med surg test 1 nclex style questions

The nurse is revising an agency's recommended central line catheter-related bloodstream infection prevention (CR-BSI) bundle. Which actions decrease the client's risk for this complication? (Select all that apply.) -During insertion, draping the area around the site with a sterile barrier Incorrect -Immediately removing the client's venous access device (VAD) when it is no longer needed Correct -Making certain that observers of the insertion are instructed to look away during the procedure -Thorough hand hygiene (i.e., no quick scrub) before insertion Correct - Using chlorhexidine for skin disinfection Correct

B D E As soon as the VAD is deemed unnecessary, it should be removed to reduce the risk for infection. Thorough handwashing is a key factor in insertion and maintenance of a central line device; quick handwashing is not sufficient. Chlorhexidine is recommended for skin disinfection because it has been shown to have the best outcomes in infection prevention. During the insertion, the whole body (head to toe) of the client is draped with a sterile barrier; draping only the area around the site will increase risk for infection. Looking away will not reduce the risk for infection. Reducing the number of people in the room and having everyone wear a mask will help reduce the risk for infection

The nurse is administering a drug to a client through an implanted port. Before giving the medication, what does the nurse do to ensure safety? Administer 5 mL of a heparinized solution. Check for blood return. Correct Flush the port with 10 mL of normal saline. Incorrect Palpate the port for stability.

B. Before a drug is given through an implanted port, it is critical that the nurse check for blood return. If no blood return is observed, the drug should be held until patency is reestablished. Ports are flushed with heparin or saline after, rather than before, use. The port is palpated for stability, but this action alone does not ensure the client's safety.

client is admitted to the cardiothoracic surgical intensive care unit after cardiac bypass surgery. The client is still sedated on a ventilator and has an arterial catheter in the right wrist. What assessment does the nurse make to determine patency of the client's arterial line? Blood pressure Capillary refill and pulse Correct Neurologic function Questioning the client about the pain level at the site

B. Capillary refill and pulse should be assessed to ensure that the arterial line is not occluding the artery. Blood pressure and neurologic function are not pertinent to the client's arterial line. Although the client's comfort level is important with an arterial line, it is not a determinant of patency of the line

The nurse is admitting clients to the same-day surgery unit. Which insertion site for routine peripheral venous catheters does the nurse choose most often? Back of the hand for an older adult Cephalic vein of the forearm Correct Lower arm on the side of a radical mastectomy Subclavian vein

B. For same-day surgery, the cephalic or basilic vein allows insertion of a larger IV catheter while allowing movement of the arm without impairing intravenous flow. Peripheral venous catheters should never be inserted into the back of the hand in an older adult because the veins are brittle. Peripheral venous catheters should never be inserted into the lower arm on the same side as a radical mastectomy because they interfere with limited circulation. Catheters are typically inserted into the subclavian vein by the health care provider, not by the nurse

The nurse checking an IV fluid order questions its accuracy. What does the nurse do first? Asks the charge nurse about the order Contacts the health care provider who ordered it Correct Contacts the pharmacy for clarification Starts the fluid as ordered, with plans to check it later

B. The nurse is responsible for accuracy and has the duty to verify the order with the health care provider who ordered it. Although the nurse can consult the charge nurse, this is not the definitive action that the nurse should take. Contacting the pharmacy is not the definitive action that the nurse should take. Giving (or starting) the fluid when the order is questionable is not appropriate.

During a preoperative assessment, which statement by a client requires further investigation by the nurse to assess surgical risks? "I am taking vitamins." "I drink a glass of wine a night." "I had a heart attack 4 months ago." Correct "I don't like latex balloons."

"I had a heart attack 4 months ago." Cardiac problems increase surgical risks, and the risk for a myocardial infarction during surgery is higher in clients who have heart problems. The type of vitamins the client takes should be assessed, but this is not the highest risk. Moderate alcohol consumption is not considered high-risk behavior. A dislike for latex is not the same as a latex allergy (however, it might be a good idea to ask why the client doesn't like latex balloons).

A client is having an arthroscopy of the left knee and has just been moved to the surgical holding area. Which statement by the nurse properly identifies the client while the nurse checks the identification label? "Are you Mr. Smith?" Incorrect "Good morning, Mr. Smith." "What is your name, and where were you born?" Correct "What surgery are you having today?"

"What is your name, and where were you born The nurse must verify the client's identity with two types of identifiers. This practice prevents errors by drowsy or confused clients. When asked to verify his or her name, or respond to a greeting, the client may respond inappropriately if he or she is anxious or sedated. Asking the client about his or her surgery does help with identification; however, it is really done to ascertain that the client's perception of the procedure, the operative permit, and the operative schedule are the same.

