med/surge adults exam 1 (prep-U)

The nurse is assisting the client with imagery as a relaxation strategy. Which statement by the client describes imagery?

"I am lying on the beach in Florida."

Which statement by the client indicates further teaching about epidural anesthesia is necessary?

"I will become unconscious."

A nurse is teaching a client about pain management after surgery. Which client statement indicates the teaching was effective?

"I will support my incision with my hands when I cough and do my deep breathing exercises."

A client asks why a drain is in place to pull fluid from the surgical wound. What is the best response by the nurse?

"It assists in preventing infection."

You are the nurse working in an ambulatory surgery center. A teenage son of your clients ask you why so many people have surgery. What would be your best reply?

"Many people have diagnostic or short therapeutic surgical procedures."

A client asks the nurse how an inhalant general anesthetic is expelled by the body. What is the best response by the nurse?

"The lungs primarily eliminate the anesthesia."

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

0.45% NaCl

A client has chronic hyponatremia, which requires weekly laboratory monitoring to prevent the client lapsing into convulsions or a coma. What is the level of serum sodium at which a client can experience these side effects?

114 mEq/L

At which serum sodium concentration might convulsions or coma occur?

130 mEq/L (130 mmol/L)

Using the PACU room scoring guide, a nurse would give a patient an admission cardiovascular score of 2 if the patient's blood pressure is what percentage of his or her preanesthetic level?

20%

A patient's serum sodium concentration is within the normal range. What should the nurse estimate the serum osmolality to be?

275-300 mOsm/kg

The nurse is concerned that a postoperative patient may have a paralytic ileus. What assessment data may indicate that the patient does have a paralytic ileus?

Absence of peristalsis

A client refuses to remove her wedding band when preparing for surgery. What is the best action for the nurse to take?

Allow the client to wear the ring and cover it with tape.

A 78-year-old client is undergoing surgery to repair a right hip fracture. What nursing action is appropriate during the intraoperative phase?

Appropriately position the client using adequate padding and support.

A client is at postoperative day 1 after abdominal surgery. The client is receiving 0.9% normal saline at 75 mL/h, has a nasogastric tube to low wall suction with 200 mL every 8 hours of light yellow fluid, and a wound drain with 50 mL of dark red drainage every 8 hours. The 24-hour urine output total is 2430 mL. What action by the nurse is most appropriate?

Assess for signs and symptoms of fluid volume deficit.

When the nurse observes that a postoperative client demonstrates a constant low level of oxygen saturation via the O2 saturation monitor despite the client's breathing appearing normal, what action should the nurse take first?

Assess the client's heart rhythm and nail beds.

A patient is in the operating room for surgery. Which individual would be responsible for ensuring that procedure and site verification occurs and is documented?

Circulating nurse

What medication should the nurse prepare to administer in the event the client has malignant hyperthermia?

Dantrolene sodium

A 70-year-old patient who is to undergo surgery arrives at the operating room (OR). The nurse, when reviewing the patient's medical record, understands that this patient will require a lower dose of anesthetic agent because of which of the following?

Decreased lean tissue mass

A patient is to receive general anesthesia. The nurse anticipates that which of the following would be used for induction?

Etomidate

Before seeing a newly assigned client with respiratory alkalosis, a nurse quickly reviews the client's medical history. Which condition is a predisposing factor for respiratory alkalosis?

Extreme anxiety

The nursing assessment of the postoperative client reveals an incision that is well-approximated with sutures intact, minimal redness and edema, and absence of drainage. The nurse recognizes the wound is healing by:

First intention

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

First intention

A client has been administered ketamine for moderate sedation. What is the priority nursing intervention?

Frequently monitoring vital signs

Which would be included as a responsibility of the scrub nurse?

Handing instruments to the surgeon and assistants

A client is receiving general anesthesia. The nurse anesthetist starts to administer the anesthesia. The client begins giggling and kicking her legs. What stage of anesthesia would the nurse document related to the findings?

II

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

Increases arterial pH

Nursing assessment findings reveal a temperature of 96.2°F, pulse oximetry 90%, shivering, and client complains of chilling. The findings are indicative of which nursing diagnosis?

Ineffective thermoregulation

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

Lungs and kidney

The nurse is caring for a client undergoing alcohol withdrawal. Which serum laboratory value should the nurse monitor most closely?

