Med Surge Part 1
The nurse is providing teaching about tissue repair and wound healing to a patient who has a leg ulcer. Which of the following statements by the patient indicates that teaching has been effective? "My foot should feel cool or cold while my leg's healing." "I'll make sure to limit my intake of protein." "I'll eat plenty of fruits and vegetables." "I'll make sure that the bandage is wrapped tightly."
"I'll eat plenty of fruits and vegetables."
An unlicensed nursing assistant (NA) reports to the nurse that a postsurgical patient is complaining of pain that she rates as 8 on a 0-to-10 point scale. The NA tells the nurse that he thinks the patient is exaggerating and does not need pain medication. What is the nurse's best response? "It's not unusual for patients to misreport pain to get our attention when we are busy." "Unless there is strong evidence to the contrary, we should take the patient's report at face value.'" "Pain often comes and goes with postsurgical patients. Please ask her about pain again in about 30 minutes." "We need to provide pain medications because it is the law, and we must always follow the law."
"Unless there is strong evidence to the contrary, we should take the patient's report at face value.'"
A clinic nurse is conducting a preoperative interview with an adult patient who will soon be scheduled to undergo cardiac surgery. What interview question most directly addresses the patient's safety? "How long do you expect to be at home recovering after your surgery?" "Would you say that you tend to eat a fairly healthy diet?" "What prescription and nonprescription medications do you currently take?" "Have you previously been admitted to the hospital, either for surgery or for medical treatment?"
"What prescription and nonprescription medications do you currently take?"
The nurse is caring for a patient in the postoperative period following an abdominal hysterectomy. The patient states, "I don't want to use my pain meds because they'll make me dependent and I won't get better as fast." Which response is most important when explaining the use of pain medication? "You will need the pain medication for at least 1 week to help in your recovery. What do you mean you feel you won't get better faster?" "Pain medication will help to decrease your pain and increase your ability to breath. Dependency is a risk with pain medication, but you are young and won't have any problems." "Pain medication can be given by mouth to prevent the risk of dependency that you are worried about. The pain medication has not been shown to affect your risk of a slowed recovery." "You will move more easily and heal more quickly with decreased pain. Dependence only occurs when it is administered for an extended period of time."
"You will move more easily and heal more quickly with decreased pain. Dependence only occurs when it is administered for an extended period of time."
One of the things a nurse has taught to a patient during preoperative teaching is to have nothing by mouth for the specified time before surgery. The patient asks the nurse why this is important. What is the most appropriate response for the patient? "The restriction of food or fluid will prevent the development of pneumonia related to decreased lung capacity." "By withholding food for 8 hours before surgery, you will not develop constipation in the postoperative period." "The presence of food in the stomach interferes with the absorption of anesthetic agents." "You will need to have food and fluid restricted before surgery so you are not at risk for choking."
"You will need to have food and fluid restricted before surgery so you are not at risk for choking."
