dimmed vision. What does this alert the nurse to plan for?
A safe environment
Clients who have received corticosteroids preoperatively are at risk for which type of insufficiency?
Adrenal
A physically fit 86-year-old is scheduled for right knee replacement. Which factor the client at increased risk for complications during or after surgery?
Age
Many hospitals use a scoring system, called the __________ score, which is used to determine the patient's general condition and readiness for transfer from the PACU
Aldrete
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.
The circulating nurse must be vigilant in monitoring the surgical environment. Which of the following actions by the nurse is inappropriate?
Allow unnecessary personnel to enter the OR environment
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 Emergent surgery occurs when the client requires immediate attention. An elective surgery is classified as a surgery that the client should have. A required surgery means that the client needs to have surgery. An urgent surgery occurs when the client requires prompt attention.
A cluster of symptoms referred to as _________ syndrome may occur during the neutrophil recovery phase in both allogeneic and autologous transplants.
Engraftment
The nurse is teaching a healthy lifestyle class to a group of adolescents. The nurse recommends
Exercising at least 60 minutes per day doing moderate to vigorous activities at least 5 days per week
T/F: Patients who smoke are urged to stop 1 to 3 weeks before surgery to significantly reduce pulmonary and wound healing complications.
False
T/F: Rewarming a patient after surgery must be accomplished rapidly to prevent further hypothermia.
False
T/F: Surgery classification based on the degree of urgency is considered emergent if it is scheduled within 24 to 30 hours (e.g., acute gallbladder infection).
False
Which would be included as a responsibility of the scrub nurse?
Handing instruments to the surgeon and assistants
A patient with uncontrolled diabetes is scheduled for a surgical procedure. What chief life-threatening hazard should the nurse monitor for?
Hypoglycemia
A client is receiving general anesthesia. The nurse anesthetist starts to administer the anesthesia. The client begins giggling and kicking her legs. What stage of anesthesia would the nurse document related to the findings?
II
An inappropriate nursing action implemented to keep the client safe includes:
Moving the client swiftly
A client is being prepared for a same-day surgical procedure and is discussing with the nurse what potential ramifications this type of surgery has. Which of the following would the nurse correctly identify? Select all that apply.
Need for teaching is increased. The client will leave the hospital sooner than in the past. The client must be prepared to take on more self-care than he or she may have done in the past.
The nurse is caring for a postoperative client with an indwelling urinary catheter. The hourly urinary output is 80 mL at 9 am. At 10 am, the nurse assesses the hourly urinary output as 20 mL. What is the priority action by the nurse?
Notify the primary care provider immediately If the client has an indwelling urinary catheter, hourly outputs are monitored and rates <30 mL/h are reported. Any urinary output <30 mL/h should be reported to the primary care provider immediately. Though urinary output will be reassessed at 11 am, but waiting to notify the primary care provider puts the patient at risk. The findings should be documented, but this is not the highest priority. A urinary catheter may need to be irrigated, but a postoperative client with a low urinary output is demonstrating a complication of inadequate fluid imbalance that needs to be reported immediately.
The nurse is conducting a preoperative assessment on a client scheduled for gallbladder surgery. The client reports a frequent cough producing green sputum for 3 days and denies fever. Upon auscultation, the nurse notes rhonchi throughout the right lung, with an occasional expiratory wheeze. Respiratory rate is 20, temperature is 99.8 (taken orally), heart rate is 87, and blood pressure is 124/70. What is the best action by the nurse?
Notify the surgeon to possibly delay the surgery
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.
An OR nurse needs to assist a patient to the Trendelenburg position. Which of the following is the correct position?
On his back, with his head lowered, so that the plane of his body meets the horizontal on an angle
A client is scheduled for a cholecystectomy. Which finding by the nurse is least likely to contribute to surgical complications?
Osteoporosis
On postoperative day 2, a client requires care for a surgical wound using second-intention healing. What type of dressing change should the nurse anticipate doing?
Packing the wound bed with sterile saline-soaked dressing and covering it with a dry dressing
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 postanesthesia care unit (PACU) nurse is preparing to discharge a client home following ankle surgery. The client keeps staring at the ceiling while being given discharge instructions. What action by the nurse is appropriate?
Review the instructions with the client and an accompanying adult.
The nurse discovers that the client did not sign the operative consent before receiving the preoperative medication. The appropriate nursing action is:
To notify the surgeon
A client is scheduled for a prostatectomy, and the anesthesiologist plans to use a spinal (subarachnoid) block during surgery. In the operating room, the nurse positions the client according to the anesthesiologist's instructions. Why does the client require special positioning for this type of anesthesia?
