Med Surge Final

A. Serum albumin level E. Serum magnesium level

The nurse includes in the plan of care to periodically monitor which item for a client who is at risk for developing hypocalcemia? Select all that apply. A. Serum albumin level B. Fluid overload related to intravenous saline therapy C. Blood urea nitrogen (BUN) and creatinine levels D. Constipation E. Serum magnesium level

-Withhold the pain medication and contact the prescriber -A drug prescription must include the name of the drug, date and time the prescription was written, dosage, route, frequency, and signature of the prescriber.

A client is postoperative with an IV in place. During assessment, the client rates pain at being 6 on a 0-10 scale. The nurse notes a prescription in the client's chart for morphine sulfate 6-8 mg every 4 hours as needed for pain. Given the prescription and the client's condition, what action should the nurse take and why?

-incision made in the windpipe -to bypass an obstructed upper airway -to clean/remove secretions from airway -to deliver oxygen to lungs

What is a tracheostomy and why is it done?

c. The patient's report that her last menstrual period was 8 weeks ago Rationale: This statement suggests that the patient may be pregnant and pregnancy testing is needed before administration of anesthetic agents.

A 38-yr-old woman is admitted for an elective surgical procedure. Which information obtained by the nurse during the preoperative assessment is most important to communicate to the anesthesiologist and surgeon before surgery? a. The patient's lack of knowledge about postoperative pain control b. The patient's history of an infection following a cholecystectomy c. The patient's report that her last menstrual period was 8 weeks ago d. The patient's concern about being able to resume lifting heavy items

C. Open the dressing, and view the problem. D. Have someone notify the healthcare provider. E. Use a sterile dressing and sterile saline to keep the open incision moist.

A 78-year-old client with chronic obstructive pulmonary disease (COPD) has had abdominal surgery, and suddenly feels something "let go" in the incision underneath the dressing when coughing. What should the nurse's immediate actions? Select all that apply. A. Sit the client upright in bed. B. Apply pressure over the site. C. Open the dressing, and view the problem. D. Have someone notify the healthcare provider. E. Use a sterile dressing and sterile saline to keep the open incision moist.

A. Cover the wound with a sterile, saline-moistened dressing. Rationale: In wound dehiscence, the layers of the wound are disrupted, but there is no protrusion of vital organs. Covering the wound with sterile, saline-moistened gauze keeps the wound moist, and protects it from infection.

A client experiences wound dehiscence when coughing. After assisting the client to a low Fowler's position with legs slightly elevated, what is the next best action? A. Cover the wound with a sterile, saline-moistened dressing. B. Push the internal organs back into the abdominal opening. C. Cover the wound with a moist hydrocolloid dressing. D. Use Steri-Strips to hold the wound together.

During a 4-hour period on the second postoperative day, 500 mL of sanguineous fluid was noted.

A client had a total hip replacement with the insertion of a Hemovac suction drain for drainage during the postoperative period. When assessing the drainage, which statement would require immediate intervention by the nurse? A. A 3-inch circle of sanguineous fluid was noted on the 4-by-4 dressing after the client was up walking after the drain was removed on the third day. B. During a 4-hour period on the second postoperative day, 500 mL of sanguineous fluid was noted. C. On the third postoperative day, less than 30 mL/hour of serous fluid was noted. D. In the first hour postoperative, 250 mL of sanguineous fluid was drained.

Hypocalcemia Rationale: Citric acid in the transfused blood binds with calcium; the multiple transfusions would put the client at risk for hypocalcemia.

A client has received 10 units of stored blood following massive blood loss. The nurse plans to check for which electrolyte imbalance in this client? A. Hypernatremia B. Hypocalcemia C. Hypokalemia D. Hyperphosphatemia

Decreased respiratory rate Rationale: the lungs will not have to work as hard to oxygenate the blood, as greater oxygen exchange will occur at the pulmonary capillary level with more RBCs available. This leads to a decrease in respiratory rate.