Magnesium

The nurse on a surgical unit is caring for a client recovering from recent surgery with the placement of a nasogastric tube to low continuous suction Which acid-base imbalance is most likely to occur?

Metabolic alkalosis

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

Monitoring respiratory status for signs and symptoms of pulmonary complications.

An OR nurse needs to assist a patient to the Trendelenburg position. Which of the following is the correct position?

On his back, with his head lowered, so that the plane of his body meets the horizontal on an angle

Fentanyl is categorized as which type of intravenous anesthetic agent?

Opioid

A client continuously repeats, "I know all will go well." What cognitive coping strategy should the nurse document?

Optimistic self-recitation

A client is scheduled for a cholecystectomy. Which finding by the nurse is least likely to contribute to surgical complications?

Osteoporosis

A list of commonly used medications for a particular surgical procedure is provided to the nurse. The anesthesiologist announces the administration of a nondepolarizing muscle relaxant. Which medication should the nurse document as having been administered?

Pancuronium

The nurse is caring for a client needing emergency surgery. Which preoperative teaching is least important to prepare the client for surgery?

Post-discharge diet

A nurse is witnessing a client sign the consent form for surgery. After signing the consent form, the client starts asking questions regarding the risks and benefits of a surgical procedure. What action by the nurse is most appropriate?

Request that the surgeon come and answer the questions.

A nurse reviews the arterial blood gas (ABG) values of a client admitted with pneumonia: pH, 7.51; PaCO2, 28 mm Hg; PaO2, 70 mm Hg; and HCO3--, 24 mEq/L. What do these values indicate?

Respiratory alkalosis

A postanesthesia care unit (PACU) nurse is preparing to discharge a client home following ankle surgery. The client keeps staring at the ceiling while being given discharge instructions. What action by the nurse is appropriate?

Review the instructions with the client and an accompanying adult.

A client at risk for malignant hyperthermia returns to the surgical unit. For what time period will the nurse monitor the client for development of malignant hyperthermia?

The client can develop malignant hyperthermia up to 24 hours after surgery.

Treatment of FVE involves dietary restriction of sodium. Which of the following food choices would be part of a low-sodium diet, mild restriction (2 to 3 g/day)?

Three ounces of light or dark meat chicken, 1 cup of spaghetti and a garden salad

A recently extubated postoperative client starts to gag and make vomiting sounds. What action should the nurse perform first?

Turn the client onto their side.

The nurse is caring for a client 6 hours post surgery. The nurse observes that the client voids urine frequently and in small amounts. The nurse knows that this most probably indicates what?

Urine retention

A nurse is teaching a client with chronic bronchitis about breathing exercises. Which instruction should the nurse include in the teaching?

Use diaphragmatic breathing.

The nurse cares for a client who is three hours post op abdominal hysterectomy and begins to develop hiccups. What nursing assessment will the nurse monitor more closely with the client's new symptoms?

Wound approximation

A client with hypervolemia asks the nurse what mechanism in the sodium potassium pump will move the excess body fluid. What is the nurse's best answer?

active transport

A client had a nephrectomy 2 days ago and is now complaining of abdominal pressure and nausea. The first nursing action should be to:

auscultate bowel sounds.

A client presents with anorexia, nausea and vomiting, deep bone pain, and constipation. The following are the client's laboratory values.

calcium 12.9 mg/dL (3.2 mmol/L)

A 17-year-old client is having same-day surgery. Solely during the intraoperative phase of perioperative care, the nurse:

continuously monitors the sedated client.

The nurse recognizes that the older adult is at risk for surgical complications due to:

decreased renal function

A client was admitted to the hospital unit after 2 days of vomiting and diarrhea. The client's spouse became alarmed when the client demonstrated confusion and elevated temperature, and reported "dry mouth." The nurse suspects the client is experiencing which condition?

dehydration

A nurse is administering moderate sedation to a client with chronic obstructive pulmonary disease (COPD). The nurse bases her next action on the principle that:

it may be necessary to raise the head of this client's bed.

The nurse recognizes the client has reached stage III of general anesthesia when the client:

lies quietly on the table

The nurse understands that the purpose of the "time out" is to:

maintain the safety of the client.