To prevent cerebrospinal fluid (CSF) leakage
When is the ideal time to discuss preoperative teaching
Preadmission visit
The scrub nurse is responsible for:
Preparing the sterile instruments for the surgical procedure
An obese client is scheduled for open abdominal surgery. What priority education should the nurse provide to this client?
Prevention of respiratory complications
The oncology nurse is giving chemotherapy to a client in a short stay area. The client confides that they are very depressed. The nurse recognizes depression as which of the following?
a normal reaction to the diagnosis of cancer
What measurement should the nurse report to the physician in the immediate postoperative period?
a systolic blood pressure lower than 90 mm Hg
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 Paralytic ileus and intestinal obstruction are potential postoperative complications that occur more frequently in patients undergoing intestinal or abdominal surgery. Manipulation of the abdominal organs during surgery may produce a loss of normal peristalsis for 24 to 48 hours, depending on the type and extent of surgery.
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
After cancer chemotherapy, a client experiences nausea and vomiting. The nurse should assign highest priority to which intervention?
administering metoclopromide and dexamethasone as ordered The nurse should assign highest priority to administering an antiemetic, such as metoclopramide, and an anti-inflammatory agent, such as dexamethasone, because it may reduce the severity of chemotherapy-induced nausea and vomiting. This intervention, in turn, helps prevent dehydration, a common complication of chemotherapy. Serving small portions of bland food, encouraging rhythmic breathing exercises, and withholding fluids for the first 4 to 6 hours are less likely to achieve this outcome.
Patient __________ in the OR entails maintaining the patient's physical and emotional comfort, privacy, rights, and dignity.
advocacy
Which is a sign or symptom of septic shock?
altered mental status
To prevent pneumonia and promote the integrity of the pulmonary system, an essential postoperative nursing intervention includes:
ambulating the client as soon as possible
The nurse is conducting a screening for familial predisposition to cancer. Which element should the nurse note as a possible indication of hereditary cancer syndrome?
an aunt and uncle diagnosed with cancer
Which of the following is a term used to describe the process of programmed cell death?
apoptosis Apoptosis is the innate cellular process of programmed cell death. Mitosis is the phase of the cell cycle in which cell division occurs. Carcinogenesis is the process by which cancer arises. Angiogenesis is the process by which a new blood supply is formed.
A client who had abdominal surgery 4 days ago reports that "something gave way" when he sneezed. The nurse observes a wound evisceration. Which nursing action is the first priority?
apply a sterile, moist dressing
When should the nurse encourage the postoperative patient to get out of bed?
as soon as it is indicated
The purpose of withholding food and fluid before surgery is to prevent _________.
aspiration
A client is at postoperative day 1 after abdominal surgery. The client is receiving 0.9% normal saline at 75 mL/h, has a nasogastric tube to low wall suction with 200 mL every 8 hours of light yellow fluid, and a wound drain with 50 mL of dark red drainage every 8 hours. The 24-hour urine output total is 2430 mL. What action by the nurse is most appropriate?
assess for signs and symptoms of fluid volume deficit
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
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
The nurse is providing client teaching for a client undergoing chemotherapy. What dietary modifications should the nurse advise?
avoid spicy and fatty foods
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?
avoid using soap on the irritated areas
The nurse is evaluating bloodwork results of a client with cancer who is receiving chemotherapy. The client's platelet count is 60,000/mm3. Which is an appropriate nursing action?
avoiding the use of products containing aspirin
A post op client reports severe abdominal pain. The nurse cannot auscultate bowel sounds and notes the client's abdomen is rigid. What is the nurse's priority action?
call the health care provider
A major nursing diagnosis in the postoperative period may include decreased _________ output related to shock or hemorrhage.
cardiac
Which oncologic emergency involves the accumulation of fluid in the pericardial space?
cardiac tamponade
The nurse is completing a postoperative assessment for a patient who has received a depolarizing neuromuscular blocking agent. The nursing assessment includes careful monitoring of which body system?
cardiovascular system
A nurse is performing a home visit for a client who received chemotherapy within the past 24 hours. The nurse observes a small child playing in the bathroom, where the toilet lid has been left up. Based on these observations, the nurse modifies the client's teaching plan to include:
chemotherapy exposure and risk factors.
The client is experiencing intractable hiccups following surgery. What would the nurse expect the surgeon to order?
chlorpromazine Chlorpromazine (Thorazine) is used to treat intractable hiccups.