A client has received 4 units of packed red blood cells (RBCs) for severe anemia. Which assessment findings would the nurse expect to see? A. Decreased respiratory rate B. Decreased blood pressure C. Decreased tissue perfusion D. Increased heart rate

Respiratory rate and breath sounds

A client has returned to the nursing unit following a tracheostomy. Which action is the highest priority and should be completed first? A. Status of tracheostomy dressing B. Amount of oxygen ordered to be delivered C. Time when client last received pain medication D. Respiratory rate and breath sounds

A. Folic acid deficiency anemia

A client is admitted to the medical/surgical unit with liver cirrhosis related to chronic alcohol use. The client also has a low hemoglobin level and a decreased red blood cell count. The nurse suspects that the client's anemia is caused by which of the following? A. Folic acid deficiency anemia B. Hemolytic anemia C. Vitamin B12-deficiency anemia D. Iron deficiency anemia

Diminished posterior breath sounds bilaterally

A client is one day postoperative for an abdominal hernia repair. Which symptom alerts the nurse that the client might be developing atelectasis? A. Crackles in the upper lobes the of anterior chest B. Diminished posterior breath sounds bilaterally C. Friction rub at fifth anterior intercostal space at the midclavicular line D. Wheezing in the upper bronchi on expiration

6 or more

What pH reading indicates that a nasogastric tube's placement is in the intestine?

Thrombocytopenia Rationale: characterized by a platelet count lower than 50,000/mm3, and often presents as purple spots on the client's skin.

A client presents to the emergency department (ED) with numerous ecchymotic areas on the arms, legs, and chest. The client's platelet count level is 45,000/mm3. The nurse suspects the client has what condition? A. Polycythemia vera B. Leukemia C. Leukopenia D. Thrombocytopenia

Provides proteins to increase the osmotic pressure in the blood Rationale: In burn injuries, protein is lost allowing fluid to escape into the tissues. Albumin is used to replace the lost proteins and pull fluids from the interstitial space back into the vascular system.

A client received a severe burn in a house fire. On the second day of hospitalization, the physician orders the client to receive albumin. Which reason should the nurse cite while explaining the rationale for albumin administration? A. Provides proteins to increase the osmotic pressure in the blood B. Provides fluid resuscitation to prevent dehydration C. Improves the level of clotting factors and prevent bleeding D. Replaces the lost red blood cells and reduce the anemia

Stop the transfusion

A client receiving a transfusion of PRBCs suddenly sounds hoarse, begins wheezing, is diaphoretic and short of breath, and reports palpitations. Blood pressure is 76/52. What is the priority nursing action?

Vitamin B12

A client recently was diagnosed with pernicious anemia. The nurse anticipates that the client will be treated with which of the following therapies? A. Vitamin B12 B. Folic acid C. Albumin D. Iron

Alcohol can affect the client's response to anesthesia and surgery.

A client who arrives for an outpatient surgical procedure has the odor of alcohol on the breath. Before completing the preoperative assessment, the nurse reports this finding to the surgeon, after drawing which conclusion about the significance of this finding? A. Alcohol can decrease the effectiveness of preoperative sedatives or hypnotics. B. Alcohol can affect the client's response to anesthesia and surgery. C. Alcohol can increase the risk for respiratory complications. D. Physiological and psychological responses are slowed down by recent alcohol intake.

0.9% sodium chloride Rationale: 0.9 sodium chloride (normal saline) is the only solution that can be administered with blood or blood products. -Other solutions may cause the blood cells to clump or cause clotting.

A client who is receiving 5% dextrose in 0.45% sodium chloride has a prescription to receiveone unit of packed red blood cells. Prior to hanging the blood, the nurse will prime the blood tubing with which solution? A. Lactated Ringer's B. 5% dextrose in 0.45% sodium chloride C. 0.9% sodium chloride D. 5% dextrose

D. A corticosteroid Rationale: Corticosteroids can delay wound healing and decrease the immune system, putting the patient at a higher risk for infection.

A client who takes numerous medications is being prepared for surgery. The nurse reviewing the client medication list is most concerned about which medication that may pose a post-surgical risk? A. A sedative-hypnotic B. An antidysrhythmic C. An oral hypoglycemic D. A corticosteroid

"I will weigh myself daily and notify the physician if I develop a fever or diarrhea."

A client with a history of congestive heart failure (CHF) has been carefully rehydrated with normal (0.9%) saline solution for isotonic dehydration related to overzealous diuresis. What statement by the client indicates that the nurse's discharge teaching has been effective? A. "I will take my diuretic pill every other day." B. "I will drink only one glass of water a day so I can eventually stop taking my pill." C. "I will increase my salt intake and double up on my fluid intake." D. "I will weigh myself daily and notify the physician if I develop a fever or diarrhea."

