more review questions
A patient has an anal fissure. Which intervention most effectively promotes perineal comfort for the patient? Administering a Fleet's enema when needed Applying heat to acute inflammation for pain relief Avoiding the use of bulk-forming agents Using hydrocortisone cream to relieve pain
D The intervention that most effectively promotes perineal comfort in a patient with anal fissure is using hydrocortisone skin cream to relieve perineal pain.
A client has an acute case of opioid depression and receives a dose of naloxone (Narcan). Which statement is true about this client? Supplemental pain reduction is needed. One dose is needed. This is an acute emergency. The client will be hostile.
Supplemental pain reduction is needed. The client has breakthrough pain after the opioid antagonist is given, so other interventions to promote comfort are needed.
While in the hospital, the client has developed a methicillin-resistant infection in the foot. The client had undergone surgical débridement for gangrene. Which precaution is best for this client? A. Wear a gown and gloves to prevent contact with the client or client-contaminated items. B. Assign the client to a private room with a negative airflow. C. Wear a mask when working within 3 feet (91 cm) of the client. D. Have the client wear a surgical mask when being transported out of the room.
A Caregivers should wear a gown and gloves to prevent contact with the client or contaminated items when caring for a client with this infection. This is the best way to prevent the spread of infection. Gloves should also be worn when entering the room.
The nurse is assessing an alert client who had abdominal surgery yesterday. What method provides the most accurate data about resumption of peristalsis in the client? Asking the client whether he or she has passed flatus (gas) within the previous 12 to 24 hours. (p. 17) Auscultating bowel sounds in all abdominal quadrants Counting the number of bowel sounds in each abdominal quadrant over one minute. Observing the abdomen for symmetry and distention
A The best and most reliable method for assessing the return of peristalsis following abdominal surgery is the client's report of passing flatus within the past 8 hours or stool within the past 12 hours.
A patient with a history of osteoarthritis has a 10-inch (25.5 cm) incision following a colon resection. The incision has become infected, and the wound requires extensive irrigation and packing. What aspect of the patient's care does the nurse make certain to discuss with the primary health care provider before the patient's discharge? Having a home health consultation for wound care Requesting an antianxiety medication Requesting pain medication for the patient's osteoarthritis Placing the patient in a skilled nursing facility for rehabilitation
A The nurse makes sure to discuss an order for a home health consultation for wound care with the primary health care provider. Home health services are most appropriate for this patient because wound care will be extensive and the patient's mobility may be limited.
A male patient with a long history of ulcerative colitis experienced massive bleeding and had emergency surgery for creation of an ileostomy. He is very concerned that sexual intercourse with his wife will be impossible because of his new ileostomy pouch. How does the nurse respond? "A change in position may be what is needed for you to have intercourse with your wife." "Have you considered going to see a marriage counselor with your wife?" "What has your wife said about your pouch system?" "You must get clearance from your primary health care provider before you attempt to have intercourse."
A The nurse tells the patient who had an emergency ileostomy that a simple change in positioning during intercourse may alleviate the patient's apprehension and facilitate sexual relations with his wife. Telling the patient that he needs to get clearance from his primary health care provider is an evasive response that does not address the patient's primary concern.
The nurse is preparing a client for discharge on postoperative day 1 after a modified radical mastectomy. Which instruction is most important for the nurse to include in this client's discharge plan? A) "Please report any increased redness, swelling, warmth, or pain to your health care provider." B) "Do not allow anyone to take your blood pressure or draw blood on the side where you had your breast removed." Incorrect C) "A referral has been made to the American Cancer Society's Reach to Recovery program, and a volunteer will call you next week." D) "Avoid the prone and hunchback positions, and ask your health care provider for any other needed activity restrictions."
A instruction on increased signs and symptoms of inflammation could reveal signs of potential infection and is most important.Although information about having blood pressure taken or having blood drawn should be included, it is not the most important instruction for postoperative day 1 discharge.
Which statement accurately explains otitis media? The inflammatory response is triggered by the invasion of foreign proteins. Phagocytosis by macrophages and neutrophils destroys and eliminates foreign invaders. It is caused by a left shift or increase in immature neutrophils. Many immune system cells released into the blood have specific effects.