As the surgical incision is closed, the scrub person and the __________ nurse count all needles, sponges, and instruments to be sure they are accounted for and not retained as a foreign body in the patient.
circulating
A patient is in the operating room for surgery. Which individual would be responsible for ensuring that procedure and site verification occurs and is documented?
circulating nurse
The OR personnel responsible for maintaining the safety of the client and the surgical environment is the:
circulating nurse
When the surgeon performs an appendectomy, the nurse recognizes that the surgical category will be identified as
clean contaminated Clean contaminated cases are those with a potential, limited source for infection, the exposure to which can largely be controlled. Clean cases are those with no apparent source of potential infection. Contaminated cases are those that contain an open and obvious source of potential infection. A traumatic wound with foreign bodies, fecal contamination, or purulent drainage would be considered dirty.
The nurse is conducting a community education program using the American Cancer Society's colorectal screening and prevention guidelines. The nurse determines that the participants understand the teaching when they identify that people over the age of 50 should have which screening test every 10 years?
colonoscopy
A PACU nurse is caring for a postoperative client who received general anesthesia and has a hard, plastic oral airway in place. The patient has clear lung sounds, even and unlabored respirations of 16, and 98% oxygen saturation. The client is minimally responsive to painful stimuli. What action by the nurse is most appropriate?
continue with frequent client assessments
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 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
The nurse is changing the dressing of a client who is 4 days postoperative with an abdominal wound. The nurse has changed this dressing daily since surgery. Today, the nurse notes increased serosanguinous drainage, wound edges not approximated, and a ¼-inch (6 mm) gap at the lower end of the incision. The nurse concludes which of the following conditions exists?
dehiscence
In phase III of postanesthesia care, the patient would be prepared for ___________.
discharge
The nurse assesses that extravasation of a chemotherapy agent has occurred. What is the nurse's initial action?
discontinue the infusion.
_________ is an uncomfortable awareness of breathing that is common in patients approaching the end of life.
dyspnea
Individuals use complementary approaches to prevent and treat cancer, although there are no data to support ___________.
efficacy
Dehydration, hypovolemia, and ___________ imbalances can lead to significant problems in patients with comorbid medical conditions or in older adults.
electrolyte
When the indication for surgery is without delay, the nurse recognizes that the surgery will be classified as
emergency. Emergency surgery means that the client requires immediate attention and the disorder may be life threatening. Urgent surgery means that the client requires prompt attention within 24 to 30 hours. Required surgery means that the client needs to have surgery, and it should be planned within a few weeks or months. Elective surgery means that there is an indication for surgery, but failure to have surgery will not be catastrophic.
An oncology nurse is caring for a client who relates that certain tastes have changed. The client states that "meat tastes bad." What nursing intervention can be used to increase protein intake for a client with taste changes?
encourage eating cheese, eggs, and legumes
What intervention should the nurse provide to reduce the incidence of renal damage when a patient is taking a chemotherapy regimen?
encourage fluid intake to dilute the urine
A side-effect of chemotherapy is renal damage. To prevent this, the nurse should:
encourage fluid intake, if possible, to dilute the urine
A nurse asks a client who had abdominal surgery 3 days 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 application of technology to prolong life raises numerous _________ issues.
ethical
Which term refers to the protrusion of abdominal organs through the surgical incision?
evisceration
A patient will be having an endoscopic procedure with a diagnostic biopsy. What type of biopsy does the nurse explain will remove an entire piece of suspicious tissue?
excisional biopsy Excisional biopsy is most frequently used for small, easily accessible tumors of the skin, breast, and upper or lower gastrointestinal and upper respiratory tracts. In many cases, the surgeon can remove the entire tumor as well as the surrounding marginal tissues. The removal of normal tissue beyond the tumor area decreases the possibility that residual microscopic malignant cells may lead to a recurrence of the tumor. Incisional biopsy is performed if the tumor mass is too large to be removed. In this case, a wedge of tissue from the tumor is removed for analysis. Needle biopsy is performed to sample suspicious masses that are easily and safely accessible, such as some masses in the breasts, thyroid, lung, liver, and kidney. A core needle biopsy uses a specially designed needle to obtain a small core of tissue that permits histologic analysis.
The ___________ stage of general anesthesia is characterized by struggling, shouting, laughing, or crying and can often be avoided if the anesthetic is administered smoothly and quickly.
excitement
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
Assisted suicide is expressly prohibited, under statutory or common law, in every state in the United States.
false
For those Americans over the age of 65, the most common place for death remains the home.
false
T/F: Nausea and vomiting occurs in about 10% of patients in the PACU. The nurse should not intervene at the patient's first report of nausea, rather should wait for it to progress to vomiting.
false
T/F: Pain and fatigue are the two most common side effects of chemotherapy.
false
T/F: Patients with seed implants typically aren't able to return home; radiation exposure to others is probable.
false
T/F: Prophylactic cancer vaccines have been proven to prevent prostrate, breast, and lung cancers.
false
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
Which type of healing occurs when granulation tissue is not visible and scar formation is minimal?
first intention
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 Wounds with a small amount of tissue damage that are the result of procedures that use sterile technique and that are properly closed, such as with stitches, heal by first intention. Granulation tissue is generally not visible and scar formation is minimal. Second intention healing occurs in infected wounds or wounds with edges that aren't approximated. These wounds are usually packed with moist dressings. Third intention healing occurs with deep wounds that aren't sutured together, resulting in a deep, wide scar. There is no fourth intention of wound healing.