A decrease in heart rate Rationale: Treatment with normal saline should expand the extracellular fluid (ECF) volume, because it is an isotonic fluid like the ECF. Expansion of this volume in turn will increase blood pressure and decrease heart rate.

A client with an isotonic fluid volume deficit is being appropriately treated with normal saline solution. Which change would the nurse expect to assess in this client?A. A decrease in body weight B. An increase in urine specific gravity C. A decrease in urine output D. A decrease in heart rate

0.9% sodium chloride Rationale: Since the client's serum osmolality is normal, the client has a fluid volume loss. The IV fluids to restore fluid volume without changing electrolyte concentrations is a isotonic fluid which is 0.9% sodium chloride.

A client with dry skin and mucous membranes is weak, has orthostatic blood pressure changes, and has decreased urine output. The client's serum osmolality, however, is normal. Which of the following IV fluids would the nurse anticipate being prescribed for this client? A. 0.45 % sodium chloride B. Dextrose 5% in 0.45% sodium chloride C. 0.9% sodium chloride D. Dextrose 5% in 0.9% sodium chloride

0.9% sodium chloride (normal saline) Rationale: Normal saline solution is an isotonic solution that will replace lost vascular volume and promote perfusion. In addition, when blood is available, it can be hung with the normal saline.

A client with gastrointestinal (GI) bleeding suddenly develops diaphoresis with a rapid and thready pulse, and the nurse finds it difficult to hear a blood pressure. Which V fluid does the nurse anticipate the physician will order stat? A. 0.45% sodium chloride (� normal saline) B. Dextrose 5% in 0.45% sodium chloride (D5�NS) C. 0.9% sodium chloride (normal saline) D. Dextrose in water (D5W)

Ventrogluteal

A nurse giving an intramuscular injection places the heel of the hand on the client's greater trochanter, with the fingers pointing toward the client's head. The nurse places the index finger on the client's anterior superior iliac spine, while the middle finger is stretched dorsally, palpating the iliac crest. After giving the injection in the triangle formed, the nurse documents the injection as being given in which intramuscular injection site?

-coolness to touch -intolerance to cold -tachycardia -orthostatic hypotension -headaches.

A nurse has received a report on a client being admitted with anemia who requires a blood transfusion. The nurse will anticipate which assessment findings?

4 or less

A nurse is assigned to a client with a nasogastric tube and is checking gastric pH to verify correct tube placement. What gastric pH would indicate that the tube is placed properly in the stomach?

c. Serum potassium 3.2 mEq/L Rationale: The low potassium level may increase the risk for intraoperative complications such as dysrhythmias.

A patient who takes a diuretic and a -blocker to control blood pressure is scheduled for breast reconstruction surgery. Which patient information is most important to communicate to the health care provider before surgery? a. Hematocrit 36% c. Serum potassium 3.2 mEq/L b. Blood pressure 144/82 d. Pulse rate 54-58 beats/minute

1. a. Increase the IV infusion rate. 2. c. Increase the oxygen flow rate. 3. b. Assess the patient's dressing. 4. d. Check the patient's temperature. Rationale:Because the most common cause of hypotension is volume loss, the IV rate should be increased 1st. The oxygen flow rate should be increased next to maximize oxygenation of hypoperfused organs. Because hemorrhage is a common cause of postoperative volume loss, the nurse should check the dressing. Finally, the patient's temperature should be assessed to determine the effects of vasodilation caused by rewarming.

A patient's blood pressure in the postanesthesia care unit (PACU) has dropped from an admission blood pressure of 140/86 to 102/60 mm Hg with a pulse change of 70 to 96 beats/min. SpO2 is 92% on 3 L of oxygen. In which order should the nurse take these actions? a. Increase the IV infusion rate. b. Assess the patient's dressing. c. Increase the oxygen flow rate. d. Check the patient's temperature.

B. Transfuse type O, Rh-negative blood. E. Establish an intravenous line.

A trauma victim admitted to the emergency department is hemorrhaging, in shock, and has lost a significant percentage of blood volume. Since there is no time to perform a cross-match, which action should the nurse take immediately? Select all that apply. A. Transfuse albumin to expand the remaining plasma volume. B. Transfuse type O, Rh-negative blood. C. Transfuse type AB, Rh-positive blood. D. Transfuse platelets to restore adequate clotting ability. E. Establish an intravenous line.