A perioperative nurse is assigned to complete a preoperative assessment on a client who is scheduled for surgery for kidney stones the next day. What category of surgery does this procedure fall into?

urgent

The nurse is caring for a client diagnosed with bulimia. The client is being treated for a serum potassium concentration of 2.9 mEq/L (2.9 mmol/L). Which statement made by the client indicates the need for further teaching?

"I can use laxatives and enemas but only once a week."

The nurse is preparing the client with an abdominal incision for discharge. Which statement by the client indicates that further teaching is required?

"I can resume my usual activities as soon as I get home."

A client asks the nurse about possible ill effects from general anesthesia. What is the best response by the nurse?

"Some possible negative effects include difficulty waking up and slow heart rate."

A client who is scheduled for knee surgery is anxious about the procedure, saying, "You hear stories on the news all the time about doctors working on the wrong body part. What if that happens to me?" What is the nurse's best response? Select all that apply.

"The client can be involved in marking the knee, the site for the surgery." "The client will be involved in the verification process prior to surgery." "The surgical team performs a 'time-out' prior to surgery to conduct a final verification."

A client having a surgical procedure takes aspirin 325 mg daily for prevention of platelet aggregation. When should the client stop taking the aspirin before the surgery?

7 to 10 days

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

<30 mL

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

A 52-year-old with diarrhea

The nurse is correct to state that a client's body needs to have adequate nutrition to maintain energy. Which type of transport of dissolved substances requires adenosine triphosphate (ATP)?

Active transport

Clients who have received corticosteroids preoperatively are at risk for which type of insufficiency?

Adrenal

Which is the most common cause of symptomatic hypomagnesemia?

Alcoholism

A patient is scheduled for a surgical procedure. For which surgical procedure should the nurse prepare an informed consent form for the surgeon to sign?

An open reduction of a fracture

A client undergoing coronary artery bypass surgery is subjected to intentional hypothermia. The client is ready for rewarming procedures. Which action by the nurse is appropriate?

Apply a warm air blanket, gradually increasing body temperature.

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

As soon as it is indicated

To prevent thromboembolism in the postoperative client, the nurse should include which of the following in the plan of care?

Assist with oral fluid intake.

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

Bicarbonate

Which is an insensible mechanism of fluid loss?

Breathing

What are the circulating nurse's responsibilities, in contrast to the scrub nurse's responsibilities?

Coordinating the surgical team

A fractured skull would be classified under which category of surgery based on urgency?

Emergent

Which intervention is most appropriate for a client with an arterial blood gas (ABG) of pH 7.5, a partial pressure of arterial carbon dioxide (PaCO2) of 26 mm Hg, oxygen (O2) saturation of 96%, bicarbonate (HCO3-) of 24 mEq/L, and a PaO2 of 94 mm Hg?

Instruct the client to breathe into a paper bag.

As a circulating nurse, what task are you solely responsible for?

Keeping records.

A client is undergoing preoperative assessment. During admission paperwork, the client reports having enjoyed a hearty breakfast this morning to be ready for the procedure. What is the nurse's next action?

Notify the surgeon.

A novice nurse provides aftercare instructions to a client who has just had sutures removed. Which statement by the novice nurse requires the nurse preceptor to clarify?

"If the wound edges are red or raised, you should call your doctor."

Which nursing statement would best decrease a client's anxiety before an emergency operative procedure?

"Let me explain to you what will happen next."

Which question is most important for the nurse to ask the client when obtaining the preoperative admission history?

"When is the last time you ate or drank?"

A client is undergoing a lumbar puncture. The nurse educates the client about surgical positioning. Which statement by the nurse is appropriate?

"You will be lying on your side with your knees to your chest."

For the client who is taking aspirin, it is important to stop taking this medication at least how many day(s) before surgery?

7

The nurse is preparing to discharge a client from the PACU using a PACU room scoring guide. With what score can the client be transferred out of the recovery room?

7

The nurse recognizes that which of the following clients is at least risk for perioperative complications?

A 65-year-old Caucasian man who has a history of arthritis

A patient with renal failure is scheduled for a surgical procedure. When would surgery be contraindicated for this patient due to laboratory results?

A blood urea nitrogen level of 42 mg/dL

The surgical unit nurse is developing a postoperative plan of care. In which client's plan of care would the nurse document interventions of coughing and deep breathing, gastrointestinal assessment, and effective regulation of temperature?