Maintaining an aseptic environment in the OR is essential to patient safety and infection control. When moving around surgical areas, what distance must the nurse maintain from the sterile field? 6 inches 18 inches 1 foot 2 feet
1 foot
A circulating nurse provides care in a surgical department that has multiple surgeries scheduled for the day. The nurse should know to monitor which patient most closely during the intraoperative period because of the increased risk for hypothermia? A 17-year-old boy with traumatic injuries A 13-year-old girl undergoing craniofacial surgery A 45-year-old woman having an abdominal hysterectomy A 74-year-old woman with a low body mass index
A 74-year-old woman with a low body mass index
A nurse on an oncology unit has arranged for an individual to lead meditation exercises for patients who are interested in this nonpharmacological method of pain control. The nurse should recognize the use of what category of nonpharmacological intervention? A biologically based therapy An energy therapy A mind-body method A body-based modality
A mind-body method
An intraoperative nurse is applying interventions that will address surgical patients' risks for perioperative positioning injury. Which of the following factors contribute to this increased risk for injury in the intraoperative phase of the surgical experience? Select all that apply. Absence of reflexes Nausea resulting from anesthetic Reduced blood pressure Loss of pain sensation Diminished ability to communicate
Absence of reflexes Loss of pain sensation Diminished ability to communicate
You are the emergency department (ED) nurse caring for an adult patient who was in a motor vehicle accident. Radiography reveals an ulnar fracture. What type of pain are you addressing when you provide care for this patient? Chronic Intermittent Acute Osteopenic
Acute
A surgical patient has been in the PACU for the past 3 hours. What are the determining factors for the patient to be discharged from the PACU? Select all that apply. Adequate respiratory function Ability to tolerate oral fluids Absence of pain Sufficient oxygen saturation Stable blood pressure
Adequate respiratory function Sufficient oxygen saturation Stable blood pressure
Your patient is receiving postoperative morphine through a patient-controlled analgesic (PCA) pump and the patient's orders specify an initial bolus dose. What is your priority assessment? Assessment for decreased level of consciousness (LOC) Assessment for paradoxical increase in pain Assessment for respiratory depression Assessment for fluid overload
Assessment for respiratory depression
A newly admitted patient has gained weight steadily over the past 2 years and the nurse recognizes the need for a nutritional assessment. What assessment parameters are included when assessing a patient's nutritional status? Select all that apply. Clinical examination findings BMI Ethnic mores Wrist circumference Dietary data
BMI, Dietary data, Clinical examination findings
A hospital's current quality improvement program has integrated the principles of the Institute for Healthcare Improvement (IHI) 5 Million Lives Campaign. How can the hospital best achieve the campaign goals of reducing preventable harm and death? By involving patients and families in their care planning By having researchers from outside the facility evaluate care By reducing nurse-to-patient ratios and increasing accountability By adhering to EBP guidelines
By adhering to EBP guidelines
A patient is scheduled for surgery the next day and the different phases of the patient's surgical experience will require input from members of numerous health disciplines. How should the patient's care best be coordinated? By identifying the professional with the most knowledge of the patient By planning care using a surgical approach By using the nursing process to guide all aspects of care and treatment By implementing an interdisciplinary approach to care
By implementing an interdisciplinary approach to care
As an intraoperative nurse, you are the advocate for each of the patients who receives care in the surgical setting. How can you best exemplify the principles of patient advocacy? By maintaining each of your patients' privacy By encouraging the patient to perform deep breathing preoperatively By eliciting informed consent from patients By limiting the patient's contact with family members preoperatively
By maintaining each of your patients' privacy
A 52-year-old female patient is receiving care on the oncology unit for breast cancer that has metastasized to her lungs and liver. When addressing the patient's pain in her plan of nursing care, the nurse should consider what characteristic of cancer pain? Cancer pain is often related to the stress of the patient knowing she has cancer and requires relatively low doses of pain medications along with a high dose of anti-anxiety medications. Cancer pain can be acute or chronic and it typically requires comparatively high doses of pain medications. Cancer pain is often misreported by patients because of confusion related to their disease process. Cancer pain is always chronic and challenging to treat, so distraction is often the best intervention.
Cancer pain can be acute or chronic and it typically requires comparatively high doses of pain medications.
You are the nurse coming on shift in a rehabilitation unit. You receive information in report about a new patient who has fibromyalgia and has difficulty with her ADLs. The off-going nurse also reports that the patient is withdrawn, refusing visitors, and has been vacillating between tears and anger all afternoon. What do you know about chronic pain syndromes that could account for your new patient's behavior? Chronic pain can cause intense emotional responses. The patient likely has an underlying psychiatric disorder. Fibromyalgia is not a chronic pain syndrome, so further assessment is necessary. The patient is likely frustrated because she has to be in the hospital.
Chronic pain can cause intense emotional responses.
A gerontologic nurse has observed that patients often fail to adhere to a therapeutic regimen. What strategy should the nurse adopt to best assist an older adult in adhering to a therapeutic regimen involving wound care? Provide a detailed pamphlet on a dressing change. Delegate the dressing change to a trusted family member. Verbally instruct the patient how to change a dressing and check for comprehension. Demonstrate a dressing change and allow the patient to practice.
Demonstrate a dressing change and allow the patient to practice.