A) The inflammatory bacterial response of otitis media is stimulated by invading foreign proteins caused by infection.Macrophages and neutrophils are involved in the process of inflammation, but otitis media is an inflammation caused by infection. It is not caused by a left shift or increase in immature neutrophil forms. The change in form is caused by infection, such as sepsis. The action of immune system cells occurs when encountering a non-self or foreign protein to neutralize, destroy, or eliminate a foreign invader. This does not cause inflammation.
A nurse cares for a client who has a Giardia infection. Which medication should the nurse anticipate being prescribed for this client? a. Metronidazole (Flagyl) b. Ciprofloxacin (Cipro) c. Sulfasalazine (Azulfidine) d. Ceftriaxone (Rocephin)
ANS: A Metronidazole is the drug of choice for a Giardia infection. Ciprofloxacin and ceftriaxone are antibiotics used for bacterial infections. Sulfasalazine is used for ulcerative colitis and Crohns disease.
A nurse teaches a client who has viral gastroenteritis. Which dietary instruction should the nurse include in this clients teaching? a. Drink plenty of fluids to prevent dehydration. b. You should only drink 1 liter of fluids daily. c. Increase your protein intake by drinking more milk. d. Sips of cola or tea may help to relieve your nausea.
ANS: A The client should drink plenty of fluids to prevent dehydration. Milk products may not be tolerated. Caffeinated beverages increase intestinal motility and should be avoided.
A nurse assesses a client with peritonitis. Which clinical manifestations should the nurse expect to find? (Select all that apply.) a. Distended abdomen b. Inability to pass flatus c. Bradycardia d. Hyperactive bowel sounds e. Decreased urine output
ANS: A, B, E A client with peritonitis may present with a distended abdomen, diminished bowel sounds, inability to pass flatus or feces, tachycardia, and decreased urine output secondary to dehydration. Bradycardia and hyperactive bowel sounds are not associated with peritonitis.
After teaching a client with an anal fissure, a nurse assesses the clients understanding. Which client actions indicate that the client correctly understands the teaching? (Select all that apply.) a. Taking a warm sitz bath several times each day b. Utilizing a daily enema to prevent constipation c. Using bulk-producing agents to aid elimination d. Self-administering anti-inflammatory suppositories e. Taking a laxative each morning
ANS: A, C, D Taking warm sitz baths each day, using bulk-producing agents, and administering anti-inflammatory suppositories are all appropriate actions for the client with an anal fissure. The client should not use enemas or laxatives to promote elimination, but rather should rely on bulk-producing agents such as psyllium hydrophilic mucilloid (Metamucil).
A nurse teaches a client how to avoid becoming ill with Salmonella infection again. Which statements should the nurse include in this clients teaching? (Select all that apply.) a. Wash leafy vegetables carefully before eating or cooking them. b. Do not ingest water from the garden hose or the pool. c. Wash your hands before and after using the bathroom. d. Be sure meat is cooked to the proper temperature. e. Avoid eating eggs that are sunny side up or undercooked.
ANS: A, C, D, E Salmonella is usually contracted via contaminated eggs, beef, poultry, and green leafy vegetables. It is not transmitted through water in garden hoses or pools. Clients should wash leafy vegetables well, wash hands before and after using the restroom, make sure meat and eggs are cooked properly, and, because it can be transmitted by flies, keep flies off of food.
A nurse teaches a community group about food poisoning and gastroenteritis. Which statements should the nurse include in this groups teaching? (Select all that apply.) a. Rotavirus is more common among infants and younger children. b. Escherichia coli diarrhea is transmitted by contact with infected animals. c. To prevent E. coli infection, dont drink water when swimming. d. Clients who have botulism should be quarantined within their home. e. Parasitic diseases may not show up for 1 to 2 weeks after infection.
ANS: A, C, E Rotavirus is more common among the youngest of clients. Not drinking water while swimming can help prevent E. coli infection. Parasitic diseases may take up to 2 weeks to become symptomatic. People with botulism need to be hospitalized to monitor for respiratory failure and paralysis. Escherichia coli is not transmitted by contact with infected animals.
A nurse assesses a client who is hospitalized for botulism. The clients vital signs are temperature: 99.8 F (37.6 C), heart rate: 100 beats/min, respiratory rate: 10 breaths/min, and blood pressure: 100/62 mm Hg. Which action should the nurse take? a. Decrease stimulation and allow the client to rest. b. Stay with the client while another nurse calls the provider. c. Increase the clients intravenous fluid replacement rate. d. Check the clients blood glucose and administer orange juice.