The RN has just received reports about all of these clients on the inpatient surgical unit. Which client does the nurse care for first? A 43-year-old who had a bowel resection 7 days ago and has new serosanguineous drainage on the dressing Correct A 46-year-old who had a thoracotomy 5 days ago and needs discharge teaching before going home A 48-year-old who had bladder surgery earlier in the day and is reporting pain when coughing A 49-year-old who underwent repair of a dislocated shoulder this morning and has a temperature of 100.4° F (38° C)

A 43-year-old who had a bowel resection 7 days ago and has new serosanguineous drainage on the dressing New drainage on the seventh postoperative day is unusual and suggests a complication that would require further assessment and possible immediate action. A temperature of 100.4° F and pain upon coughing following bladder surgery are normal on the first postsurgical day. The client awaiting discharge teaching is not a priority.

The nurse is starting a peripheral IV catheter on a recently admitted client. What actions does the nurse perform before insertion of the line? (Select all that apply.) -Apply povidone-iodine to clean skin, dry for 2 minutes. -Clean the skin around the site. Correct -Prepare the skin with 70% alcohol or chlorhexidine. - Shave the hair around the area of insertion. -Wear clean gloves and touch the site only with fingertips after applying antiseptics.

A B C Povidone-iodine (Betadine) is applied to the selected insertion site before insertion. The solution is allowed to dry, which takes about 2 minutes. The insertion site should be cleansed before the antiseptic skin preparations are completed. After soap and water cleansing, prepping with 70% alcohol or chlorhexidine is done. Clipping, rather than shaving, hair around the selected IV site is done; shaving is abrasive and makes the skin more vulnerable to infection (i.e., microbial invasion). The insertion site should not be palpated again after it has been prepped; this mistake is frequently made with IV starts

The nurse who is starting the shift finds a client with an IV that is leaking all over the bed linens. What does the nurse do initially? Assess the insertion site. Correct Check connections. Check the infusion rate. Discontinue the IV and start another.

A. Assessing the insertion site to check for patency is the priority. IV assessments typically begin at the insertion site and move "up" the line; that is, from the insertion site to the tubing, to the tubing's connection to the bag. Checking the IV connection is important, but is not the priority in this situation. Checking the infusion rate is not the priority. Discontinuing the IV to start another may be required, but it may be possible to "save" the IV, and the problem may be positional or involve a loose connection.

The nurse is teaching a hospitalized client who is being discharged about how to care for a peripherally inserted central catheter (PICC) line. Which client statement indicates a need for further education? "I can continue my 20-mile running schedule as I have for the past 10 years." Correct "I can still go about my normal activities of daily living." "I have less chance of getting an infection because the line is not in my hand."

A. Excessive physical activity can dislodge the PICC and should be avoided. Clients with PICCs should be able to perform normal activities of daily living. PICCs have low complication rates because the insertion site is in the upper extremity. The dry skin of the arm has fewer types and numbers of microorganisms, leading to lower rates of infection. PICC lines can be used long term (months).

A client who takes corticosteroids daily for rheumatoid arthritis requires insertion of an IV catheter to receive IV antibiotics for 5 days. Which type of IV catheter does the nurse teach the new graduate nurse to use for this client? Midline catheter Correct Nontunneled percutaneous central catheter Peripherally inserted central catheter Short peripheral catheter

A. For a client with fragile veins (which occur with long-term corticosteroid use) and the need for a catheter for 5 days, the midline catheter is the best choice. Nontunneled central catheters usually are used for clients who require IV access for longer periods. Peripherally inserted central catheters usually are used for clients who require IV access for longer periods. A short peripheral catheter is likely to infiltrate before 5 days in a client with fragile veins, requiring reinsertion.

A client admitted to the intensive care unit is expected to remain for 3 weeks. The nurse has orders to start an IV. Which vascular access device is best for this client? Midline catheter Correct Peripherally inserted central catheter (PICC) Incorrect Short peripheral catheter Tunneled central catheter

A. Midline catheters are used for therapies lasting from 1 to 4 weeks. PICCs are typically used when IV therapy is expected to last for months. Short peripheral catheters are allowed to dwell (stay in) for 72 to 96 hours, but they then require removal and insertion at another venous site. Tunneled central catheters must be inserted by a health care provider; the nurse typically is not qualified to start this type of IV.

Which statement is true about the special needs of older adults receiving IV therapy? Placement of the catheter on the back of the client's dominant hand is preferred. Skin integrity can be compromised easily by the application of tape or dressings. Correct To avoid rolling the veins, a greater angle of 25 degrees between the skin and the catheter will improve success with venipuncture. Incorrect When the catheter is inserted into the forearm, excess hair should be shaved before insertion.