A client with gastrointestinal surgery and general anesthesia

The nurse expects informed consent to be obtained for insertion of:

A gastrostomy tube

The nurse assesses an older adult patient who complains of dimmed vision. What does this alert the nurse to plan for?

A safe environment

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

A systolic blood pressure lower than 90 mm Hg

Which of the following mobility criteria must a postoperative client meet to be discharged to home? Select all that apply.

Ambulate the length of the client's house Be able to self-toilet Get out of bed without assistance

You are caring for a client preoperatively who is very anxious and fearful about their surgery. You know that this client's anxiety can cause problems with the surgical experience. What type of problems can this client have because of their anxiety and fear?

Anxious clients have a poor response to surgery and are prone to complications.

Following a splenectomy, a client has a hemoglobin (Hb) level of 7.5 g/dL, and a blood pressure lying in bed of 110/70 mm Hg. The nurse suspects abnormal orthostatic changes when the client gets out of bed and reports vertigo. What vital sign value most supports the client's orthostatic changes?

Blood pressure of 90/50 mm Hg

A patient complains of tingling in the fingers as well as feeling depressed. The nurse assesses positive Trousseau's and Chvostek's signs. Which decreased laboratory results does the nurse observe when the patient's laboratory work has returned?

Calcium

The nurse is completing a postoperative assessment for a patient who has received a depolarizing neuromuscular blocking agent. The nursing assessment includes careful monitoring of which body system?

Cardiovascular system

The nurse is responsible for monitoring cardiovascular function in a postoperative patient. What method can the nurse use to measure cardiovascular function?

Central venous pressure

A client who is receiving the maximum levels of pain medication for postoperative recovery asks the nurse if there are other measures that the nurse can employ to ease pain. Which of the following strategies might the nurse employ? Select all that apply.

Changing the client's position Performing guided imagery Putting on soothing music

Which is the least important issue concerning safety for the perioperative team before proceeding to the operating room?

Client's ambulatory aids

What is the priority action by the scrub nurse when the surgeon begins to close the surgical wound?

Count the sponges.

When practicing perioperative care, the nurse monitors clients for what symptoms that are indicative of malignant hyperthermia? Select all that apply.

Cyanosis Muscle rigidity Diaphoresis Irregular heart rate

You are caring for a 72-year-old client who has been admitted to your unit for a fluid volume imbalance. You know which of the following is the most common fluid imbalance in older adults?

Dehydration

The anesthesiologist administered a transsacral conduction block. Which documentation by the nurse is consistent with the anesthesia being administered?

Denies sensation to perineum and lower abdomen

Several of the clients at the clinic are preparing to have surgery within the next 2 weeks. They are completing preoperative paperwork today with their visit. What are some of the reasons that people might need to have surgery? Select all that apply.

Diagnostic Cosmetic Palliative

Which of the following actions by the nurse is appropriate?

Discarding an object that comes in contact with the 1-inch border

A client was admitted to the unit with a diagnosis of hypovolemia. When it is time to complete discharge teaching, which of the following will the nurse teach the client and family? Select all that apply.

Drink at least eight glasses of fluid each day. Respond to thirst Drink water as an inexpensive way to meet fluid needs.

At which time does the nurse realize that it is best to begin teaching about care needed during the postoperative period?

During the preoperative period

What action by the nurse best encompasses the preoperative phase?

Educating clients on signs and symptoms of infection

A gunshot wound would be classified under which category of surgery based on urgency?

Emergent

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

Evisceration

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

Extracellular fluid volume deficit

The nurse is teaching the client about usual side effects associated with spinal anesthesia. Which of the following should the nurse include when teaching?

Headache

The nurse is assessing a client for local complications of intravenous therapy. Which are local complications? Select all that apply.

Hematoma Extravasation Phlebitis

A nurse is caring for a client with metastatic breast cancer who is extremely lethargic and very slow to respond to stimuli. The laboratory report indicates a serum calcium level of 12.0 mg/dl, a serum potassium level of 3.9 mEq/L, a serum chloride level of 101 mEq/L, and a serum sodium level of 140 mEq/L. Based on this information, the nurse determines that the client's symptoms are most likely associated with which electrolyte imbalance?

Hypercalcemia

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

Hypocalcemia

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

Hypokalemia

Which could be a potential cause of respiratory acidosis?

Hypoventilation

Which stage of anesthesia is referred to as surgical anesthesia?