Discontinue the infusion of RBCs and maintain the IV with normal saline solution. Rationale: The symptoms indicate a hemolytic reaction, usually as a result of ABO incompatibility. Clumping of RBCs can block capillaries and reduce blood flow to vital organs, necessitating immediate discontinuation of the infusion. The IV line should be kept patent with normal saline to allow for emergency access as needed.

After receiving 100mL of RBCs, a client develops lumbar pain and nausea. After quickly assessing the client, what action should the nurse take next?

a. Obese patient who had abdominal surgery 3 days ago and whose wound edges are separating Rationale: The patient's history and assessment suggests possible wound dehiscence, which should be reported immediately to the surgeon.

After receiving change-of-shift report about these postoperative patients, which patient should the nurse assess first? a. Obese patient who had abdominal surgery 3 days ago and whose wound edges are separating b. Patient who has 30 mL of sanguineous drainage in the wound drain 10 hours after hip replacement surgery c. Patient who has bibasilar crackles and a temperature of 100° F (37.8 °C) on the first postoperative day after chest surgery d. Patient who continues to have incisional pain 15 minutes after hydrocodone and acetaminophen (Vicodin) was given

Iron deficiency anemia rationale: Iron deficiency anemia can result from blood loss and is common in menstruating women; this is the most likely source of anemia in an adult female client.

An adult female client has a hemoglobin level of 9.2 grams/dL. The nurse interprets that this is most likely related to what condition? A. Iron deficiency anemia B. Vitamin B12 deficiency anemia C. Amenorrhea D. Leukemia

B. Side-lying, with the face slightly down rationale: gravity keeps the tongue forward, which helps to prevents aspiration.

The client arrives in the post-anesthesia care unit (PACU) in an unconscious state. In what position would the nurse place this client in this immediate postanesthetic stage? A. Dorsal recumbent, with the head turned to the side B. Side-lying, with the face slightly down C. Semi-prone, with the head tilted to the side D. Side-lying, with a pillow under the client's head

D. Urinary output of 150 mL for last shift Rationale: Urinary output should be at least 30 mL per hour, and 150 mL per shift does not show adequate renal perfusion or function. Without adequate renal function, the client could go into complete renal shutdown, and further assessment should be made immediately.

In a client who is one day postoperative following lumbar laminectomy, which finding would be of greatest concern to the nurse? A. Hemoglobin 10.5 grams/dL B. Blood urea nitrogen (BUN) 8 mg/dL; creatinine 1.2 mg/dL C. Decreased bowel sounds in all four quadrants D. Urinary output of 150 mL for last shift

b. Encourage the patient to take deep breaths. Rationale: The patient's borderline SpO2 and sleepiness indicate hypoventilation. The nurse should stimulate the patient and remind the patient to take deep breaths.

In the postanesthesia care unit (PACU), a patient's vital signs are blood pressure 116/72 mm Hg, pulse 74 beats/min, respirations 12 breaths/min, and SpO2 91%. The patient is sleepy but awakens easily. Which action should the nurse take first? a. Place the patient in a side-lying position. b. Encourage the patient to take deep breaths. c. Prepare to transfer the patient to a clinical unit. d. Increase the rate of the postoperative IV fluids.

-EKG changes -anorexia -muscle weakness -ileus (inability of the intestine to contract normally)

What symptoms would indicate excessive electrolytes have been removed from a client with a nasogastric tube who has been eating large amounts of ice?

-Discontinue the IV and apply a warm compress to the IV site. -Relocate the IV site and document the event.

The client is receiving 5% dextrose and 0.45% sodium chloride intravenously and is complaining of pain at the IV site. The nurse assesses the site and notes erythema and edema. What actions should the nurse take?

0.45% Sodium Chloride (NS)

The health care provider is going to prescribe a hypotonic intravenous solution for a client with cellular dehydration. The nurse would expect which fluid to be administered? A. 0.9% Sodium Chloride (normal saline, NS) B. 0.45% Sodium Chloride (NS) C. 5% Dextrose in Normal Saline D. Lactated Ringer's

Flushing the central line with a 3 mL syringe Rationale: All catheters should be flushed with syringes with barrels of 10 mL or larger. The smaller the barrel size, the greater the pressure that comes from the tip.