A. Skin in older adults tends to be thin. Tape or dressings used with IV therapy can compromise skin integrity. Placement on the back of the dominant hand is contraindicated because hand movement can increase the risk of catheter dislodgement. An angle smaller than 25 degrees is required for venipuncture success in older adults. This technique is less likely to puncture through the older adult client's vein. Clipping the hair around the insertion site typically is necessary only for younger men.

A client is being admitted to the burn unit from another hospital. The client has an intraosseous IV that was started 2 days ago, according to the client's medical record. What does the admitting nurse do first? Anticipate an order to discontinue the intraosseous IV and start an epidural IV. Correct Call the previous hospital to verify the date. Immediately discontinue the intraosseous IV. Nothing; this is a long-term treatment.

A. The intraosseous route should be used only during the immediate period of resuscitation and should not be used for longer than 24 hours. Alternative IV routes, such as epidural access, should then be considered for pain management. The nurse should know what to do in this client's situation without contacting the previous hospital. Other client data, such as the date and time that the burn occurred, should validate the date and time of insertion of the IV. Discontinuing the IV is not the priority in this situation—the client is in a precarious fluid balance situation. One IV access should not be stopped until another is established. This type of IV is not used for long-term therapy; an action must be taken.

The nurse is to administer a unit of whole blood to a postoperative client. What does the nurse do to ensure the safety of the blood transfusion? Asks the client to both say and spell his or her full name before starting the blood transfusion Ensures that another qualified health care professional checks the unit before administering Correct Checks the blood identification numbers with the laboratory technician at the blood bank at the time it is dispensed Makes certain that an IV solution of 0.9% normal saline is infusing into the client before starting the unit

B. To ensure safety, blood must be checked by two qualified health care professionals, usually two registered nurses. Administering an incorrectly matched unit of blood creates great consequences for the client and is considered to be a sentinel event. It requires a great amount of follow-up and often changing of policies to improve safety. The Joint Commission requires that the client provide two identifiers, but they are the name and date of birth or some other identifying data, depending on the facility; saying and spelling the name is only one identifier. Although a check is provided at the blood bank, this is not the one that is done before administration to the client. Clients do need to have normal saline running with blood, but this is not considered to be part of the safety check before administration of blood and blood products.

A severely dehydrated client requires a rapid infusion of normal saline and needs a midline IV placed. Which staff member does the emergency department (ED) charge nurse assign to complete this task? - RN who is certified in the administration of oral and infused chemotherapy medications - RN with 2 years of experience in the ED who is skilled at insertion of short peripheral catheters Incorrect - RN with 10 years of experience on a medical-surgical unit who has cared for many clients requiring IV infusions -RN with certified registered nurse infusion (CRNI) certification who is assigned to the ED for the day Correct

D> The nurse with CRNI certification is most likely to be able to quickly insert a midline catheter for a client who is dehydrated. The chemotherapy nurse and the ED nurse have the appropriate scope of practice, but will not be as skilled in inserting a midline IV catheter. The medical-surgical nurse may be skilled at inserting short peripheral catheters, but will not be skilled in inserting midline IV catheters.

The nurse completes the preoperative checklist on a client scheduled for general surgery. Which factor contributes the greatest risk for the planned procedure? Age 59 years Incorrect General anesthesia complications experienced by the client's brother Diet-controlled diabetes mellitus Correct Ten pounds over the client's ideal body weight

Diet-controlled diabetes mellitus Diabetes contributes an increased risk for surgery or postsurgical complications. Older adults are at greater risk for surgical procedures, but this client is not classified as an older adult. Family medical history and problems with anesthetics may indicate possible reactions to anesthesia, but this is not the best answer. Obesity increases the risk for poor wound healing, but being 10 pounds overweight does not categorize this client as obese.

A client has undergone an 8-hour surgical procedure under general anesthesia. In assessing the client for complications related to positioning, the nurse is most concerned with which finding? Decreased sensation in the lower extremities Diminished peripheral pulses in the lower extremities Pale, cool extremities Reddened areas over bony prominences

Diminished peripheral pulses in the lower extremities Diminished peripheral pulses in the lower extremities indicate diminished blood flow. Decreased sensation; pale, cool extremities; and reddened areas over bony prominences can be normal occurrences in clients who have undergone a long surgical procedure

A diabetic client who is scheduled for vascular surgery is admitted on the day of surgery with several orders. Which order does the nurse accomplish first? Use electric clippers to cut hair at the surgical site. Start an infusion of lactated Ringer's solution at 75 mL/hr. Incorrect Administer one-half of the client's usual lispro insulin dose. Draw blood for glucose, electrolyte, and complete blood count values.