ANS: B A client with botulism is at risk for respiratory failure. This clients respiratory rate is slow, which could indicate impending respiratory distress or failure. The nurse should remain with the client while another nurse notifies the provider. The nurse should monitor and document the IV infusion per protocol, but this client does not require additional intravenous fluids. Allowing the client to rest or checking the clients blood glucose and administering orange juice are not appropriate actions.
After teaching a client who was hospitalized for Salmonella food poisoning, a nurse assesses the clients understanding. Which statement made by the client indicates a need for additional teaching? a. I will let my husband do all of the cooking for my family. b. Ill take the ciprofloxacin until the diarrhea has resolved. c. I should wash my hands with antibacterial soap before each meal. d. I must place my dishes into the dishwasher after each meal.
ANS: B Ciprofloxacin should be taken for 10 to 14 days to treat Salmonella infection, and should not be stopped once the diarrhea has cleared. Clients should be advised to take the entire course of medication. People with Salmonella should not prepare foods for others because the infection may be spread in this way. Hands should be washed with antibacterial soap before and after eating to prevent spread of the bacteria. Dishes and eating utensils should not be shared and should be cleaned thoroughly. Clients can be carriers for up to 1 year.
A nurse cares for an older adult client who has Salmonella food poisoning. The clients vital signs are heart rate: 102 beats/min, blood pressure: 98/55 mm Hg, respiratory rate: 22 breaths/min, and oxygen saturation: 92%. Which action should the nurse complete first? a. Apply oxygen via nasal cannula. b. Administer intravenous fluids. c. Provide perineal care with a premedicated wipe. d. Teach proper food preparation to prevent contamination.
ANS: B Dehydration caused by diarrhea can occur quickly in older clients with Salmonella food poisoning, so maintenance of fluid balance is a high priority. Monitoring vital signs and providing perineal care are important nursing actions but are of lower priority than fluid replacement. The nurse should teach the client about proper hand hygiene to prevent the spread of infection, and preparation of food and beverages to prevent contamination.
After teaching a client who has a new colostomy, the nurse provides feedback based on the clients ability to complete self-care activities. Which statement should the nurse include in this feedback? a. I realize that you had a tough time today, but it will get easier with practice. b. You cleaned the stoma well. Now you need to practice putting on the appliance. c. You seem to understand what I taught you today. What else can I help you with? d. You seem uncomfortable. Do you want your daughter to care for your ostomy?
ANS: B The nurse should provide both approval and room for improvement in feedback after a teaching session. Feedback should be objective and constructive, and not evaluative.
After teaching a client with a parasitic gastrointestinal infection, a nurse assesses the clients understanding. Which statements made by the client indicate that the client correctly understands the teaching? (Select all that apply. )a. Ill have my housekeeper keep my toilet clean. b. I must take a shower or bathe every day. c. I should have my well water tested. d. I will ask my sexual partner to have a stool test. e. I must only eat raw vegetables from my own garden.
ANS: B, C, D Parasitic infections can be transmitted to other people. The client himself or herself should keep the toilet area clean instead of possibly exposing another person to the disease. Parasites are transmitted via unclean water sources and sexual practices with rectal contact. The client should test his or her well water and ask sexual partners to have their stool examined for parasites. Raw vegetables are not associated with parasitic gastrointestinal infections. The client can eat vegetables from the store or a home garden as long as the water source is clean.
After teaching a client with diverticular disease, a nurse assesses the clients understanding. Which menu selection made by the client indicates the client correctly understood the teaching? a. Roasted chicken with rice pilaf and a cup of coffee with cream b. Spaghetti with meat sauce, a fresh fruit cup, and hot tea c. Garden salad with a cup of bean soup and a glass of low-fat milk d. Baked fish with steamed carrots and a glass of apple juice
ANS: D Clients who have diverticular disease are prescribed a low-residue diet. Whole grains (rice pilaf), uncooked fruits and vegetables (salad, fresh fruit cup), and high-fiber foods (cup of bean soup) should be avoided with a low-residue diet. Canned or cooked vegetables are appropriate. Apple juice does not contain fiber and is acceptable for a low-residue diet.