III

An anxious client being prepared for surgery is encouraged to concentrate on a pleasant experience or restful scene. What cognitive coping strategy would the nurse document as being used?

Imagery

When planning care for a client in the postoperative period, prioritize nursing diagnoses in the sequence from highest to lowest priority?

Impaired Gas Exchange Fluid Volume Deficit Altered Comfort Anxiety Risk for Infection

An obese client is undergoing abdominal surgery. During the procedure a surgical resident states, "The amount of fat we have to cut through is disgusting." What is the best response by the nurse?

Inform the resident that all communication needs to remain professional.

The nursing instructor is talking with her class about spinal anesthesia. What would be the nursing care intervention required when caring for a client recovering from spinal anesthesia?

Instruct the client to remain flat for 6 to 12 hours.

A physician orders an isotonic I.V. solution for a client. Which solution should the nurse plan to administer?

Lactated Ringer's solution

Your client has a diagnosis of hypervolemia. What would be an important intervention that you would initiate?

Limit sodium and water intake.

A student nurse is scheduled to observe a surgical procedure. The nurse provides the student nurse with education on the dress policy and provides all attire needed to enter a restricted surgical zone. Which observation by the nurse requires immediate intervention?

Mask is placed over nose and extends to bottom lip.

The nurse is educating new employees about wearing masks in the operating room. What information should the nurse provide? Select all that apply.

Masks should fit tightly. Masks should cover the nose and mouth completely. You must change masks between treating clients.

The nurse is caring for a client with severe diarrhea. The nurse recognizes that the client is at risk for developing which acid-base imbalance?

Metabolic acidosis

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

Metabolic acidosis

A postoperative client is moving from the bed to a chair when blood drips from the dressing. The nurse assesses the incision and notes evisceration. What does the nurse do first?

Moisten sterile gauze with normal saline and place on the protruding organ.

During the admission history the client reports to the nurse of taking the usual dose of warfarin the previous day. What is an appropriate nursing action?

Notify the surgeon that the client took warfarin the day before surgery.

The nurse is conducting a preoperative assessment on a client scheduled for gallbladder surgery. The client reports a frequent cough producing green sputum for 3 days and denies fever. Upon auscultation, the nurse notes rhonchi throughout the right lung, with an occasional expiratory wheeze. Respiratory rate is 20, temperature is 99.8 (taken orally), heart rate is 87, and blood pressure is 124/70. What is the best action by the nurse?

Notify the surgeon to possibly delay the surgery.

On postoperative day 2, a client requires care for a surgical wound using second-intention healing. What type of dressing change should the nurse anticipate doing?

Packing the wound bed with sterile saline-soaked dressing and covering it with a dry dressing

Which is a classic sign of hypovolemic shock?

Pallor

Which conduction block anesthetizes the nerves supplying the chest, abdominal wall, and extremities?

Paravertebral anesthesia

The nurse positions the client in the lithotomy position in preparation for

Perineal surgery

Which health care profession has the ultimate responsibility to provide appropriate information regarding a nonemergent surgery?

Physician

A postoperative client is experiencing a flash pulmonary edema. What finding in the client's sputum is consistent with this problem?

Pink color

The nurse documents the presence of granulation tissue in a healing wound. How should the nurse describe the tissue?

Pink to red and soft, bleeding easily

You are physically preparing a client for surgery and instruct the person to remove any jewelry. The client refuses to remove a wedding band. What should you do in this situation with approval from your facility?

Place gauze under and over the ring and apply adhesive tape over it.

The nurse in the preoperative area has just medicated her client according to the anesthesiologist's orders. What is the nurse's priority action at this time?

Place the side rails in the up position and make sure the call button is in reach.

A nurse prepares to suction a client's tracheostomy tube. Place the procedure steps in correct order.

Position the client in Fowlers position. Don sterile gloves. Lubricate the sterile suction catheter. Insert suction catheter into the lumen of the tube. Apply intermittent suction while withdrawing the catheter.

A client with pancreatic cancer has the following blood chemistry profile: Glucose, fasting: 204 mg/dl; blood urea nitrogen (BUN): 12 mg/dl; Creatinine: 0.9 mg/dl; Sodium: 136 mEq/L; Potassium: 2.2 mEq/L; Chloride: 99 mEq/L; CO2: 33 mEq/L. Which result should the nurse identify as critical and report immediately?