The nurse is working with a client who has had an allohematopoietic 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 Graft-versus-host disease is a major cause of morbidity and mortality in clients who have had allogeneic transplant. Clinical manifestations of the disease include diffuse rash that progresses to blistering and desquamation, and mucosal inflammation of the eyes and the entire gastrointestinal tract with subsequent diarrhea, abdominal pain, and hepatomegaly.
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 Dietary substances that appear to increase the risk of cancer include fats, alcohol, salt-cured or smoked meats, nitrate and nitrite-containing foods, and red and processed meats. Nitrates are added to cured meats, such as ham and bacon.
Which of the following is a duty of the registered nurse first assistant? Select all that apply.
handling tissue suturing maintaining hemostasis providing exposure at the operative field
A patient develops malignant hyperthermia. Which of the following most likely would be the first indicator of this complication?
heart rate over 150 beats per minute
A benign tumor of the blood vessels is a(n)
hemangioma
The primary cardiovascular complications seen in the PACU include hypotension and shock, ____________, hypertension, and dysrhythmias.
hemorrhage
Headache, an aftereffect of spinal anesthesia, is related to three factors: the size of the spinal needle used, leakage of fluid from the subarachnoid space through the puncture site, and the patient's ____________ status.
hydration
The patient with diabetes is at risk for ____________, either during anesthesia or postoperatively, from inadequate carbohydrates or excessive administration of insulin.
hypoglycemia
___________ can result from blood loss, hypoventilation, position changes, pooling of blood in the extremities, or side effects of medications and anesthetics.
hypotension
The three most common biopsy methods used to obtain a tissue sample for histologic analysis of possible malignant cells are: excisional, ___________, and needle methods.
incisional
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
An obese client is undergoing abdominal surgery. During the procedure a surgical resident states, "The amount of fat we have to cut through is disgusting." What is the best response by the nurse?
inform the resident that all communication needs to remain professional
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
Scrub nurses and circulating nurses care for patients during the _____________ phase of perioperative nursing.
intraoperative
A client is diagnosed with metastatic adenocarcinoma of the stomach. The physician orders mitomycin and other chemotherapeutic agents for palliative treatment. How does mitomycin exert its cytotoxic effects?
it inhibits deoxyribonucleic acid (DNA) synthesis
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
As a circulating nurse, what task are you solely responsible for?
keeping records
A decrease in circulating white blood cells is
leukopenia A decrease in circulating WBCs is referred to as leukopenia. Granulocytopenia is a decrease in neutrophils. Thrombocytopenia is a decrease in the number of platelets. Neutropenia is an abnormally low absolute neutrophil count.
The preferred anesthetic method in any surgical procedure is __________ anesthesia.
local
A client has received several treatments of bleomycin. It is now important for the nurse to assess
lung sounds Bleomycin has cumulative toxic effects on lung function. Thus, it will be important to assess lung sounds.
The primary objective in the immediate postoperative period is
maintaining pulmonary ventilation
which is a growth-based classification of tumors?
malignancy
During a procedure, a client's temperature begins to rise rapidly. This is likely the result of which complication?
malignant hyperthermia
A student nurse is scheduled to observe a surgical procedure. The nurse provides the student nurse with education on the dress policy and provides all attire needed to enter a restricted surgical zone. Which observation by the nurse requires immediate intervention?
mask is placed over nose and extends to bottom lip
In which phase of the cell cycle does cell division occur?
mitosis
A postoperative client is moving from the bed to a chair when blood drips from the dressing. The nurse assesses the incision and notes evisceration. What does the nurse do first?
moisten sterile gauze with normal saline and place on the protruding organ
According to the TNM classification system, T0 means there is
no evidence of primary tumor
Unless contraindicated, how should the nurse position an unconscious patient?
on the side with a pillow at the patient's back and chin extended, to minimize the dangers of aspiration
Fentanyl is categorized as which type of intravenous anesthetic agent?
opioid
An approach to care for the seriously ill with emphasis on management of psychological, spiritual, and social problems; control of pain and other physical symptoms is known as _________ care.
palliative
Which type of surgery is used in an attempt to relieve complications of cancer?
palliative
Which is a classic sign of hypovolemic shock?
pallor
Nursing assessment findings reveal a temperature of 96.2°F, pulse oximetry 90%, shivering, and client complains of chilling. Which of the following actions by the nurse would be inappropriate?
restrict oral fluids The client exhibits clinical manifestations of hypothermia. The nurse should maintain adequate hydration of the client rather than restrict fluids.