A patient who has a 40 pack-year history of smoking may have dysplasia of the epithelial cells in her bronchi. What would the nurse tell the patient about dysplastic cells in the bronchi? This is a benign process that occurs as lung tissue regenerates. Dysplastic cells have a high potential to become malignant. This process involves a rapid increase in number of cells. Dysplasia may cause uncontrolled growth of scar tissue.
Dysplastic cells have a high potential to become malignant.
The nurse is doing a preoperative assessment of an 87-year-old man who is slated to have a right lung lobe resection to treat lung cancer. What underlying principle should guide the nurse's preoperative assessment of an elderly patient? Elderly patients have less physiologic reserve than younger patients. Elderly patients have more sophisticated coping skills than younger patients. Elderly patients require higher medication doses than younger patients. Elderly patients have a smaller lung capacity than younger patients.
Elderly patients have less physiologic reserve than younger patients.
The nurse is admitting a patient to the medical-surgical unit from the PACU. What should the nurse do to help the patient clear secretions and help prevent pneumonia? Encourage the patient to limit his activity for the first 72 hours. Encourage the patient to use the incentive spirometer every 2 hours. Encourage the patient to take his medications as ordered. Encourage the patient to eat a balanced diet that is high in protein.
Encourage the patient to use the incentive spirometer every 2 hours.
An adult patient has just been admitted to the PACU following abdominal surgery. As the patient begins to awaken, he is uncharacteristically restless. The nurse checks his skin and it is cold, moist, and pale. The nurse concerned the patient may be at risk for what? Aspiration Hemorrhage and shock Postoperative infection Hypertension and dysrhythmias
Hemorrhage and shock
The PACU nurse is caring for a 45-year-old male patient who had a left lobectomy. The nurse is assessing the patient frequently for airway patency and cardiovascular status. The nurse should know that the most common cardiovascular complications seen in the PACU include what? Select all that apply. Hypervolemia Hypotension Dysrhythmias Heart murmurs Hypertension
Hypotension, Dysrhythmias, Hypertension
A teenage boy who was the victim of a near drowning has been admitted to the emergency department. The patient was submerged for several minutes and remains unconscious. What pathophysiological process has occurred as a result of the submersion? Necrosis to the brain Hypoxia to the brain Atrophy of brain cells Cellular lysis
Hypoxia to the brain
You are admitting a patient to your medical unit after the patient has been transferred from the emergency department. What is your priority nursing action at this time? Checking the admitting physician's orders Allowing the family to be with the patient Obtaining a baseline set of vital signs Identifying the immediate needs of the patient
Identifying the immediate needs of the patient
Achieving adequate pain management for a postoperative patient will require sophisticated critical thinking skills by the nurse. What are the potential benefits of critical thinking in nursing? Select all that apply. Identifying the patient's individual preferences Helping identify the patient's priority needs Increasing the accuracy of the nurse's judgments Enhancing the nurse's clinical decision making Planning the best nursing actions to assist the patient
Identifying the patient's individual preferences Helping identify the patient's priority needs Increasing the accuracy of the nurse's judgments Enhancing the nurse's clinical decision making
A 35-year-old woman comes to the local health center with a large mass in her right breast. She has felt the lump for about a year, but was afraid to come to the clinic because she was sure it was cancer. What is the most appropriate nursing diagnosis for this patient? Altered family process related to inability to obtain treatment Self-esteem disturbance related to late diagnosis Ineffective denial related to reluctance to seek care Ineffective individual coping related to reluctance to seek care
Ineffective individual coping related to reluctance to seek care
A medical nurse has obtained a new patient's health history and completed the admission assessment. The nurse has followed this by documenting the results and creating a care plan for the patient. Which of the following is the most important rationale for documenting the patient's care? It creates a teaching log for the family. It verifies appropriate staffing levels. It provides continuity of care. It keeps the patient fully informed.
It provides continuity of care.