A nurse cares for a client who has food poisoning resulting from a Clostridium botulinum infection. Which assessment should the nurse complete first? a. Heart rate and rhythm b. Bowel sounds c. Urinary output d. Respiratory rate
ANS: D Severe infection with C. botulinum can lead to respiratory failure, so assessments of oxygen saturation and respiratory rate are of high priority for clients with suspected C. botulinum infection. The other assessments may be completed after the respiratory system has been assessed.
Which statement about why multidrug-resistant organisms and other infections are increasing in incidence is correct? Antibiotics have been given to clients for conditions that do not require antibiotics. Microorganisms are more susceptible to antibiotics today than when they were given years ago. Additional precautions are taken, along with Standard Precautions, to prevent infection. Most antibiotics are effective for infection.
Antibiotics have often been prescribed for conditions that do not require them, or have been given at higher doses or for longer periods of time than needed. As a result, a number of microorganisms have become resistant to certain antibiotics.Microorganisms are more resistant to certain antibiotics. Strictly adhered-to Standard Precautions are adequate to prevent infection. Most antibiotics are not effective for every infection.
The nurse is instructing a client about the use of antiembolism stockings. Which statement by the client indicates the need for further teaching? "I will take off my stockings one to three times a day for 30 minutes." "My stockings are too loose." "It's better if they are too tight rather than too loose." "These stockings help promote blood flow."
Antiembolism stockings should fit properly to achieve the desired result. Stockings that are too tight will impede blood flow.Frequent removal of the stockings is appropriate to allow for hygiene and a break from their wear. Stockings that are too loose are ineffective. Antiembolism stockings may be used during and after surgery to promote venous return.
Which client does the charge nurse on the adult medical unit assign to an RN who has floated from the outpatient gastrointestinal (GI) clinic? A. A 38-year-old who needs discharge instructions after having an endoscopic retrograde cholangiopancreatography (ERCP) B. A 40-year-old who needs laxatives administered and effectiveness monitored before a colonoscopy Correct C. A 43-year-old recently admitted with nausea, abdominal pain, and abdominal distention D. A 50-year-old with epigastric pain who needs conscious sedation during a scheduled endoscopy procedure
B A 40-year-old who needs laxatives administered and effectiveness monitored before a colonoscopy is the least complicated client. This client would be assigned to the float nurse who would have the experience and training to adequately care for this client. A clinic nurse typically cares for clients with chronic conditions.Discharge instructions following an ERCP, assessment of an admitted acutely ill client, and monitoring a client who is receiving conscious sedation would be accomplished best by nurses with experience in caring for adults with acute GI problems.
Which is a correct statement differentiating Crohn's disease (CD) from ulcerative colitis (UC)? Patients with CD experience about 20 loose, bloody stools daily. Patients with UC may experience hemorrhage. The peak incidence of UC is between 15 and 40 years of age. Very few complications are associated with CD.
B A correct statement about differentiating Crohn's disease (CD) from ulcerative colitis (UC) is that patients with UC may experience hemorrhage. Patients with CD can have 5-6 soft, loose stools per day, but they are nonbloody.Five to six stools daily is common with CD, not 20 loose, bloody stools. The peak incidences of UC are between 30 and 40 years and again at 55 to 65 years of age, and not just 15 to 40 years of age. Fistulas commonly occur as a complication of CD.
A client who was treated last month for a bad case of bronchitis and walking pneumonia reports many of the same symptoms today. Which factor in the client's antibiotic therapy most likely caused the client's relapse? Taking the antibiotic before jogging 2 miles daily Taking the antibiotic most days Taking the antibiotic as prescribed Taking the antibiotic with a full glass of water
B Antibiotics not taken as prescribed can result in recurring symptoms, as well as the development of drug-resistant infections and other emerging infections.
A patient with a recent surgically created ileostomy refuses to look at the stoma and asks the nurse to perform all required stoma care. What does the nurse do next? Asks the patient whether family members could be trained in stoma care Has another patient with a stoma who performs self-care talk with the patient Requests that the primary health care provider request antidepressants and a psychiatric consult Suggests that the primary health care provider request a home health consultation so stoma care can be performed by a home health nurse
B When a patient with a recently created ileostomy refuses to look at the stoma and wants the nurse to perform all required stoma care, the nurse has another patient with a stoma who performs self-care talk with the patient.