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
A client receiving moderate sedation for a minor surgical procedure begins to vomit. What should the nurse do first?
roll the client onto his or her side
A nurse who is part of the surgical team is involved in setting up the sterile tables. The nurse is functioning in which role?
scrub role
Which method of wound healing is one in which wound edges are not surgically approximated and integumentary continuity is restored by granulation?
second-intention healing
A client is receiving chemotherapy to treat breast cancer. Which assessment finding indicates a chemotherapy-induced complication?
serum potassium level of 2.6 mEq/L
A client with a recent history of GI disturbance has been scheduled for a barium study. The physician ordered this particular test for this client because it will:
show movement of the GI tract
Eligibility for hospice care includes a life expectancy of __________ months or less.
six
The nurse is caring for a client with a benign breast tumor. The tumor may have which characteristic?
slow rate of growth Benign tumors have a slow rate of growth and well-differentiated cells. Benign tumors do not invade surrounding tissue and do not cause generalized symptoms unless the location of the tumor interferes with the functioning of vital organs.
The physician is concerned about aspiration during a surgical procedure and orders a medication to increase gastric pH. Which medication would the nurse document as being administered?
sodium citrate Sodium citrate increases gastric pH, thereby reducing damage to the respiratory tract if aspiration should occur. Vecuronium is a muscle relaxant, famotidine decreases gastric acid production, and midazolam is an anesthetic agent.
A complete diagnostic evaluation of a cancerous tumor includes pathology analysis, which is used to identify the ________ and grade of a tumor.
stage
There are four stages of general anesthesia. Select the stage during which the OR nurse knows not to touch the patient (except for safety reasons) because of possible uncontrolled movements.
stage II: excitement
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 The symptoms of swelling in gums, tongue, and lips indicate stomatitis. This usually occurs 5 to 10 days after the administration of certain chemotherapeutic agents or radiation therapy to the head and neck. Chemotherapy and radiation produce chemical toxins that lead to the breakdown of cells in the mucosa of the epithelium, connective tissue, and blood vessels in the oral cavity.
Which of the following techniques least exhibits surgical asepsis?
suctioning the nasopharyngeal cavity of a client
Which is the of the following factors stimulates the wound healing process?
sufficient oxygenation
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
A nurse is working as a registered nurse first assistant as defined by the state's nurse practice act. This nurse practices under the direct supervision of which surgical team member?
surgeon
Which clinical manifestation is often the earliest sign of malignant hyperthermia?
tachycardia (heart rate >150 beats per minute)
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
A postoperative client is being evaluated for discharge and currently has an Aldrete score of 8. Which of the following is the most likely outcome for this client?
the client can be discharged from the PACU The Aldrete score is usually 8 to 10 before discharge from the PACU. Clients with a score of less than 7 must remain in the PACU until their condition improves or they are transferred to an intensive care area, depending on their preoperative baseline score.
What should the nurse tell a client who is about to begin chemotherapy and is anxious about hair loss?
the client should consider getting a wig or cap prior to beginning treatment.
The nurse is teaching the client about patient-controlled analgesia. Which of the following would be appropriate for the nurse to include in the teaching plan?
therapeutic drug levels can be maintained more evenly with patient-controlled analgesia
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 physician is attending to a 72-year-old client with a malignant brain tumor. The physician recommends immediate radiation therapy. What is a reason for the physician's recommendation?
to prevent the formation of new cancer cells
You are caring for a client who needs to ambulate. What considerations should be included when planning the postoperative ambulatory activities for the older adult?
tolerance
A durable power of attorney for health care is an advanced directive that authorizes another person to make medical decisions when the person is no longer able to do so.
true
Advocates for improved care for the dying have stated that acceptance, management, and understanding of death should become fully integrated concepts in mainstream health care.
true
Patient and family awareness of prognosis is a key factor in acceptance of and planning for death.
true
T/F: Assessment of respiratory status in the hospitalized postoperative patient is imperative because pulmonary complications are the most frequent problem encountered by the surgical patient.
true
T/F: Genetic mutations may lead to abnormalities in cell signaling transduction processes that can in turn lead to cancer development.
