Med surg prep u

A client comes to the emergency department with status asthmaticus. His respiratory rate is 48 breaths/minute, and he is wheezing. An arterial blood gas analysis reveals a pH of 7.52, a partial pressure of arterial carbon dioxide (PaCO2) of 30 mm Hg, PaO2 of 70 mm Hg, and bicarbonate (HCO3??') of 26 mEq/L. What disorder is indicated by these findings?

Respiratory alkalosis

An elderly client takes 40 mg of furosemide twice a day. Which electrolyte imbalance is the most serious adverse effect of diuretic use?

Hypokalemia

What complication in the immediate postoperative period should the nurse understand requires early intervention to prevent?

Hypoxemia and hypercapnia

A client is to receive hypotonic IV solution in order to provide free water replacement. Which solution does the nurse anticipate administering?

0.45% NaCl

Chp 19

19

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

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

The Emergency Department (ED) nurse is caring for a client with a possible acid-base imbalance. The physician has ordered an arterial blood gas (ABG). What is one of the most important indications of an acid-base imbalance that is shown in an ABG?

Bicarbonate

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.

Which term refers to the protrusion of abdominal organs through the surgical incision?

Evisceration

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 First-intention healing is characterized by a closed incision with little tissue reaction and the absence of signs and symptoms of infection.p468

A patient with diabetes insipidus presents to the emergency room for treatment of dehydration. The nurse knows to review serum laboratory results for which of the diagnostic indicators?

Sodium level of 150 mEq/L

The client is experiencing nausea and vomiting following surgery. What will the nurse expect the surgeon to order?

ondansetron

The nurse is caring for a client who has been admitted with a possible clotting disorder. The client is complaining of excessive bleeding and bruising without cause. The nurse knows to take extra care to check for signs of bruising or bleeding in what condition?

Hypocalcemia

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

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

A client with cancer is being treated on the oncology unit for bilateral breast cancer. The client is undergoing chemotherapy. The nurse notes the client's serum calcium concentration is 12.3 mg/dL (3.08 mmol/L). Given this laboratory finding, the nurse should suspect that the

malignancy is causing the electrolyte imbalance.

Which type of healing occurs when granulation tissue is not visible and scar formation is minimal?

First intention

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

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.

Which is a classic sign of hypovolemic shock?

Pallor The classic signs of hypovolemic shock are pallor, rapid, weak thready pulse, low blood pressure, and rapid breathing

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

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.

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

Early signs of hypervolemia include

increased breathing effort and weight gain.

The nurse is caring for a patient with diabetes type I who is having severe vomiting and diarrhea. What condition that exhibits blood values with a low pH and a low plasma bicarbonate concentration should the nurse assess for?

Metabolic acidosis

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 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

What abnormal postoperative urinary output should the nurse report to the physician for a 2-hour period?

<30 mL

What measurement should the nurse report to the physician in the immediate postoperative period?

A systolic blood pressure lower than 90 mm Hg

A nurse assesses a postoperative client as having abdominal organs protruding through the surgical incision. Which term best describes this assessment finding?

Evisceration

A nurse is caring for an adult client with numerous draining wounds from gunshots. The client's pulse rate has increased from 100 to 130 beats per minute over the last hour. The nurse should further assess the client for which of the following?

Extracellular fluid volume deficit

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 Changing position Watching television

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.

A nurse is caring for a client with obesity and diabetes after abdominal surgery. What is the client at increased risk for?

Wound dehiscence

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

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.

The nurse is caring for four clients on a medical unit. The nurse is most correct to review which client's laboratory reports first for an electrolyte imbalance?

A 52-year-old with diarrhea

The nurse is caring for a client with a serum sodium concentration of 113 mEq/L (113 mmol/L). The nurse should monitor the client for the development of which condition?

Confusion

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

A client has a respiratory rate of 38 breaths/min. What effect does breathing faster have on arterial pH level?

Increases arterial pH

The nurse is caring for a client with multiple organ failure and in metabolic acidosis. Which pair of organs is responsible for regulatory processes and compensation?

Lungs and kidney

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.

A priority nursing intervention for a client with hypervolemia involves which of the following?

Monitoring respiratory status for signs and symptoms of pulmonary complications.

The nurse observes bloody drainage on the surgical dressing of the client who has just arrived on the nursing unit. Which intervention should the nurse plan to do next?

Outline the drainage with a pen and record the date and time next to the drainage.

What complication is the nurse aware of that is associated with deep venous thrombosis?

Pulmonary embolism

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.

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.

A nurse is caring for a client admitted with a diagnosis of exacerbation of myasthenia gravis. Upon assessment of the client, the nurse notes the client has severely depressed respirations. The nurse would expect to identify which acid-base disturbance?

Respiratory acidosis

The nurse is participating in the care of a client who had a peripherally inserted central catheter (PICC) placed in the right arm. After catheter placement, the nurse should complete which action?

Send the client for a chest x-ray.

A client is diagnosed with syndrome of inappropriate antidiuretic hormone (SIADH). The nurse should anticipate which laboratory test result?

Serum sodium level of 124 mEq/L

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 nurse is planning care for a client following abdominal surgery. Which outcome demonstrates a return of functioning to the gastrointestinal tract?

The client reports a small bowel movement.

A nurse is assessing a client's reflexes. Which condition does the nurse need to confirm when tapping the facial nerve of a client who has dysphagia?

hypomagnesemia

When should the nurse encourage the postoperative patient to get out of bed?

As soon as it is indicated

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

The nurse is caring for a female postoperative client who is having difficulty voiding. Which nursing action is most helpful to promote normal voiding?

Assist to the bathroom.

A client has been admitted to the hospital unit with signs and symptoms of hypovolemia; however, the client has not lost weight. The client exhibits a localized enlargement of her abdomen. What condition could the client be presenting?

third-spacing