Draw blood for glucose, electrolyte, and complete blood count values. blood work is abnormal, the surgery may be rescheduled. The blood sample needs to be drawn and sent to the laboratory first to confirm that results are within normal limits. Removal of hair can be accomplished in the operating room directly before the start of surgery. The IV infusion can be accomplished after the laboratory orders have been completed. The nurse should check blood glucose with the laboratory orders before administration of lispro.

A client who is preparing to undergo a vaginal hysterectomy is concerned about being exposed. How does the nurse ensure that this client's privacy will be maintained? Tell the client that she will be asleep. Ensure that drapes will minimize perianal exposure. Explain postoperative expectations. Restrict the number of technicians in the procedure.

Ensure that drapes will minimize perianal exposure.

An unidentified client from the emergency department requires immediate surgery, but he is not conscious and no one is with him. What must the nurse, who is verifying the informed consent, do? Ensure written consultation of two noninvolved physicians. Correct Read the surgeon's consult to determine whether the client's condition is life-threatening. Sign the operative permit. Withhold surgery until the next of kin is notified.

Ensure written consultation of two noninvolved physicians. In a life-threatening situation in which every effort has been made to contact the person with medical power of attorney, consent is desired but not essential. In place of written or oral consent, written consultation by at least two physicians who are not associated with the case may be requested by the health care provider. It is not within the nurse's role to make a judgment about the client based on the surgeon's consult. Signing documents on the client's behalf is not legal. Withholding surgery is not in this client's best interests.

Which statement best exemplifies a client's protection from cancer provided by cell-mediated immunity (CMI) after exposure to asbestos? Cytotoxic and cytolytic T cells destroy cells that contain the major histocompatibility complex of a processed antigen. Helper and inducer T cells recognize self cells versus non-self cells and secrete lymphokines that can enhance the activity of white blood cells. Suppressor T cells prevent hypersensitivity when a client is exposed to non-self cells or to proteins. Incorrect Balance elicits protection when helper or inducer T cells outnumber suppressor T cells by a ratio of 2:1.

Balance elicits protection when helper or inducer T cells outnumber suppressor T cells by a ratio of 2:1 Optimal function of CMI requires a balance between helper and inducer T cells and suppressor T cells. This balance occurs when helper and inducer T cells outnumber suppressor T cells by a ratio of 2:1. The activity of cytotoxic and cytolytic T cells is most effective against self cells infected by parasites. Overreactions can cause tissue damage if an imbalance exists between helper and inducer T cells. When suppressor T cells are increased, immune function is suppressed and the risk for infection increases.

A complete blood count with differential is performed in a client with chronic sinusitis. Which finding does the nurse expect? Segmented neutrophils, 62% Incorrect Lymphocytes, 28% Bands, 5% Basophils, 4%

Basophils, 4% The normal count for basophils (basos) is 0.5%; an elevated count indicates inflammation, which is common with chronic sinusitis. Segmented neutrophils (segs) are mature neutrophils, which, along with macrophages, eliminate invaders (infection) by phagocytosis; 62% is a normal neutrophil count. For lymphocytes (lymphs), 28% is a normal count in the differential. For bands, 4% is a normal count; bands are elevated only when an infection is present and the bone marrow cannot keep up with mature segmented neutrophils.

A 22-year-old client is seen in the emergency department (ED) with acute right lower quadrant abdominal pain, nausea, and rebound tenderness. It appears that surgery is imminent. What gauge catheter does the ED nurse choose when starting this client's intravenous solution? 24 22 Incorrect 18 Correct 14

C. An 18-gauge catheter is the size of choice for clients who will undergo surgery. If they need to receive fluids rapidly, or if they need to receive more viscous fluids (such as blood or blood products), a lumen of this size would accommodate those needs. Neither a 24-gauge nor a 22-gauge catheter is an appropriate size (too small) for clients who will undergo surgery. If it becomes necessary to administer fluids to the client rapidly, another IV would be needed with a larger needle—18, for example. Administering through the smallest gauge necessary is usually best practice, unless the client may be going into hypovolemic status (shock). A 14-gauge catheter is an extremely large-gauge needle that is very damaging to the vein

When flushing a client's central line with normal saline, the nurse feels resistance. Which action does the nurse take first? Decrease the pressure being used to flush the line. Obtain a 10-mL syringe and reattempt flushing the line. Stop flushing and try to aspirate blood from the line. Correct Use "push-pull" pressure applied to the syringe while flushing the line.