Potassium

Which electrolyte is a major cation in body fluid?

Potassium

When is the ideal time to discuss preoperative teaching

Preadmission visit

A nurse is reviewing the medications of a postoperative client. What medication related to the recent surgery may be of concern to the nurse?

Prednisone

A client with a suspected overdose of an unknown drug is admitted to the emergency department. Arterial blood gas values indicate respiratory acidosis. What should the nurse do first?

Prepare to assist with ventilation.

What intervention by the nurse is most effective for reducing hospital-acquired infections?

Proper hand-washing techniques

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

Pulmonary embolism

A client with chronic renal failure has a serum potassium level of 6.8 mEq/L. What should the nurse assess first?

Pulse

The nurse observes that a postsurgical client has hemorrhaged and is in hypovolemic shock. Which nursing intervention will manage and minimize hemorrhage and shock?

Reinforcing the dressing or applying pressure if bleeding is frank

The circulating nurse is unsure whether proper technique was followed when an object was placed in the sterile field during a surgical procedure. What is the best action by the nurse?

Remove the entire sterile field from use.

A scrub nurse is diagnosed with a skin infection to the right forearm. What is the priority action by the nurse?

Report the infection to an immediate supervisor.

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

Respiratory alkalosis

Once the operating team has assembled in the room, the circulating nurse calls for a "time out." What action should the nurse take during the time out?

Review the scheduled procedure, site, and client.

A 55-year-old patient arrives at the operating room. The nurse is reviewing the medical record and notes that the patient has a history of osteoporosis in her lower back and hips. The patient is scheduled to receive epidural anesthesia. Which of the following nursing diagnoses would be a priority for this patient?

Risk for perioperative positioning injury related to operative position

A nurse is working as part of the surgical team in the semi-restricted area. Which of the following would be appropriate to wear? Select all that apply.

Scrub clothes Caps

A client is placed on the operating room table for the surgical procedure. Which surgical team member is responsible for handing sterile instruments to the surgeon and assistants?

Scrub nurse

Which method of wound healing is one in which wound edges are not surgically approximated and integumentary continuity is restored by granulation?

Second-intention healing

A client with nausea, vomiting, and abdominal cramps and distention is admitted to the health care facility. Which test result is most significant?

Serum potassium level of 3 mEq/L

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

Serum sodium level of 124 mEq/L

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

Sodium level of 150 mEq/L

A client is undergoing thoracic surgery. What priority education should the nurse provide to assist in preventing respiratory complications?

Splint the incision site using a pillow during deep breathing and coughing exercises.

There are four stages of general anesthesia. Select the stage during which the OR nurse knows not to touch the patient (except for safety reasons) because of possible uncontrolled movements.

Stage II: excitement

The surgical client has been intubated and general anesthesia has been administered. The client exhibits cyanosis, shallow respirations, and a weak, thready pulse. The nurse recognizes that the client is in which stage of general anesthesia?

Stage IV

Which of the following techniques least exhibits surgical asepsis?

Suctioning the nasopharyngeal cavity of a client

A nurse is working as a registered nurse first assistant as defined by the state's nurse practice act. This nurse practices under the direct supervision of which surgical team member?

Surgeon

Nursing assessment findings reveal that the client is afraid of dying during the surgical procedure. Which surgical team member would be most helpful in addressing the client's concern?

Surgeon

An unconscious patient with normal pulse and respirations would be considered to be in what stage of general anesthesia?

Surgical anesthesia

The nurse is caring for a client during an intra operative procedure. When assessing vital signs, which result indicates a need to alert the anesthesiologist immediately?

Temperature of 102.5°F (39°C)

A client with an intravenous infusion is rubbing his arm. The nurse assesses the site and decides to discontinue the current infusion because of concern that the client has developed phlebitis. Which of the following clinical manifestations would the nurse assess with phlebitis? Select all that apply.

Tender area around the insertion site Reddened area along the path of the vein

A nurse is caring for a client who is three hours post op from open abdominal surgery. During routine assessment, the nurse notes the previously stable client now appears anxious, apprehensive, and has a blood pressure of 90/56. What does the nurse consider is the most likely cause of the client's change in condition?

The client is displaying early signs of shock.

A client is having a surgical procedure that requires the client to be in the prone position. What is an expected client outcome?

The client remains free of perioperative positioning injury.