The home health nurse is monitoring a client who performs self-care of a central line. The nurse observes the client doing all of the following activities. Which activity indicates the need for further education? A. Flushing the central line with a 3 mL syringe B. Using sterile gloves to change the central line dressing C. Cleaning the needleless injection cap with alcohol before accessing D. Wearing a mask while changing the central line dressing

c. Assist the patient to ambulate. Rationale: Ambulation encourages peristalsis and the passing of flatus, which will relieve the patient's discomfort.

The nasogastric (NG) tube is removed on the second postoperative day, and the patient is placed on a clear liquid diet. Four hours later, the patient complains of frequent, cramping gas pains. What action by the nurse is the most appropriate? a. Reinsert the NG tube. c. Assist the patient to ambulate. b. Give the PRN IV opioid. d. Place the patient on NPO status.

d. 200 mL sanguineous fluid in the wound drain Rationale: Wound drainage should decrease and change in color from sanguineous to serosanguineous by the second postoperative day. The color and amount of drainage for this patient are abnormal and should be reported.

The nurse assesses a patient on the second postoperative day after abdominal surgery to repair a perforated duodenal ulcer. Which finding is most important for the nurse to report to the surgeon? a. Tympanic temperature 99.2° F (37.3° C) b. Fine crackles audible at both lung bases c. Redness and swelling along the suture line d. 200 mL sanguineous fluid in the wound drain

C. Voiding Rationale: It is most important to ensure that the client has voided eight hrs after surgery. If not, the nurse should assess urine volume using a bladder scanner and contact the healthcare provider for a prescription for catheterization to prevent acute urinary retention.

The nurse assigned to the care of a client who returned from surgery 8 hours ago. Which assessment is of the highest priority at this time? A. Use of the incentive spirometer B. Voiding C. Absence of nausea and vomiting D. Bowel sounds

C. Obtain vital signs every 5 minutes. D. The healthcare provider should be notified. E. Run normal saline at keep vein open (KVO) rate.

The nurse determines that a client receiving a unit of packed red blood cells (PRBCs) is experiencing a transfusion reaction. After stopping the blood transfusion, what actions should the nurse promptly take next? (select all that apply) A. Infuse a normal saline bolus. B. Obtain a white blood cell count. C. Obtain vital signs every 5 minutes. D. The healthcare provider should be notified. E. Run normal saline at keep vein open (KVO) rate.

"I should notify my healthcare provider if I start to feel tingling or numbness around my mouth." Explanation: TUMS can be used as a calcium supplement when calcium intake is inadequate. Tingling or numbness around the mouth is a sign of impending tetany. A health care provider should be notified immediately. To prevent hypocalcemia, the client should increase the protein in the diet. Kidney stones are a sign of hypercalcemia. normal range: 8.5 - 10.2

The nurse evaluates that discharge teaching has been effective when the client with a calcium level of 7.2 mg/dL makes which statement? A. "I will watch my urine for signs of kidney stones." B. "I should notify my healthcare provider if I start to feel tingling or numbness around my mouth." C. "I will need to cut down on the amount of protein I include in my diet each day." D. "I shouldn't take antacids, such as TUMS."

Holding the inhaler 5.1 cm (2 in.) away from the mouth

The nurse has instructed the client in using a metered-dose inhaler. The nurse determines that the client understands the instructions when the client is observed doing what? A. Holding the inhaler 5.1 cm (2 in.) away from the mouth B. Not shaking the canister before puffs C. Administering the two puffs in rapid order between breaths D. Exhaling immediately after administering the puff

Mild swelling at the insertion site Rationale: The nurse would refrain from advancing the catheter if mild swelling at the insertion site occurs. Mild swelling indicated the needle has damaged the vein.