C. If resistance is felt when flushing any IV line, the nurse should stop and further assess the line. Aspiration of blood would indicate that the central line is intact and is not obstructed by thrombus. Continuing or reattempting to flush the line, or using a push-pull action on the syringe, might result in thrombus or injection of particulate matter into the client's circulation.

A client is to receive an IV solution of 5% dextrose and 0.45% normal saline at 125 mL/hr. Which system provides the safest method for the nurse to accurately administer this solution? Controller Glass container Infusion pump Correct Syringe pump

C. Infusion pumps are used for drugs or fluids under pressure. They accurately measure the volume of fluid being infused. A controller is a stationary, pole-mounted electronic device that uses a sensor to monitor fluid flow and detect when flow has been interrupted. Because controllers rely completely on gravity to create fluid flow and do not create pressure, they do not ensure infusion but only control the drip rate. A glass container is necessary to use only with IV solutions that may cling to the plastic bag; this is not an issue with this solution. A syringe pump does not hold sufficient volume to be practical in this situation.

A client who used to work as a nurse asks, "Why is the hospital using a 'fancy new IV' without a needle? That seems expensive." How does the nurse respond? "OSHA, a government agency, requires us to use this new type of IV." "These systems are designed to save time, not money." "They minimize health care workers' exposure to contaminated needles."

C. Needleless IVs were designed to protect health care personnel from exposure to contaminated needles. The Occupational Safety and Health Administration (OSHA) requires the use of devices with engineered safety mechanisms only. It does not mandate that they be needleless. Saving time and money is not the purpose of the needleless IV, and it was not designed to protect clients from exposure to contaminated needles.

The nurse is inserting a peripheral intravenous (IV) catheter. Which client statement is of greatest concern during this procedure? "I hate having IVs started." "It hurts when you are inserting the line." "My hand tingles when you poke me." Correct "My IV lines never last very long."

C. The client's statement about a tingling feeling indicates possible nerve puncture. To avoid further nerve damage, the nurse should stop immediately, remove the IV catheter, and choose a new site. The other statements indicate a need for client teaching, but are not indicators of immediate complications of catheter insertion—pain at the insertion site is common, and IV sites that "never last very long" should be addressed with teaching about the importance of proper protection of the site.

Which action does the nurse implement for a client with wound evisceration? Apply direct pressure to the wound. Cover the wound with a sterile, warm, moist dressing. Correct Irrigate the wound with warm, sterile saline. Replace tissue protruding into the opening.

Cover the wound with a sterile, warm, moist dressing. Covering the wound with a sterile, warm, moist dressing protects the organs until the surgeon can repair the wound. Applying direct pressure to a wound traumatizes the organs. Irrigating the wound is not necessary. Replacing protruding tissue could induce infection.

A 70-year-old client with severe dehydration is ordered an infusion of an isotonic solution at 250 mL/hr through a midline IV catheter. After 2 hours, the nurse notes that the client has crackles throughout all lung fields. Which action does the nurse take first? Assess the midline IV insertion site. Have the client cough and deep-breathe. Incorrect Notify the health care provider about the crackles. Slow the rate of the IV infusion.

D. The presence of crackles throughout the lungs is a sign of possible fluid overload. The nurse should slow the rate of infusion and further assess for indicators of volume overload and/or respiratory distress. Assessing the site, having the client cough and deep-breathe, and notifying the provider may be appropriate, but are not the initial actions for this client.

At 8:00 a.m., the registered nurse is admitting a client scheduled for sinus surgery to the outpatient surgery department. Which information given by the client is of most immediate concern to the nurse? An allergy to iodine and shellfish Incorrect Being nauseated after a previous surgery Having a small glass of juice at 7:00 a.m. Correct Expressing anxiety about the surgery

Having a small glass of juice at 7:00 a.m Clients need to be NPO for a sufficient length of time before surgery. Intake of food or fluids may delay the start time of the surgery, so the nurse must notify the surgeon and anesthesiologist for possible rescheduling. The nurse should confirm that all allergies are charted, and that the client has the correct allergy band identification. Many clients experience nausea after surgery; the nurse should document this in the client's information as well. The nurse should talk with the client and explore the anxiety; this is a normal feeling before surgery

The nurse reviews with a client a routine discharge teaching plan concerning postoperative care. Which statement by the client indicates that teaching was effective? "I may need to restrict my activities for several months." Correct "The dressing should stay in place unless it gets wet." "The incision needs to be cleaned every 4 hours with hydrogen peroxide." "The wound will completely heal in about 2 months."