A nurse is providing preoperative teaching to a patient who will soon undergo a cardiac bypass. The nurse's teaching plan includes exercises of the extremities. What is the purpose of teaching a patient leg exercises prior to surgery? Leg exercises increase the patient's muscle mass postoperatively. Leg exercises improve circulation and prevent venous thrombosis. Leg exercise help increase the patient's level of consciousness after surgery. Leg exercises help to prevent pressure sores to the sacrum and heels.
Leg exercises improve circulation and prevent venous thrombosis.
The nurse is caring for a patient who has just been transferred to the PACU from the OR. What is the highest nursing priority? Assessing vital signs every 30 minutes Assessing for hemorrhage Managing the patient's pain Maintaining a patent airway
Maintaining a patent airway
An OR nurse is teaching a nursing student about the principles of surgical asepsis as a requirement in the restricted zone of the operating suite. What personal protective equipment should the nurse wear at all times in the restricted zone of the OR? Mask covering the nose and mouth Goggles Reusable shoe covers Gloves
Mask covering the nose and mouth
A patient's intractable neuropathic pain is being treated on an inpatient basis using a multimodal approach to analgesia. After administering a recently increased dose of IV morphine to the patient, the nurse has returned to assess the patient and finds the patient unresponsive to verbal and physical stimulation with a respiratory rate of five breaths per minute. The nurse has called a code blue and should anticipate the administration of what drug? Naloxone Celecoxib Acetylsalicylic acid Acetylcysteine
Naloxone
You walk into your patient's room and find her sobbing uncontrollably. When you ask what the problem is, your patient responds, "I am so scared. I have never known anyone who goes into a hospital and comes out alive." On this patient's care plan you note a pre-existing nursing diagnosis of Ineffective Coping related to stress. What is the best outcome you can expect for this patient? Patient will adopt coping mechanisms to reduce stress. Patient will avoid all stressful situations. Patient will be stress free for the duration of treatment. Patient will be treated with an antianxiety agent.
Patient will adopt coping mechanisms to reduce stress.
You are caring for a 20-year-old patient with a diagnosis of cerebral palsy who has been admitted for the relief of painful contractures in his lower extremities. When creating a nursing care plan for this patient, what variables should the nurse consider? Select all that apply. Patient's comorbid conditions Changes in neurologic function due to the procedure Prior effectiveness in relieving the pain Type of procedure be performed Patient's gender
Patient's comorbid conditions Changes in neurologic function due to the procedure Prior effectiveness in relieving the pain
A patient is scheduled for a bowel resection in the morning and the patient's orders include a cleansing enema tonight. The patient wants to know why this is necessary. The nurse should explain that the cleansing enema will have what therapeutic effect? Facilitating better absorption of medications Preventing aspiration of gastric contents Preventing potential contamination of the peritoneum Preventing the accumulation of abdominal gas postoperatively
Preventing potential contamination of the peritoneum
The nurse is teaching a local community group about the importance of disease prevention. Why is the nurse justified in emphasizing disease prevention as a component of health promotion? Most Americans die of preventable causes. External environment affects the outcome of most disease processes. Health maintenance organizations (HMOs) now emphasize prevention as the main criterion of health care. Prevention is emphasized as the link between personal behavior and health.
Prevention is emphasized as the link between personal behavior and health.
The nurse is discharging a patient home from an outpatient surgery center. The nurse has reviewed all of the discharge instructions with the patient and her caregiver. What else should the nurse do before discharging the patient from the facility? Select all that apply. Provide the nurse's or surgeon's contact information. Give prescriptions to the patient. Irrigate the patient's incision and perform a sterile dressing change. Administer a bolus dose of an opioid analgesic. Provide all discharge instructions in writing.