true
T/F: Passive smoke (i.e., secondhand smoke) has been linked to lung cancer; nonsmokers who live with a smoker have about a 20% to 30% greater risk of developing lung cancer.
true
T/F: The first symptom of deep vein thrombosis may be a pain or a cramp in the calf.
true
T/F: The nurse who admits the patient to the PACU reviews essential information with the anesthesiologist or CRNA and the circulating nurse.
true
T/F: The primary objective in the immediate postoperative period is to maintain ventilation and prevent hypoxemia and hypercapnia.
true
When vomiting occurs postoperatively, what is the most important nursing intervention?
turn the patient's head completely to one side to prevent aspiration of vomitus into the lungs
The nurse evaluates teaching as effective when a female client states that she will
use sunscreen when outdoors
Which of the following clinical manifestations increase the risk for evisceration in the postoperative client?
valsalva maneuver The Valsalva maneuver produces tension on abdominal wounds, which increases the risk for evisceration.
A client is brought to the operating room for an elective surgery. What is the priority action by the circulating nurse?
verify consent
Which of the following sets of clinical data would allow the nurse to conclude that the nursing actions taken to prevent postoperative pneumonia have been effective?
vital signs within normal limits; absence of chills and cough
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
Which of the following is an inappropriate nursing action by the surgical nurse?
wearing sterile gloves over artificial nails
You are caring for a client who is an obese diabetic. The client is 48 hours post surgery. What is this client at increased risk for?
wound dehiscence Risk factors for wound dehiscence include: Advanced age over 65 years; Chronic disease such as diabetes, hypertension, obesity; History of radiation or chemotherapy; Malnutrition, particularly insufficient protein and vitamin C; Hypoalbuminemia. This client is not at increased risk for hypotension; contractures, or phlebitis.
The nurse's assessment of a postop client reveals a temperature of 103.2°F, tachycardia, and client complaints of increased incisional pain. What does the nurse recognize that this client is experiencing?
wound infection
The patient asks the nurse why food is withheld before surgery. What is the best response by the nurse?
"Aspiration is a concern and can be a complication if food or fluid is taken close to the surgery time."
The nurse is preparing the client with an abdominal incision for discharge. Which statement by the client indicates teaching has been ineffective?
"I can resume my usual activities as soon as I get home."
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." A client with a platelet count of 30,000/mm3 is at risk for bleeding and shouldn't floss his teeth. Flossing may increase the risk of bleeding in a client with a platelet count less than 40,000/mm3. Using an electric razor is appropriate because doing so helps minimize the risk of cutting when shaving. Taking a stool softener helps decrease potential trauma to the GI tract that may cause bleeding. Removing throw rugs from the house helps prevent falls, which could lead to uncontrolled bleeding.
A client is recovering from a craniotomy with tumor debulking. Which comment by the client indicates to the nurse a correct understanding of what the surgery entailed?
"I guess the doctor could not remove the entire tumor."
Which statement by the client indicates further teaching about epidural anesthesia is necessary?
"I will become unconscious"
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."
Which nursing statement would best decrease a client's anxiety before an emergency operative procedure?
"Let me explain to you what will happen next."
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 is working in the preoperative area with a client going to surgery for a cholecystectomy. The client has histamine2-receptor antagonists ordered preoperatively. The client asks the nurse why these medications are needed. What would be the nurse's best answer?
"These medications decrease gastric acidity and volume."
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 young female client has received chemotherapeutic medications and asks about any effects the treatments will have related to her sexual health. The most appropriate statement by the nurse is
"You will need to practice birth control measures."
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."
After a bone marrow transplant (BMT), the client should be monitored for at least
100 days
Your patient has a tri-malleolar fracture/dislocation and is scheduled for a closed reduction and casting. The RN in the procedures room has an infusion of Midazolam 100 mg in 100 mL of D5W that is to be infused at 0.25 mg/min. He will set the infusion pump to deliver ______ mL/hour?
15 mL/hour
Your patient with ovarian cancer has been receiving chemotherapy and her Absolute neutrophil Count (ANC) is <1000/mm3. You receive an order to administer Filgrastim (Neupogen) 5 mcg/kg/day. She weighs 110 pounds. The pharmacist has delivered a vial of Neupogen 480 mcg in 1.6 mL D5W. The concentration of this solution is ________________________mcg/mL.
300
A nurse knows that she must obtain a signed informed consent for which of the following procedures? Select all that apply.
Arteriography Open reduction of a fracture Cystoscopy Paracentesis
A client undergoes a biopsy of a suspicious lesion. The biopsy report classifies the lesion according to the TNM staging system as follows: Tis, N0, M0. What does this classification mean?