I may need to restrict my activities for several months." To protect the integrity of the wound, activities may need to be restricted. The wound will need to be open to air for healing. Using hydrogen peroxide can cause wound irritation, unless specifically ordered. The length of time it takes for a wound to heal varies; a wound can take up to 2 years to heal.

The nurse anesthetist notices that a surgical client has an unexpected rise in the end-tidal carbon dioxide level, with a decrease in oxygen saturation and sinus tachycardia. What is the nurse's first action? Administer cardiopulmonary resuscitation. Continue as normal. Immediately stop all inhalation anesthetic agents and succinylcholine. Correct Inform the surgeon.

Immediately stop all inhalation anesthetic agents and succinylcholine. This client is exhibiting early symptoms of malignant hyperthermia (MH). The most sensitive indication of MH is an unexpected rise in the end-tidal carbon dioxide level, along with a decrease in oxygen saturation. Another early indication is sinus tachycardia. Survival depends on early diagnosis and the actions of the entire surgical team. Time is crucial when MH is diagnosed, and MH requires immediate intervention. This client does not require resuscitation. Informing the surgeon is not the priority.

If sterile gauze falls to the ground and hits the front of the surgeon's gown on the way down, what does the nurse do to ensure proper infection control? Helps the surgeon change the gown Picks the gauze up with a pair of sterile gloves Picks the gauze up without touching the surgeon Correct Sprays an antimicrobial on the surgeon's gown

Picks the gauze up without touching the surgeon The surgeon is sterile, but the gauze is now nonsterile and must be removed and counted. A sterile gauze touching a sterile gown does not require a gown change. Sterile gloves are not needed to pick the gauze up. An antimicrobial spray is inappropriate in this situation

The nurse is preparing a client for discharge on postoperative day 1 after a modified radical mastectomy. Which instruction is most important for the nurse to include in this client's discharge plan? "Please report any increased redness, swelling, warmth, or pain to your health care provider." Correct "Do not allow anyone to take your blood pressure or draw blood on the side where you had your breast removed." "A referral has been made to the American Cancer Society's Reach to Recovery program, and a volunteer will call you next week." "Avoid the prone and hunchback positions, and ask your health care provider for any other needed activity restrictions."

Please report any increased redness, swelling, warmth, or pain to your health care provider." Instruction on increased signs and symptoms of inflammation could reveal signs of potential infection and is most important. Although information about having blood pressure taken or having blood drawn should be included, it is not the most important instruction for postoperative day 1 discharge. Referrals are important in helping with coping but are not the most important consideration when the client is being sent home on postoperative day 1. Positioning is important but is not the priority here.

The nurse assesses a client's wound 24 hours postoperatively. Which finding causes the nurse the greatest concern? Crusting along the incision line Redness and swelling around the incision Correct Sanguineous drainage at the suture site Serosanguineous drainage on the dressing

Redness and swelling around the incision Redness and swelling around the incision indicate an infection. Crusting along the incision line, sanguineous drainage, and serosanguineous drainage are normal.

A client is being prepared for gastrointestinal surgery and undergoes a bowel preparation. Why is this preoperative procedure done? Decrease expected blood loss during surgery Eliminate any risk of infection Ensure that the bowel is sterile Reduce the number of intestinal bacteria

Reduce the number of intestinal bacteria Bowel or intestinal preparations are performed to empty the bowel to minimize the leaking of bowel contents, prevent injury to the colon, and reduce the number of intestinal bacteria. Decreasing expected blood loss and sterilizing the bowel are not the goals of a bowel preparation. While the bowel prep may reduce the number of intestinal bacteria, it will not completely eliminate the risk of infection.

A client who is exposed to invading organisms recovers rapidly after the invasion without damage to healthy body cells. How has the immune response protected the client? Intact skin and mucous membranes Self-tolerance Correct Inflammatory response against invading foreign proteins Antibody-antigen interaction

Self-tolerance The ability to recognize self versus non-self is necessary to prevent healthy body cells from being destroyed along with the invading organisms. This meets the client's protection needs. The body has some defenses to prevent organisms from gaining access to the internal environment, such as intact skin and mucous membranes; however, they are not perfect—invasion of the body's internal environment by organisms often occurs. Inflammation provides immediate protection against the effects of tissue injury and invading foreign proteins. The inflammatory response is immediate but short-term against injury or invading organisms; it does not provide true immunity. Seven steps (phagocytosis) are needed to produce a specific antibody directed against a specific antigen whenever the person is exposed to that antigen.

A client has an acute case of opioid depression and receives a dose of naloxone (Narcan). Which statement is true about this client? Supplemental pain reduction is needed. Correct One dose is needed. This is an acute emergency. Incorrect The client will be hostile.