Provide the nurse's or surgeon's contact information, Give prescriptions to the patient, Provide all discharge instructions in writing
The nurse is caring for a 79-year-old man who has returned to the postsurgical unit following abdominal surgery. The patient is unable to ambulate and is now refusing to wear an external pneumatic compression stocking. The nurse should explain that refusing to wear external pneumatic compression stockings increases his risk of what postsurgical complication? Infection Sepsis Pulmonary embolism Hematoma
Pulmonary embolism
The nurse is caring for a patient on the medical-surgical unit postoperative day 5. During each patient assessment, the nurse evaluates the patient for infection. Which of the following would be most indicative of infection? Red, warm, tender incision Rectal temperature of 99.5ºF (37.5ºC) Presence of an indwelling urinary catheter White blood cell (WBC) count of 8,000/mL
Red, warm, tender incision
A patient is experiencing intense stress during his current hospital admission for the exacerbation of chronic obstructive pulmonary disease (COPD). Which of the patient's actions best demonstrates adaptively coping? Reprioritizing needs and roles Withdrawing Using benzodiazepines as ordered Becoming controlling
Reprioritizing needs and roles
A 90-year-old female patient is scheduled to undergo a partial mastectomy for the treatment of breast cancer. What nursing diagnosis should the nurse prioritize when planning this patient's postoperative care? Risk for Delayed Growth and Development related to prolonged hospitalization Risk for Infection related to reduced immune function Risk for Decisional Conflict related to discharge planning Risk for Impaired Memory related to old age
Risk for Infection related to reduced immune function
A nurse is planning care for an older adult who lives with a number of chronic health problems. For which of the following nursing diagnoses would education of the patient be the nurse's highest priority? Functional urinary incontinence related decreased mobility Activity intolerance related to contractures Risk for ineffective health maintenance related to nonadherence to therapeutic regimen Risk for impaired physical mobility related to joint pain
Risk for ineffective health maintenance related to nonadherence to therapeutic regimen
The nurse is admitting a 51-year-old patient to the medical-surgical unit after a diagnosis of cellulitis of the calf. What factors does the nurse know impact the processes of inflammation, repair, and replacement? Select all that apply. Severity of the injury Condition of the host Nature of the injury Familial support Social relationships
Severity of the injury Condition of the host Nature of the injury
The nurse is caring for a 78-year-old man who has had an outpatient cholecystectomy. The nurse is getting him up for his first walk postoperatively. To decrease the potential for orthostatic hypotension and consequent falls, what should the nurse have the patient do? Perform range-of-motion exercises for each joint. Stand upright for 2 to 3 minutes prior to ambulating. Drink plenty of fluids to increase circulating blood volume. Sit in a chair for 10 minutes prior to ambulating.
Stand upright for 2 to 3 minutes prior to ambulating
An OR nurse is participating in an interdisciplinary audit of infection control practices in the surgical department. The nurse should know that a basic guideline for maintaining surgical asepsis is what? Sterile supplies can be used on another patient if the packages are intact. The scrub nurse may pour a sterile solution from a nonsterile bottle. Sterile surfaces or articles may touch other sterile surfaces. The outer lip of a sterile solution is considered sterile.
Sterile surfaces or articles may touch other sterile surfaces.
A nurse has been studying research that examines the association between stress levels and negative health outcomes. Which relationship should underlie the educational interventions that the nurse chooses to teach? Stress impairs sleep patterns. Stress decreases immune function. Stress increases weight. Stress decreases concentration.
Stress decreases immune function.
A nurse in the preoperative holding area is admitting a woman prior to reduction mammoplasty. What should the nurse include in the care given to this patient? Select all that apply. Taking measures to ensure the patient's comfort Applying a grounding device to the patient Verifying the surgical site with the patient Establishing an IV line Preparing the medications to be administered in the OR
Taking measures to ensure the patient's comfort Verifying the surgical site with the patient Establishing an IV line
A 60-year-old patient who has diabetes had a below-knee amputation 1 week ago. The patient asks "why does it still feel like my leg is attached, and why does it still hurt?" The nurse explains neuropathic pain in terms that are accessible to the patient. The nurse should describe what pathophysiologic process? The proliferation of nociceptors during times of stress The abnormal reorganization of the nervous system Age-related deterioration of the central nervous system Psychosocial dependence on pain medications
The abnormal reorganization of the nervous system
A group of students have been challenged to prioritize ethical practice when working with a marginalized population. How should the students best understand the concept of ethics? The adherence to culturally rooted, behavioral norms The adherence to informal personal values The informal study of patterns of ideal behavior The formal, systematic study of moral beliefs
The formal, systematic study of moral beliefs
The nurse at the student health center is seeing a group of students who are interested in reducing their stress level. The nurse identifies guided imagery as an appropriate intervention. What will be included in the nurse's intervention? Using a positive self-image to increase and intensify physical exercise, which decreases stress The mindful use of a word, phrase, or visual, which allows oneself to be distracted and temporarily escape from stressful situations The use of music and humor to create a calm and relaxed demeanor, which allows escape from stressful situations The use of progressive tensing and relaxing of muscles to release tension in each muscle group
The mindful use of a word, phrase, or visual, which allows oneself to be distracted and temporarily escape from stressful situations
The nurse admitting a patient who is insulin dependent to the same-day surgical suite for carpal tunnel surgery. How should this patient's diagnosis of type 1 diabetes affect the care that the nurse plans? The nurse should administer a bolus of dextrose IV solution preoperatively. The nurse should initiate a subcutaneous infusion of long-acting insulin. The nurse should assess the patient's blood glucose levels vigilantly. The nurse should keep the patient NPO for at least 8 hours preoperatively.
