Med Surge Surgery Review

A nurse in the postanesthesia care unit identifies a progressive decrease in blood pressure in a client who had major abdominal surgery. What clinical finding supports the conclusion that the client is experiencing internal bleeding? 1. oliguria 2. bradypnea 3. pulse deficit 4. high potassium levels

1. oliguria

a nurse in the postanesthesia unit is caring for a client who received a general anesthetic. which finding should the nurse report to the primary healthcare provider? 1. client pushes the airway out 2. client has snoring respirations 3. clients respirations are 16 bpm and shallow 4. clients systolic blood pressure drops from 130 to 90 mm Hg

4. clients systolic blood pressure drops from 130 to 90 mm Hg

a nurse is caring for a client who had a major abdominal surgery one day ago. what factor increases the risk of this client developing a wound dehiscence? 1. placement of a T-tube 2. client being overweight 3. presence of excessive fluids 4. client receiving prophylactic antibiotics

2. client being overweight

the nurse is caring for a client in the postanesthesia care unit immediately after the client had a subtotal gastrectomy. the nurse identifies small blood clots in the clients gastric drainage. what action should the nurse take? 1. clamp the tube 2. consider this an expected event 3. instill the tube with iced normal saline 4. notify the surgeon immediately

2. consider this an expected event

when providing preoperative teaching, what should the nurse focus primarily on? 1. helping the client and family decide if surgery is necessary 2. providing emotional support to the client and family 3. giving minute-by-minute details of the surgery to the client and family 4. providing general information to reduce client and family anxiety

4. providing general information to reduce client and family anxiety

in the post anesthesia care unit after below the knee amputation, a client begins crying after feeling for the affected leg. how should the nurse respond? 1. administer medication to induce sleep 2. allow the client to ventilate feeling of loss 3. provide time for privacy by leaving the room do no address the behavior until the client is more alert

2. allow the client to ventilate feeling of loss

a nurse is providing preoperative teaching for a client regarding use of an incentive spirometer and should include what instructions? 1. "inhale completely and exhale in short, rapid breaths" 2. "inhale deeply through the spirometer, hold it as long as possible, and slowly exhale" 3. "exhale completely; take a slow, deep breath; hold it as long as possible, and slowly exhale" 4. "exhale halfway, then inhale a rapid, small breath; repeat several times"

2. "inhale deeply through the spirometer, hold it as long as possible, and slowly exhale"

while receiving a preoperative enema, a client starts to cry and says, "I'm sorry you have to do this messy thing for me". what is the nurses best response? 1."I don't mind it" 2. "you seem upset" 3. "this is part of my job" 4. "nurses get used to this"

2. "you seem upset"

what does the nurse plan to do before administering preoperative medication to a client? 1. verify the consent 2. have the client void 3. check the vital signs 4. remove the client's dentures

1. verify the consent

a client with a known history of opioid addiction is treated for multiple stab wounds to the abdomen. after surgical repair the nurse notes that the clients pain is not relieved by the prescribed morphine injections. the nurse realizes that the failure to achieve pain relief indicated that the client is probably experiencing what phenomenon? 1. tolerance 2. habituation 3. physical addiction 4. psychological dependence

1. tolerance

a client who is scheduled for a muscle biopsy tells the nurse, "they better give me a general anesthetic. I don't want to feel anything". what is the most therapeutic response by the nurse? 1. "you seem to be worried about the test." 2. "this is done under local anesthesia." 3. "tell them when you have pain so they can take care of it" 4. "you probably will not have pain so try not to worry about it"

1. "you seem to be worried about the test."

which technique is not used to manage mild sleep apnea? 1. polysomnography 2. avoiding sedatives 3. a weight-loss program 4. use of an oral appliance

1. polysomnography

in what position should the nurse place a client recovering from general anesthesia? 1. supine 2. side-lying 3. high fowler 4. trendelenburg

2. side-lying

Which is observed in the preoperational stage of Piaget's cognitive development? 1. inductive reasoning 2. transductive reasoning 3. sense of cause and effect 4. deductive and abstract reasoning

2. transductive reasoning

before a treatment requiring informed consent can be performed. what information must the client be given? select all that apply. 1. the cost of the treatment 2. alternative treatment options 3. the risks and benefits of the treatment 4. the risks involved in refusing the treatment 5. the nature of the problem requiring the treatment