Supplemental pain reduction is needed The client has breakthrough pain after the opioid antagonist is given, so other interventions to promote comfort are needed. Several doses of naloxone may be needed because the drug has a short half-life. Opioid depression is a manageable situation, not an acute emergency. The client with opioid depression usually is not fully conscious

A preoperative client smokes a pack of cigarettes a day. What is the nurse's teaching priority for the best physical outcomes? Instruct the client to quit smoking. Teach about the dangers of tobacco. Teach the importance of incentive spirometry. Correct Tell the client where the smoking lounge is.

Teach the importance of incentive spirometry. Incentive spirometry is good for lung hygiene; it encourages deep breathing. The nurse can suggest quitting or advise about the dangers of tobacco, but it is not therapeutic to instruct it at this time. Directing the client to the smoking lounge is not helpful or therapeutic.

Which statement accurately explains otitis media? The inflammatory response is triggered by the invasion of foreign proteins. Correct Phagocytosis by macrophages and neutrophils destroys and eliminates foreign invaders. It is caused by a left shift or increase in immature neutrophils. Incorrect Many immune system cells released into the blood have specific effects.

The inflammatory response is triggered by the invasion of foreign proteins Inflammation is the process that occurs in response to invasion by organisms. In otitis media, it is bacteria. Macrophages and neutrophils are involved in inflammation; otitis media is an inflammation caused by infection. Immature neutrophil forms should not be in the blood; the change in form is caused by infection, such as sepsis. Immune system cells take action when encountering a non-self or foreign protein to neutralize, destroy, or eliminate a foreign invader, but this does not cause inflammation

The nurse is instructing a client about the use of antiembolism stockings. Which statement by the client indicates the need for further teaching? "I will take off my stockings one to three times a day for 30 minutes." "My stockings are too loose." Incorrect "These stockings will prevent blood clots." Correct "These stockings help promote blood flow."

These stockings will prevent blood clots." Antiembolism stockings alone will not prevent deep vein thrombosis (DVT). However, along with exercise, they will help promote venous return, which aids in preventing DVT. Frequent removal of the stockings is appropriate to allow for hygiene and a break from their wear. Stockings should be neither too loose (ineffective) nor too tight (inhibit blood flow). Antiembolism stockings may be used during and after surgery to promote venous return.

As the nurse is about to give a preoperative medication to a client going into surgery, it is discovered that the surgical consent form is not signed. What does the nurse do? Calls the surgeon Incorrect Calls the anesthesiologist Gives the medication as ordered Asks the client to sign the consent form

ask the client to sign the form The nurse may ask the client to sign the consent form, after which the medication can be administered. Calling the surgeon or the anesthesiologist is not necessary. It is illegal for the client to sign the permit after being sedated.

A client who is receiving intravenous antibiotic treatments every 6 hours has an intermittent IV set that was opened and begun 20 hours ago. What action does the nurse take? Change the set immediately. Change the set in about 4 hours. Correct Change the set in the next 12 to 24 hours. Nothing; the set is for long-term use.

b. Because both ends of the set are being manipulated with each dose, standards of practice dictate that the set should be changed every 24 hours, so the set should be changed in about 4 hours. It is not necessary to change out the set immediately, but it must be changed before the next 12 to 24 hours.

In conducting a postoperative assessment of a client, what is important for the nurse to examine first? Breathing pattern Correct Level of consciousness Incorrect Oxygen saturation Surgical site

breathing pattern Respiratory assessment is the most important. Assessing level of consciousness, oxygen saturation, and the surgical site are important, but not the priority.

The nurse is documenting peripheral venous catheter insertion for a client. What does the nurse include in the note? (Select all that apply.) Client's name and hospital number Client's response to the insertion Correct Date and time inserted Correct Type and size of device Correct Type of dressing applied Correct Vein used for insertion Correct

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During surgery, who is most responsible for monitoring for possible breaks in sterile technique? Circulating nurse Correct Holding nurse Anesthesiologist Surgeon

circulating nurse All OR team members are responsible, but the circulating nurse moves around the room and can see more of what is happening. The holding nurse is not in the operating room. The anesthesiologist is focused on providing sedation to the client. The surgeon is concentrating on the surgery and usually cannot monitor all staff.

Who is the most likely person to administer blood products in an operating suite? Circulating nurse Correct Holding area nurse Scrub nurse Specialty nurse

circulating nurse Circulating nurses or "circulators" are registered nurses who coordinate, oversee, and are involved in the client's nursing care in the operating room. Holding area nurses manage the client's care before surgery; blood would not yet be needed at this point. Scrub nurses set up the sterile field, drape the client, and hand sterile supplies, sterile equipment, and instruments to the surgeon and the assistant. Specialty nurses may be in charge of a particular type of surgical specialty; they are responsible for nursing care specific to clients who need that type of surgery, such as assessing, maintaining, and recommending equipment, instruments, and supplies.