The nurse should assess the patient's blood glucose levels vigilantly.
A mother has brought her young son to the emergency department (ED). The mother tells the triage nurse that the boy was stung by a bee about an hour ago. The mother explains to the nurse, "It hurts him so bad and it looks swollen, red, and infected." What can the triage nurse teach the mother? The infection was probably caused by the stinger, which may still be in the wound. The pain, redness, and swelling are part of the inflammatory process, but it is probably too early for an infection. The mother's assessment is accurate and the ED doctor will probably prescribe antibiotics to fix the problem. Bee stings frequently cause infection, pain, and swelling, and, with treatment, the infection should begin to subside late today.
The pain, redness, and swelling are part of the inflammatory process, but it is probably too early for an infection.
The nurse is checking the informed consent for a 17-year-old who has just been married and expecting her first child. She is scheduled for a cesarean section. She is still living with her parents and is on her parents' health insurance. When obtaining informed consent for the cesarean section, who is legally responsible for signing? Her husband The obstetrician The patient Her parents
The patient
The nurse is caring for a postoperative patient who needs daily dressing changes. The patient is 3 days postoperative and is scheduled for discharge the next day. Until now, the patient has refused to learn how to change her dressing. What would indicate to the nurse the patient's possible readiness to learn how to change her dressing? Select all that apply. The patient assists in opening the packages of dressing material for the nurse. The patient wants you to teach a family member to do dressing changes. The patient expresses interest in the dressing change. The patient is willing to look at the incision during a dressing change. The patient expresses dislike of the surgical wound.
The patient assists in opening the packages of dressing material for the nurse. The patient expresses interest in the dressing change. The patient is willing to look at the incision during a dressing change.
A patient underwent an open bowel resection 2 days ago and the nurse's most recent assessment of the patient's abdominal incision reveals that it is dehiscing. What factor should the nurse suspect may have caused the dehiscence? The patient has vomited three times in the past 12 hours. The patient used PCA until this morning. The patient's surgical dressing was changed yesterday and today. The patient has begun voiding on the commode instead of a bedpan.
The patient has vomited three times in the past 12 hours.
The nurse is caring for a patient after abdominal surgery in the PACU. The patient's blood pressure has increased and the patient is restless. The patient's oxygen saturation is 97%. What cause for this change in status should the nurse first suspect? The patient is hypothermic. The patient is in shock. The patient is hypoxic. The patient is in pain.
The patient is in pain.
The OR nurse is taking the patient into the OR when the patient informs the operating nurse that his grandmother spiked a 104°F temperature in the OR and nearly died 15 years ago. What relevance does this information have regarding the patient? The patient may be at risk for malignant hyperthermia. The patient may be experiencing presurgical anxiety. The grandmother's surgery has minimal relevance to the patient's surgery. The patient may be at risk for a sudden onset of postsurgical infection.
The patient may be at risk for malignant hyperthermia.