The nurse is inserting an intravenous (IV) line into a client. After piercing the skin and entering the vein, what manifestation should cause the nurse to refrain from advancing the catheter? A. Blood backflow into the IV catheter B. IV catheter was inserted bevel side up C. No reports of client discomfort D. Mild swelling at the insertion site

2.5 cm (1 in.), 25 gauge

The nurse is preparing to administer a non-viscous medication via an intramuscular injection into the deltoid muscle of a 160-pound male. What is the preferred needle size for the medication, muscle, and weight of the client? A. 3.8 cm (1.5 in.), 20 gauge B. 2.5 cm (1 in.), 25 gauge C. 3.8 cm (1.5 in.), 25 gauge D. 2.5 cm (1 in.), 20 gauge

Ventrolgluteal -has a large muscle mass

The nurse is to administer 25 mg of promethazine IM to a 150-pound client. The nurse prepares to inject the dose into which site and why? A. Dorsogluteal B. Ventrolgluteal C. Deltoid D. Vastus lateralis

A client with a history of congestive heart failure (CHF) Rationale: A client with CHF should not receive albumin therapy due to potential side effects of circulatory failure and fluid overload that may further exacerbate the client's cardiac status.

The nurse recognizes that albumin therapy would be contraindicated for which of the following clients? A. A client who has hypoalbuminemia B. An infant with hemolytic disease of the newborn C. A client with a history of congestive heart failure (CHF) D. A client in hypovolemic shock

Fluid overload Rationale: Circulatory overload is a complication associated with rapid transfusion administration. Symptoms include bounding pulse, dyspnea, and crackles in the lungs.

The nurse returns to evaluate a client whose blood transfusion has been infusing for 30 minutes. Upon assessment, the nurse notes that the client is dyspneic and auscultates the presence of crackles in the lung bases with an apical heart rate of 110 beats per minute. What complication should the nurse suspect that the client is experiencing? A. Hypovolemia B. Polycythemia vera C. Immune response to transfusion D. Fluid overload

A. A male client weighing 150 kg who has noisy breathing and a history of narcolepsy Rationale: The client with impaired respirations due to increased weight would be at greatest risk for respiratory complications when receiving a narcotic that suppresses respirations. Snoring loudly reflects poor air exchange. Narcolepsy suggests that he is sleep-deprived from respiratory obstruction at night.

The nurse working in a busy surgical unit has four postsurgical clients who are receiving patient-controlled analgesia (PCA) with fentanyl. Which client does the nurse plan to assess most frequently? A. A male client weighing 150 kg who has noisy breathing and a history of narcolepsy B. A client with COPD who has an oxygen saturation of 92% C. A 94-year-old female who has never been sick, but weighs only 45 kg D. A client with respirations of 14 per minute who is easily awakened by spoken command

2.5 cm (1 in.)

To administer 1 mL of an in fluenza vaccine intramuscularly (IM) to an obese adult in the deltoid area, the nurse would use what size needle? A. 1.6 cm (5/8 in.) B. 2.5 cm (1 in.) C. 5.1 cm (2 in.) D. 3.8 cm (1 1/2 in.)

B. 0.45% sodium chloride with 20 mEq of potassium Rationale: The client presents with hypochloremia, and most likely is experiencing other electrolyte deficiencies as well, most notably sodium and potassium. A solution with 0.45% saline with added potassium would be an appropriate option, because this would correct all fluid and electrolyte imbalances.

When a client is admitted with a chloride level of 80 mEq/L, the nurse anticipates administration of which of the following intravenous solutions? A. 5% dextrose and water B. 0.45% sodium chloride with 20 mEq of potassium C. 0.9% sodium chloride D. 3% sodium chloride

Tetany Rationale: Tetany occurs with the increased neuromuscular irritability that accompanies hypocalcemia.

When assessing a client with hypercalcemia, the nurse concludes that which finding in the neuromuscular examination is consistent with that electrolyte imbalance? A. Muscle weakness B. A positive Trousseau's sign C. Tetany D. Hyperactive deep tendon reflexes

b. Have the patient use the incentive spirometer. Rationale: A temperature of 100.8° F (38.2° C) in the first 48 hours is usually caused by atelectasis, and the nurse should have the patient deep breathe, cough, and use the incentive spirometer.

When caring for a patient the second postoperative day after abdominal surgery for removal of a large pancreatic cyst, the nurse obtains an oral temperature of 100.8° F (38.2° C). Which action should the nurse take next? a. Place ice packs in the patient's axillae. b. Have the patient use the incentive spirometer. c. Request an order for acetaminophen (Tylenol). d. Ask the health care provider to prescribe a different antibiotic.