As the nurse obtains the informed consent, the client asks, "Now what exactly are they going to do to me?" What is the nurse's response? Contact the anesthesiologist. Contact the surgeon. Correct Explain the procedure. Have the client sign the form.

contact the surgeon The nurse is not responsible for providing detailed information about the surgical procedure. Rather, the nurse's role is to clarify facts that have been presented by the health care provider and dispel myths that the client or family may have heard about the surgical experience. The anesthesiologist is responsible for the anesthesia, not the surgical details. Although the nurse is only witnessing the signature, it is the nurse's role to ensure that the facts are clarified before the consent form is signed.

Which statement by a student nurse indicates a need for further teaching about operating room (OR) surgical attire? "I must cover my facial hair." "I don't need a sterile gown to be in the OR." "If I go into the OR, I must wear a protective mask." "My scrubs are sterile." Correct

my scrubs are sterile Scrub attire is provided by the hospital and is clean, not sterile. All members of the surgical team must cover their hair, including any facial hair. Team members who are not scrubbed (e.g., anesthesia provider, student nurse) are not required to be sterile; they may wear cover scrub jackets that are snapped or buttoned closed to prevent shedding of organisms from bare arms. Everyone who enters an OR in which a sterile field is present must wear a mask.

Which intervention does the nurse implement for an older adult client to minimize skin breakdown related to surgical positioning? Apply elastic stockings to lower extremities. Monitor for excessive blood loss. Pad bony prominences. Correct Secure joints on a board in anatomic positions.

pad bony prominences

The nurse is educating a client who is about to undergo cardiac surgery with general anesthesia. Which statement by the client indicates the need for further instruction? "I will wake up with a tube in my throat." "I will have a bandage on my chest." "My family will not be able to see me right away." "Pain medication will take away my pain."

pain med will take away my pain Pain medication will minimize pain, but will not take it away completely. The client statement about waking up with a tube in the throat is accurate, because the client will be intubated. Following heart surgery, a dressing is placed on the chest. The client will not be able to see family immediately because he or she will go to recovery first.

Colostomy surgery is categorized as what type of surgery? Cosmetic Curative Incorrect Diagnostic Palliative

palliative Palliative surgery is performed to relieve symptoms of a disease process, but does not cure the disease. Cosmetic surgery is performed primarily to alter or enhance personal appearance. Curative surgery is performed to resolve a health problem by repairing or removing the cause. Diagnostic surgery is performed to determine the origin and cause of a disorder or the cell type for cancer.

Which assessment finding in a postoperative client after general anesthesia requires immediate intervention? Heart rate of 58 beats/min Pale, cool extremities Respiratory rate of 6 breaths/min Suppressed gag reflex

respiratory rate of 6 bpm The most important postoperative assessment is respiratory assessment, and a rate of 6 breaths/min is too low. A heart rate of 58 beats/min, pale and cool extremities, and a suppressed gag reflex are all normal postoperative findings.

A client has just undergone a surgical procedure with general anesthesia. Which finding indicates that the client needs further assessment in the postanesthesia care unit? Pain at the surgical site Requirement for verbal stimuli to awaken Incorrect Snoring sounds when inhaling Correct Sore throat on swallowing

snoring sounds when inhaling Snoring sounds when inhaling may indicate respiratory depression. Postsurgical pain at the surgical site is normal. Requiring verbal stimuli to awaken and a sore throat on swallowing are normal postsedation.

An older client's adult child tells the nurse that the client does not want life support. What does the nurse do first? Call the legal department to draft the paperwork. Document this in the chart. Thank the person and do nothing else. Talk to the client

talk to the client The nurse should determine the client's wishes and state of mind. The nurse should not call the legal department or document in the client's chart before speaking with the client. Doing nothing is not appropriate.

In going through the preoperative checklist, the nurse notices that the client's armband does not match the handwritten name on the informed consent, but it matches the stamped name. What does the nurse do first? Call admissions. Incorrect Cancel the surgery. Contact the surgeon. Talk to the operating team

talking to the operating team The operating team should be called to see if any clients with similar names are having surgery done. The client should confirm the spelling of his or her last name. Also, confirm the procedure that is expected to be done and compare it with the informed consent form. Calling admissions is not the first step; the stamp is correct. Canceling surgery is not done by the floor nurse. This is an administrative issue, and not one for the surgeon.