In anticipation of a patient's scheduled surgery, the nurse is teaching her to perform deep breathing and coughing to use postoperatively. What action should the nurse teach the patient? The patient should take three deep breaths and exhale forcefully and then take a quick short breath and cough from deep in the lungs. The patient should take three deep breaths and cough hard three times, at least every 15 minutes for the immediately postoperative period. The patient should rapidly inhale, hold for 30 seconds or as long as possible, and exhale slowly. The patient should take a deep breath in through the mouth and exhale through the mouth, take a short breath, and cough from deep in the lungs.
The patient should take a deep breath in through the mouth and exhale through the mouth, take a short breath, and cough from deep in the lungs.
Your patient has just returned from the postanesthetic care unit (PACU) following left tibia open reduction internal fixation (ORIF). The patient is complaining of pain, and you are preparing to administer the patient's first scheduled dose of hydromorphone (Dilaudid). Prior to administering the drug, you would prioritize which of the following assessments? The patient's blood pressure The patient's hydration status The patient's electrolyte levels The patient's allergy status
The patient's allergy status
A patient waiting in the presurgical holding area asks the nurse, "Why exactly do they have to put a breathing tube into me? My surgery is on my knee." What is the best rationale for intubation during a surgical procedure that the nurse should describe? The tube protects the patient's esophagus from trauma. The patient's vital signs can be monitored with the tube. The patient may receive an antiemetic through the tube. The tube provides an airway for ventilation.
The tube provides an airway for ventilation.
A group of nurses are attending an educational inservice on adaptive and maladaptive responses to stress. When talking about the assessment of coping strategies in patients, the nurses discuss the use of drugs and alcohol to reduce stress. What is most important for the nurses to know about these coping behaviors? They are effective, but alternative, coping behaviors. They are adaptive behaviors. They do not directly influence stress in the body. They increase the risk of illness.
They increase the risk of illness.
A nurse on a medical unit is conducting a spiritual assessment of a patient who is newly admitted. In the course of this assessment, the patient indicates that she does not eat meat. Which of the following is the most likely significance of this patient's statement? This is an aspect of the patient's religious practice. This is an example of the patient's coping strategies. This constitutes a nursing diagnosis of Risk for Imbalanced Nutrition. The patient does not understand the principles of nutrition.
This is an aspect of the patient's religious practice.
The dressing surrounding a mastectomy patient's Jackson-Pratt drain has scant drainage on it. The nurse believes that the amount of drainage on the dressing may be increasing. How can the nurse best confirm this suspicion? Trace the outline of the drainage on the dressing for future comparison. Describe the appearance of the dressing in the electronic health record. Photograph the patient's abdomen for later comparison using a smartphone. Remove and weigh the dressing, reapply it, and then repeat in 8 hours.
Trace the outline of the drainage on the dressing for future comparison.
A patient is experiencing severe pain after suffering an electrical burn in a workplace accident. The nurse is applying knowledge of the pathophysiology of pain when planning this patient's nursing care. What is the physiologic process by which noxious stimuli, such as burns, activate nociceptors? Transduction Transmission Perception Modulation
Transduction
An adult patient is in the recovery room following a nephrectomy performed for the treatment of renal cell carcinoma. The patient's vital signs and level of consciousness stabilized, but the patient then complains of severe nausea and begins to retch. What should the nurse do next? Apply a cool cloth to the patient's forehead. Turn the patient completely to one side. Offer the patient a small amount of ice chips. Administer a dose of IV analgesic.
Turn the patient completely to one side.
The nurse is preparing to send a patient to the OR for a scheduled surgery. What should the nurse ensure is on the chart when it accompanies the patient to surgery? Select all that apply. Social work assessment Verification form Laboratory reports Nurses' notes Dietician's assessment
Verification form Laboratory reports Nurses' notes
A 77-year-old man's coronary artery bypass graft has been successful and discharge planning is underway. When planning the patient's subsequent care, the nurse should know that the postoperative phase of perioperative nursing ends at what time? When the patient is fully recovered from all effects of the surgery When the patient is returned to his room after surgery When the family becomes partly responsible for the patient's care When a follow-up evaluation in the clinical or home setting is done
When a follow-up evaluation in the clinical or home setting is done