A perioperative nurse is conducting an in-service education program about maintaining surgical asepsis during the intraoperative period. Which of the following would the nurse emphasize?

The edges of a sterile package, once opened, are considered unsterile.

The physician requests lidocaine 2% with epinephrine for use in local infiltration anesthesia. What does the nurse understand is the purpose of adding epinephrine to the lidocaine? (Select all that apply.)

The epinephrine prevents rapid absorption of the anesthetic drug. The epinephrine causes vasoconstriction. The epinephrine prolongs the local action of the anesthetic agent.

The nurse is teaching the client about patient-controlled analgesia. Which of the following would be appropriate for the nurse to include in the teaching plan?

Therapeutic drug levels can be maintained more evenly with patient-controlled analgesia.

You are caring for a client who needs to ambulate. What considerations should be included when planning the postoperative ambulatory activities for the older adult?

Tolerance

Which of the following clinical manifestations increase the risk for evisceration in the postoperative client?

Valsalva maneuver

The perioperative nurse has a number of major responsibilities when a patient is admitted to a surgical unit or center. Which of the following is the most important function?

Verifies that operative consent is signed

Which of the following is an inappropriate nursing action by the surgical nurse?

Wearing sterile gloves over artificial nails

The nurse's assessment of a postop client reveals a temperature of 103.2°F, tachycardia, and client complaints of increased incisional pain. What does the nurse recognize that this client is experiencing?

Wound infection

A nurse evaluates the potential effects of a client's medication therapies before surgery. Which drug classification may cause respiratory depression from an associated electrolyte imbalance during anesthesia?

diuretics

A client is taking spironolactone to control hypertension. The client's serum potassium level is 6 mEq/L. What is the nurse's priority during assessment?

electrocardiogram (ECG) results

When the indication for surgery is without delay, the nurse recognizes that the surgery will be classified as

emergency.

A PACU nurse is caring for an older adult who presents with clinical manifestations of delirium. What short-term outcome would be most important for this client?

experiences pain within tolerable limits.

A nurse is caring for a client who underwent a skin biopsy and has three stitches in place. This wound is healing by:

first intention.

A client with severe hypervolemia is prescribed a loop diuretic and the nurse is concerned with the client experiencing significant sodium and potassium losses. What drug was most likely prescribed?

furosemide

The nurse assesses a client to determine if there is increased risk for complications intraoperatively or postoperatively. Which are general risk factors? Select all that apply.

health status physical condition age nutritional status

A client develops malignant hyperthermia. What client symptom would the nurse most likely observe as the first indicator of the disorder?

heart rate over 150 beats per minute

A nurse is caring for a client in acute renal failure. The nurse should expect hypertonic glucose, insulin infusions, and sodium bicarbonate to be used to treat:

hyperkalemia.

The primary objective in the immediate postoperative period is

maintaining pulmonary ventilation.

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

malignancy is causing the electrolyte imbalance.

During a procedure, a client's temperature begins to rise rapidly. This is likely the result of which complication?

malignant hyperthermia

Monitored anesthesia care differs from moderate sedation in that monitored anesthesia care:

may result in the administration of general anesthesia.

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

ondansetron

Fluid and electrolyte balance is maintained through the process of translocation. What specific process allows water to pass through a membrane from a dilute to a more concentrated area?

osmosis

A client is to receive general anesthesia with sevoflurane. What does the nurse anticipate would be given with the inhaled anesthesia?

oxygen

When evaluating arterial blood gases (ABGs), which value is consistent with metabolic alkalosis?

pH 7.48

A client with Guillain-Barré syndrome develops respiratory acidosis as a result of reduced alveolar ventilation. Which combination of arterial blood gas (ABG) values confirms respiratory acidosis?

pH, 7.25; PaCO2 50 mm Hg

The nurse is analyzing the arterial blood gas (ABG) results of a client diagnosed with severe pneumonia. Which of the following ABG results indicates respiratory acidosis?

pH: 7.20, PaCO2: 65 mm Hg, HCO3-: 26 mEq/L

A nurse is providing an afternoon shift report and relates morning assessment findings to the oncoming nurse. Which daily assessment data is necessary to determine changes in the client's hypervolemia status?

weight

A nurse is assessing a postoperative client with hyperglycemic blood glucose levels. Which client surgical risk factor would decrease if the surgical client maintained strict blood glycemic control?

wound healing