A Certified Wound, Ostomy, and Continence Nurse (CWOCN) is teaching a patient about caring for a new ileostomy. What information is most important to include? "After surgery, output from your ileostomy may be a loose, dark-green liquid with some blood present." "Call your primary health care provider if your stoma has a bluish or pale look." "Notify the primary health care provider if output from your stoma has a sweetish odor." "Remember that you must wear a pouch system at all times."
B it is most important for the Certified Wound, Ostomy, and Continence nurse to tell the patient with a new ileostomy to call the primary health care provider if the stoma has a bluish or pale look. If the stoma has a bluish, pale, or dark look, its blood supply may be compromised and the primary health care provider must be notified immediately.
Which postoperative kidney transplantation client does the nurse assess first for signs and symptoms of hyperacute rejection? A). Older adult with Parkinson disease receiving a donation from an identical twin B). Grand multipara female with a history of subsequent blood transfusions Correct C). Middle-aged man with a 20-pack-year history D). Young adult with type 1 diabetes
B). The grand multipara female with a history of subsequent blood transfusions should be assessed first because multiple pregnancies and blood transfusions greatly increase the risk of a hyperacute rejection.
Which actions aid in the prevention and early detection of infection in a client at risk? (Select all that apply.) A. Inspect the skin for coolness and pallor. B. Promote sufficient nutritional intake. C. Encourage fluid intake, as appropriate. D. Monitor the red blood cell (RBC) count. E. Obtain cultures as needed. F. Remove unnecessary medical devices.
B, E F Promoting sufficient nutritional intake helps prevent and detect early infection in at risk clients. Nutrition has a direct correlation to improvement of general health. Malnutrition, especially protein-calorie malnutrition, places clients at increased risk for infection. Blood cultures would be used to detect a possible systemic infection. Advocating for the removal of unnecessary medical devices (e.g., intravascular or urinary catheters, endotracheal tubes, synthetic implants) may also interfere with normal host defense mechanisms and may help prevent infection.
Which statement about the transmission of hepatitis C is correct? Feces are a likely body fluid by which to transmit the disease. Airborne Precautions are used for the prevention of hepatitis C. Equipment or linen soiled with blood or body fluids should be washed with bleach or a disinfectant to prevent infection. No precautions are necessary with the use of nail clippers or scissors.
C Hepatitis C is a bloodborne pathogen. Equipment or linen that is soiled with blood or body fluids can be a likely source of infection. Washing with bleach or a disinfectant will help prevent the spread of infection.
A 14-year-old client has severe fatigue, swollen glands, and a low-grade fever. Which blood test result is used to confirm a diagnosis of mononucleosis? Decreased mononuclear leukocyte count Decreased leukocyte count Decreased neutrophil count Elevated erythrocyte sedimentation rate
C In a client with mononucleosis, a white blood cell count would show a decrease in neutrophils.An abnormally large not decreased number of mononuclear leukocytes would be seen with mononucleosis. In most active infections, especially those caused by bacteria, the total leukocyte count is elevated, not decreased. An elevated erythrocyte sedimentation rate indicates infection, but does not specifically indicate mononucleosis.
Which client is at greatest risk for developing an infection? A 54-year-old man with hypertension A 17-year-old girl with a fractured tibia in a cast A 65-year-old woman who had coronary bypass surgery 4 days ago A 71-year-old man in a nursing home
C Older clients such as the 65-year-old people with decreased vascularity to the integumentary system (from the bypass surgery) and compromised skin (surgical incision) are at risk for infection.No coexisting conditions are present for the client with hypertension to be at risk for infection. The 71-year-old client in a nursing home is not at highest risk because no coexisting conditions make this client most vulnerable to infection.
Which nurse does the charge nurse assign to care for a 64-year-old client who has pneumonia and requires IV antibiotic therapy and IV fluids at 200 mL/hr? An experienced LPN/LVN who has worked on the medical unit for 10 years An RN with experience in the operating room who transferred a month ago to the medical unit A float RN with 7 years of experience on the inpatient oncology unit An RN who has worked mostly on the same-day surgery unit since graduating a year ago
C The float RN with experience on the inpatient oncology unit would be familiar with complications and assessment for IV fluids and pneumonia.LPN/LVNs do not have the scope of practice to provide care to this client. The RN with experience in the operating room or the RN who has worked mostly on the same-day surgery unit does not have the experience needed to care for an unstable client on an unfamiliar unit.