2. alternative treatment options 3. the risks and benefits of the treatment 4. the risks involved in refusing the treatment 5. the nature of the problem requiring the treatment

a female client is scheduled for a hysterectomy. while discussing the preoperative preparations, the nurse determine that the client's understanding of the surgery is inadequate. what is the next nursing intervention? 1. describing the proposed surgery to the client 2. proceeding with the preoperative plan 3. notifying the surgeon that the client needs more information 4. explaining gently to the client that she should have asked more questions

3. notifying the surgeon that the client needs more information

when meeting the unique preoperative teaching needs of an older adult, the nurse plans a teaching program based on the principle that leaning does what? 1. reduces general anxiety 2. is negatively affected by aging 3. requires continued reinforcement 4. necessitates readiness of the learner

3. requires continued reinforcement

a nurse is changing the dressing of a sixth grader with sever burns. what basic principles of surgical asepsis must the nurse consider? select all that apply? 1. a paper field must remain dry to be considered sterile 2. sterile items held below the waist are considered sterile 3. a 1-inch border around a sterile field is considered contaminated 4. sterile objects in contact with clean objects are considered contaminated 5. a fenestrated drape is not considered sterile

1. a paper field must remain dry to be considered sterile 3. a 1-inch border around a sterile field is considered contaminated 4. sterile objects in contact with clean objects are considered contaminated

a client is scheduled for head and neck surgery. although the healthcare provider has explained the surgery, the client still has moderate to severe anxiety. which action should the nurse take initially? 1. attempt to discover what the client is concerned about 2. elaborate on what the healthcare provider has already said 3. teach the client to use the suction equipment preoperatively 4. plan for postoperative communication because a tracheostomy is likely

1. attempt to discover what the client is concerned about

a nurse should employ which technique to maintain surgical asepsis? 1. change the sterile field after sterile water is spilled on it 2. put on sterile gloves and then open a container of sterile saline 3. place a sterile dressing no more than half an inch from the edge of the sterile field 4. clean the surgical area with a circular motion, moving from the outer edge toward the center

1. change the sterile field after sterile water is spilled on it

a client with a history of closed-angle glaucoma is scheduled for abdominal surgery. because the client is extremely anxious, surgery is to be performed under general anesthesia. what should the nurse review with the client to prevent respiratory complication postoperatively? 1. deep breathing techniques 2. performing productive coughing 3. turning from side to side frequently pant breathing while gently closing the eyelids

1. deep breathing techniques

a nurse is preparing to change a clients dressing. what is the reason for using surgical asepsis during this procedure? 1. keeps the area free of microorganisms 2. confines microorganisms to the surgical site 3. protects self from microorganisms in the wound 4. reduces the risk for growing opportunistic microorganisms

1. keeps the area free of microorganisms

a nurse is caring for an adolescent in the post anesthesia care unit. what action should the nurse take to ensure accuracy of a pulse oximeter reading? 1. placing the probe on a finger or earlobe 2. fastening the probe to the abdomen or thigh attaching the probe to a different finger for each measurement 3. attaching the probe to a different finger for measurement 4. applying the probe, then waiting 10 minutes before obtaining a reading

1. placing the probe on a finger or earlobe

after reviewing a clients medical records, a nurse suspects that the client has sleep apnea. which medical diagnosis is related to sleep apnea? 1. pulmonary edema 2. increased hematocrit 3. increased white blood cell count 4. hemoglobin concentration of 20 g/dL or more

1. pulmonary edema

what should the nurse do when obtaining an informed consent from a 17 year old adolescent? 1. the client may or may not be allowed to give consent 2. the client cannot make informed decisions about health care 3. if the client is permitted to give voluntary consent when parents are not available 4. the client probably will be unable to choose between alternatives when asked to consent

1. the client may or may not be allowed to give consent

a client is transferred to the post anesthesia care unit after abdominal surgery. the client begins vomiting. what nursing action is most important when caring for this client? 1. turning the client onto the side 2. measuring the amount of vomitus 3. checking the wound for dehiscence 4. administering the prescribed antiemetic to the client

1. turning the client onto the side

a client is admitted to the postanesthesia care unit after surgery and electronic blood pressure monitoring is to be performed. the nurse should assess the client's BP every: 1. 3 to 5 mins 2. 10 to 15 mins 3. 20 to 30 mins 4. 40 to 60 mins