Carcinoma in situ, no abnormal regional lymph nodes, and no evidence of distant metastasis Tis, N0, M0 denotes carcinoma in situ, no abnormal regional lymph nodes, and no evidence of distant metastasis. No evidence of primary tumor, no abnormal regional lymph nodes, and no evidence of distant metastasis is classified as T0, N0, M0. If the tumor and regional lymph nodes can't be assessed and no evidence of metastasis exists, the lesion is classified as TX, NX, M0. A progressive increase in tumor size, no demonstrable metastasis of the regional lymph nodes, and ascending degrees of distant metastasis is classified as T1, T2, T3, or T4; N0; and M1, M2, or M3.
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
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.
Which is the least important issue concerning safety for the perioperative team before proceeding to the operating room?
Client's ambulatory aids It is imperative that the entire perioperative team participates in verifying the client's identity, the correct surgical procedure, and the appropriate surgical site before preceding to the OR. The client's ambulatory aids are not an important safety concern before proceeding to the OR.
The leading causes of cancer death in the United States, for men, are lung, prostrate, and ___________.
Colorectal (CRC)
A nursing measure for evisceration is to:
Cover the protruding coils of intestines with sterile dressings moistened with sterile saline solution.
The anesthesiologist administered a transsacral conduction block. Which documentation by the nurse is consistent with the anesthesia being administered?
Denies sensation to perineum and lower abdomen
The nurse is monitoring a presurgical patient for electrolyte imbalance. Which classification of medication may cause electrolyte imbalance?
Diuretics
Which health care profession has the ultimate responsibility to provide appropriate information regarding a nonemergent surgery?
Physician
A client who is receiving the maximum levels of pain medication for postoperative recovery asks the nurse if there are other measures that the nurse can employ to ease pain. Which of the following strategies might the nurse employ? Select all that apply.
Putting on soothing music Changing the client's position Performing guided imagery
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 anesthesiologist will use moderate (conscious) sedation during the client's surgical procedure. The circulating nurse will expect the client to:
Respond verbally during the procedure
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 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 on the left heel A stage 3 pressure ulcer is a break in the skin's protective barrier, which could lead to infection in a client who is receiving chemotherapy. The WBC count and temperature are within normal limits. Eating 75% of meals is normal and doesn't increase the client's risk for infection. A client who is malnourished is at a greater risk for infection.
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 caring for a client during an intra operative procedure. When assessing vital signs, which result indicates a need to alert the anesthesiologist immediately?
Temperature of 102.5°F (39°C)
A nurse is administering daunorubicin (DaunoXome) to a patient with lung cancer. Which situation requires immediate intervention?
The I.V. site is red and swollen
A nurse is caring for a client who is three hours post op from open abdominal surgery. During routine assessment, the nurse notes the previously stable client now appears anxious, apprehensive, and has a blood pressure of 90/56. What does the nurse consider is the most likely cause of the client's change in condition?
The client is displaying early signs of shock. The early stage of shock manifests with feelings of apprehension and decreased cardiac output. Late signs of shock include worsening cardiac compromise and leads to death if not treated. Medication or anesthesia reactions may cause client symptoms similar to these; however, these causes are not as likely as early shock.
When a client with a history of chronic alcoholism is admitted to the hospital for surgery, the nurse anticipates that the client may show signs of alcohol withdrawal delirium during which time period?
Up to 72 hours after alcohol withdrawal
The physician requests lidocaine 2% with epinephrine for use in local infiltration anesthesia. What does the nurse understand is the purpose of adding epinephrine to the lidocaine? (Select all that apply.)
The epinephrine causes vasoconstriction. The epinephrine prevents rapid absorption of the anesthetic drug. The epinephrine prolongs the local action of the anesthetic agent.
What evidence does the nurse understand indicates that a patient is ready for discharge from the recovery room or PACU? (Select all that apply.)
The patient is arousable but falls back to sleep rapidly. The patient has a blood pressure within 10 mm Hg of the baseline. The patient has sonorous respirations and occasionally requires chin lift.
T/F: Age alone confers enough surgical risk that it is a clinical predictor of cardiovascular complications related to anesthesia and surgery.
True
T/F: Any nutritional deficiency prior to surgery should be corrected before surgery to provide adequate protein for tissue repair and collagen deposition.
True
T/F: Aspirin, a common over-the-counter (OTC) medication that inhibits platelet aggregation, should be prudently discontinued 7 to 10 days before surgery or the patient may be at increased risk for bleeding.
True
T/F: Constant surveillance and conscientious technique in carrying out aseptic practices are necessary to reduce the risk of contamination and infection.