A. Naloxone Rationale: Naloxone is the acceptable antidote for narcotic overdose.

Which PRN medication would the nurse anticipate using when a postoperative client is suspected to have taken an excessive dose of a narcotic, and has a respiratory rate of approximately 8 breaths per minute? A. Naloxone B. Protamine sulfate C. Phytonadione (vitamin K) D. Flumazenil

c. Have the patient state name and date of birth. d. Verify the patient identification band number. e. Ask the patient to state the surgical procedure

Which actions will the nurse include in the surgical time-out procedure before surgery (select all that apply)? a. Check for patency of IV lines. b. Have the surgeon identify the patient. c. Have the patient state name and date of birth. d. Verify the patient identification band number. e. Ask the patient to state the surgical procedure.

Decreased serum osmolality, decreased BUN, and decreased HCT

Which change in laboratory values would the nurse anticipate after administering isotonic intravenous fluids to a client experiencing hypertonic dehydration?

b. Albumin level 2.2 g/dL Rationale: Because proteins are needed for an appropriate inflammatory response and wound healing, the low serum albumin level (normal level, 3.5 to 5.0 g/dL) indicates a risk for poor wound healing.

Which finding would indicate to the nurse that a postoperative patient is at increased risk for poor wound healing? a. Potassium 3.5 mEq/L c. Hemoglobin 10.2 g/dL b. Albumin level 2.2 g/dL d. White blood cells 11,900/µL

a. The patient takes garlic capsules every day. Rationale: Chronic use of garlic may predispose to intraoperative and postoperative bleeding.

Which information in the preoperative patient's medication history is most important to communicate to the health care provider? a. The patient takes garlic capsules every day. b. The patient quit using cocaine 10 years ago. c. The patient took a prescribed sedative the previous night. d. The patient uses acetaminophen (Tylenol) for aches and pains.

Bradycardia indicates that vagus nerve has been stimulated and can lead to cardiac arrest if the heart rate drops too low.

Which of the following would indicate a serious complication from excessive suctioning of an endotracheal tube that requires immediate nursing intervention? A. Pallor B. Bradycardia C. Slight cyanosis D. Tachycardia

Increase in blood pressure Rationale: 25% albumin is a hypertonic colloid solution that will expand the plasma volume which should increase blood pressure. This will decrease the strain on the heart decreasing heart rate.

Which outcome would the nurse anticipate after infusion of 25% albumin to a client in hypovolemic shock? A. Increase in blood pressure B. Increase in heart rate C. Decrease in temperature D. Decrease in peripheral perfusion

a. "I will assist in preparing the operating room for the patient."

Which statement, if made by a new circulating nurse, reflects understanding of the circulating nurse role? a. "I will assist in preparing the operating room for the patient." b. "I will don sterile gloves to obtain items from the unsterile field." c. "I will remain gloved while performing activities in the sterile field." d. "I will assist with suturing of incisions and maintaining hemostasis as needed."

Infiltration Rationale: Infiltration is leakage of fluids into the surrounding tissues, resulting in edema around the insertion site, blanching, and coolness of skin around the site.

While assessing a client's intravenous (IV) line, the nurse notes that the area is swollen, cool, pale, and causes the client discomfort. What complication should the nurse document?

B. Impaired wound healing Rationale: Wound and cardiovascular complications are more common among clients who are obese because the adipose tissue is not vascularized

While planning postoperative care for an obese client prior to surgery, the nurse should be most concerned about which risk that is increased by obesity during postsurgical recovery? A. Pressure ulcer development B. Impaired wound healing C. Fluid overload D. Inability to regulate body temperature

Clients with SIADH (syndrome of inappropriate antidiuretic hormone) requires a hypertonic IV solution, therefore an order of D5 W would be questioned.

Why should the order for D5W for a client with syndrome of inappropriate antidiuretic hormone (SIADH) be questioned?

Leukemia

associated with an overproduction of white blood cells.

Leukopenia

characterized by a low white blood cell count

Infection at the IV site

characterized by fever, chills, erythema, or drainage at the IV insertion site

hypocalcemia

indicated by a positive Trousseau's sign

Hypercalcemia

indicated by muscle weakness

Phlebitis

inflammation to the lumen of a vein manifested by warmth, swelling, a red streak and pain along the course of the vein, and localized warmth.

air embolism

occurs when air is introduced into an IV line; characterized by respiratory distress, chest pain, dyspnea, hypotension, and a weak and rapid pulse.