2. 10 to 15 mins

a client has undergone surgery with general anesthesia. within how many hours after surgery should the nurse notify the health care provider if the client does not void? 1. 4 hours 2. 8 hours 4. 12 hours 4. 16 hours

2. 8 hours

the nurse evaluates that the preoperative teaching regarding a bronchoscopy was understand when the client states that he cannot eat or drink for several hours after the procedure to prevent what? 1. gastric irritation 2. aspiration of food 3.projectile vomiting 4. abdominal vomiting

2. aspiration of food

after abdominal surgery, a client is transferred to the postanesthesia care unit (PACU) with a nasogastric tube in place. what action should the nurse take initially when the client vomits 90 mL of bile-colored fluid? 1. elevate head of the bed 2. check the patency of the tube 3. administer the prescribed antiemetic 4. encourage the client to take several deep breaths

2. check the patency of the tube

A 20 year old developmentally challenged women is a resident in a group home. she has had four abortions in the past 2 years and the agency supervisor recommends that she be sterilized. it is obvious that the client is unable to exercise informed consent for sterilization. the nurse understands that the procedure cannot be performed without legal from whom? 1. next of kin 2. court-appointed individual or group 3. agency designated to perform the abortion 4. organization or agency licensed to administer the group home

2. court-appointed individual or group

A nurse is discussing informed consent with a client who is scheduled for a hysterectomy. What components should the informed consent include? Select all that apply 1. duplicate of the patients bill of rights 2. explanation of available question and concerns abut the procedure 3. answers to questions and concerns abut the procedure 4. complete the description of the possible dangers and discomforts 5. countersignature by the person designated in the clients living will

2. explanation of available question and concerns abut the procedure 3. answers to questions and concerns abut the procedure 4. complete the description of the possible dangers and discomforts

a client on the psychiatric unit is undergoing a pretreatment evaluation for electroconvulsive therapy (ECT). because of the client's profoundly depressed behavior, the nurse doubts that the client can provide informed consent. what should the nurse's initial intervention be? 1. consulting with the hospital's legal staff and following their recommendation 2. having the client verbalize her understanding and the outcomes of the procedure 3. asking the client to sign the consent form because the client has not been declared incompetent 4. suggesting to the health care provider that a family member sign the consent form for the client

2. having the client verbalize her understanding and the outcomes of the procedure

a health care provider informs a client that midazolam will be administered preoperatively. later, the client ask the nurse why this medication is given. what primary reason should the nurse consider when formulating a response? 1. reduces pain 2. induces sedation 3. produces amnesia 4. limits oral secretions

2. induces sedation

a nurse is assisting the primary health care provider in examining a client. the primary health care provider confirms that the client has obstructive sleep apnea. which physical symptoms does the nurse expect the client to report? select all that apply. 1.fatigue 2. insomnia 3. morning headaches 4. decreased motivation 5. frequent awakening at night

2. insomnia 3. morning headaches 5. frequent awakening at night

a pain scale of 1 to 10 is used by a nurse to assess a clients degree of pain. the client rates the pain as an 8 before receiving an analgesic and a 7 after being medicated. what conclusion should the nurse make regarding the clients response to pain medication? 1. client has a low pain tolerance 2. medication is not adequately effective 3. medication has sufficiently decreased the pain level 4. client needs more education about the use of the pain scale

2. medication is not adequately effective

a nurse in the postanesthesia care unit (PACU) is providing care to a client who had abdominal cholecystectomy and observes serosanguineous drainage on the abdominal dressing. what is the next nursing action? 1. change the dressing 2. reinforce the dressing 3. replace the tape with montgomery ties 4. support the incision with an abdominal binder

2. reinforce the dressing

a client who sustained a large open wound as a result of an accident is receiving daily sterile dressing changes. to maintain sterility when changing the dressing, what should the nurse do? 1. put the unopened sterile glove package carefully on the sterile field 2. remove the sterile drape from its package by lifting it by the corners 3. don sterile gloves before opening the package containing the field drape 4. pour irrigation liquid from a height of at least three inches above the sterile container

2. remove the sterile drape from its package by lifting it by the corners

Neomycin, 1 gram, is prescribed preoperatively for a client with cancer of the colon. The client asks why this is necessary. How should the nurse respond? 1. "It is used to prevent you from getting a bladder infection before surgery." 2. "It will decrease your kidney function and lessen urine production during surgery." 3. "It will kill the bacteria in your bowel and decrease the risk for infection after surgery." 4. "It is used to alter the body flora, which reduces spread of the tumor to adjacent organs."