True
T/F: It is the doctor's responsibility to provide appropriate information concerning surgery and obtain the written surgical consent.
True
T/F: Nursing assessment of the intraoperative patient involves obtaining data from the patient and the patient's medical record to identify factors that can affect care.
True
T/F: Throughout surgery, nursing responsibilities include providing for the safety and well-being of the patient, coordinating the OR personnel, and performing scrub and circulating activities.
True
A patient begins to vomit during surgery. Place the actions below in the order in which they would be performed.
Turn the patient to the side Lower the head of the surgical table Provide a basin for collection Suction to remove saliva
The perioperative nurse has a number of major responsibilities when a patient is admitted to a surgical unit or center. Which of the following is the most important function?
Verifies that operative consent is signed
At what point does the preoperative period end?
When the client is transferred onto the operating table The preoperative phase begins when the decision to proceed with surgical intervention is made and ends with the transfer of the client onto the OR table. The intraoperative phase begins when the client is transferred onto the operating table and ends with admission to the PACU.
The circulating nurse is unsure whether proper technique was followed when an object was placed in the sterile field during a surgical procedure. What is the best action by the nurse?
remove the entire sterile field from use
Nurses should be both __________ aware and sensitive in their approaches to communication with patients and families about death.
culturally
What medication should the nurse prepare to administer in the event the client has malignant hyperthermia?
dantrolene sodium
During the surgical procedure, the client exhibits tachycardia, generalized muscle rigidity, and a temperature of 103°F. The nurse should prepare to administer:
dantrolene sodium (dantrium)
Nursing assessment findings reveal urinary output < 30 ml/hr, tachycardia, tachypnea, decreased hemoglobin, and acute confusion. The findings are indicative of which nursing diagnosis?
decreased cardiac output
A 70-year-old patient who is to undergo surgery arrives at the operating room (OR). The nurse, when reviewing the patient's medical record, understands that this patient will require a lower dose of anesthetic agent because of which of the following?
decreased lean tissue mass
The nurse recognizes older adults require lower doses of anesthetic agents due to:
decreased lean tissue mass. Lower doses of anesthetic agents are required in older adults, as they have decreased lean tissue mass, decreased tissue elasticity, and decreased liver mass. Bone mass is unrelated to doses of anesthesia.
The nurse recognizes that the older adult is at risk for surgical complications due to:
decreased renal function Renal function declines with age, resulting in slowed excretion of waste products and anesthetic agents.
A scrub nurse is diagnosed with a skin infection to the right forearm. What is the priority action by the nurse?
report the infection to an immediate supervisor
A postoperative client is experiencing a flash pulmonary edema. What finding in the client's sputum is consistent with this problem?
pink color Flash pulmonary edema that occurs when protein and fluid accumulate in the alveoli unrelated to elevated pulmonary artery occlusive pressure. Signs and symptoms include agitation, tachypnea, tachycardia, decreased pulse oximetry readings, frothy, pink sputum, and crackles on auscultation.
A nurse documents the presence of granulation tissue in a healing wound. Which of the following is the best description for the tissue?
pink to red and soft, noting that it bleeds easily
What does the nurse recognize as one of the most common postoperative respiratory complications in elderly clients?
pneumonia
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
The nurse is caring for the postoperative client in the postanesthesia care unit. Which of the following is the priority nursing action?
position the client to maintain a patent airway
During which step of cellular carcinogenesis do cellular changes exhibit increased malignant behavior?
progression Progression is the third step of carcinogenesis, in which cells show a propensity to invade adjacent tissues and metastasize. During promotion, repeated exposure to promoting agents causes the expression of abnormal genetic information, even after long latency periods. During initiation, initiators such as chemicals, physical factors, and biologic agents escape normal enzymatic mechanisms and alter the genetic structure of cellular DNA. No stage of cellular carcinogenesis is termed prolongation.
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
An obese patient tends to have shallow respirations when supine, increasing the risk of hypoventilation and postoperative ____________ complications.
pulmonary
What complication is the nurse aware of that is associated with deep venous thrombosis?
pulmonary embolism
A client has been receiving chemotherapy to treat cancer. Which assessment finding suggests that the client has developed stomatitis?
red, open sores on the oral mucosa
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 the dressing or applying pressure if bleeding is frank The nurse should reinforce the dressing or apply pressure if bleeding is frank. The nurse should keep the head of the bed flat unless it is contraindicated. Encouraging the client to breathe deeply will not help manage and minimize hemorrhage and shock. Monitoring vital signs every 15 minutes is an appropriate nursing intervention but will not minimize hemorrhage and shock; it will just help to determine the extent and progression of the problem.