3. "It will kill the bacteria in your bowel and decrease the risk for infection after surgery."

a nurse is reviewing preoperative instructions with a client who is scheduled for orthopedic surgery at 8:00 AM the next day. what advice does the nurse give the client? 1. "have your dinner completed by 6:00 PM tonight and then no foods or fluids after that" 2. "drink whatever liquids you want tonight and then only clear liquids tomorrow morning" 3. "consume a light evening meal tonight and then no food or fluids after midnight" 4. "eat lunch today and then do not drink or eat anything until after your surgery"

3. "consume a light evening meal tonight and then no food or fluids after midnight"

a nurse is caring for a client with pain after surgery. the nurse take the blood pressure and pulse rate of the client and asks the client to rate the level of pain on the pain scale. the nurse then notifies the primary healthcare provider. which standard of practice doe the nurse perform? 1. planning 2. diagnosis 3. assessment 4. implementation

3. assessment

a client just has returned from the postanesthesia care unit after have a laparotomy. which sign or symptom indicated to the nurse that peristalsis has begun to return? 1. stool is evacuated 2. nausea is no longer present 3. borborygmi are auscultated 4. abdomen is no longer tender

3. borborygmi are auscultated

a client who had a transurethral resection of the prostate is transferred to the post anesthesia care unit with an intravenous (IV) line and a urinary retention catheter. for which major complication is it most important for the nurse to assess during the immediate postoperative period? 1. sepsis 2. phlebitis 3. hemorrhage 4. leakage around the IV catheter

3. hemorrhage

the nurse reviews common side effects of general anesthesia with a client scheduled for surgery. the nurse concludes that the teaching has been effective when the client states, "immediately after surgery i may experience____________________." 1. transient headaches 2. an elevated temperature 3. paroxysmal hiccoughs 4. a sore throat

4. a sore throat

When obtaining an admission history of a preoperative client, the nurse learns that the client is taking several herbal supplements. which is the priority nursing action? 1. provide client with the information about the usefulness of herbal therapies 2. inform the client about taking supplemental vitamins rather than herbs 3. teach the client about herbal supplements 4. ask the client which herbs have been taken

4. ask the client which herbs have been taken

when assessing an obese client, a nurse observes dehiscence of the abdominal surgical wound with evisceration. the nurse places the client in low- fowlers position with the knees slightly bent and encourage the client to lie still. what is the next nursing action? 1. obtain the VS 2. notify the health care provider 3. reinsert the protruding organs using aseptic technique 4. cover the wound with a sterile towel moistened with normal saline

4. cover the wound with a sterile towel moistened with normal saline

a client who is scheduled for a bowel resection is to receive antibiotics preoperatively. the nurse teaches the client that the purpose of the antibiotics is to help do what? 1. prevent incisional infection 2. avoid postoperative pneumonia 3. limit the risk of a urinary tract infection 4. decrease the number of bacteria in the gastrointestinal (GI) tract

4. decrease the number of bacteria in the gastrointestinal (GI) tract

a nurse is caring for a postoperative client who had general anesthesia during surgery. what independent nursing intervention may prevent an accumulation of secretions? 1. postural drainage 2. percussing the chest 3. nasotracheal suctioning 4. frequent changes of position

4. frequent changes of position

a nurse is teaching a preoperative client about postoperative breathing exercises. what information should the nurse include? select all that apply. 1. take short, frequent breaths 2. exhale with the mouth wide open 3. perform the exercises twice a day 4. place a hand on the abdomen while feeling it rise 5. hold the breath for several seconds at the height of inspiration

4. place a hand on the abdomen while feeling it rise 5. hold the breath for several seconds at the height of inspiration

A client had an open reduction and internal fixation of the head of the femur. In the postanesthesia care unit the client's vital signs remained stable for one hour, with a blood pressure (BP) 130/78 mm Hg, pulse (P) 68, and respiration (R) 16. One hour after returning to the postsurgical unit, the client's vital signs are BP 100/60 mm Hg, P 74, and R 22, and the client is restless. What should the nurse do first? 1. Check the dressing on the incision 2. increase the intravenous flow rate 3. elevate the head of the clients bed 4. continue monitoring the clients vital signs

1. Check the dressing on the incision