The nurse is teaching a client about cyclosporine (Sandimmune) therapy after liver transplantation. Which client statement indicates the need for further teaching? A) "I will be on this medicine for the rest of my life." B). "I must undergo regular kidney function tests." C). "I must regularly monitor my blood sugar." D). "My gums may become swollen because of this drug."
C) Further teaching is needed when the client says, "I must regularly monitor my blood sugar." Blood sugar is not affected by taking cyclosporine, so the client has no need to monitor blood sugar.The client must take cyclosporine for the rest of his or her life. Kidney dysfunction is a side effect of cyclosporine, so regular monitoring is required. Swollen gums are a side effect of taking cyclosporine.
A complete blood count with differential is performed on a client with chronic sinusitis. Which finding does the nurse expect? Segmented neutrophils, 62% Lymphocytes, 28% Bands, 5% Basophils, 4%
D The normal count for basophils (basos) is 0.5%; an elevated count indicates inflammation. This is common with chronic sinusitis.
Which task would be best for the charge nurse to assign to the LPN/LVN working in the surgery admitting area? Provide preoperative teaching to a client who needs insertion of a tunneled central venous catheter. Insert a retention catheter in a client who requires a flap graft of a sacral pressure ulcer. Obtain the medical history from a client who is scheduled for a total hip replacement. Assess the client who is being admitted for an elective laparoscopic cholecystectomy.
Insertion of a catheter is the best task within the scope of skills approved for the LPN/LVN.Preoperative teaching and physical assessment of a preoperative client are under the scope of the RN. History information would be completed by the RN on the unit.
What pain management does a client who has been admitted to the post-anesthesia care unit typically receive? Intramuscular nonopioid analgesics Intramuscular opioid analgesics Intravenous nonopioid analgesics Intravenous opioid analgesics
Intravenous opioid analgesics Intravenous (IV) opioid analgesics are given in small doses to provide pain relief, but not to mask an anesthetic reaction.Intramuscular nonopioid analgesics and opioid analgesics are too long-acting. IV nonopioid analgesics usually are not given within the first 48 hours after surgery.
Which client does the charge nurse assign to an experienced LPN/LVN working on the adult medical unit? A 32-year-old who needs a nasogastric tube inserted for gastric acid analysis A 36-year-old who needs teaching about an endoscopic retrograde cholangiopancreatography A 40-year-old who will need administration of IV midazolam hydrochloride (Versed) during an upper endoscopy A 46-year-old who was recently admitted with abdominal cramping and diarrhea of unknown causes
Nasogastric tube insertion is included in LPN/LVN education and is an appropriate task for an experienced LPN/LVN.Assessment and client teaching would be done by an RN. IV hypnotic medications would be administered by an RN
Which statement by a nursing student indicates a need for further teaching about operating room (OR) surgical attire? "I must cover my facial hair." "I don't need a sterile gown to be in the OR." "If I go into the OR, I must wear a protective mask." "My scrubs will be sterile."
Scrub attire is provided by the hospital and is clean, not sterile.All members of the surgical team must cover their hair, including any facial hair. Team members who are not scrubbed (e.g., anesthesia provider, student nurse) are not required to be sterile
A client who is exposed to invading organisms recovers rapidly after the invasion without damage to healthy body cells. How has the immune response protected the client? Intact skin and mucous membranes Self-tolerance Inflammatory response against invading foreign proteins Antibody-antigen interaction
Self-tolerance is the process of recognizing and distinguishing between the body's own healthy self cells and non-self proteins and cells. The presence of different proteins on cell membranes makes the process of self-tolerance possible.
Five RNs from other units have been assigned to the post-anesthesia care unit for the day. A 16-year-old client with diabetes has also just arrived from the operating room (OR) after having laparoscopic abdominal surgery. The charge nurse assigns the RN with which kind of experience to care for this new client? RN who usually works on the inpatient pediatric unit RN who provides education to diabetic clients in a clinic RN who has 5 years of experience in the delivery room RN who ordinarily works as a scrub nurse in the OR
The RN with delivery room experience would have experience with abdominal surgery and with postoperative care of clients with diabetes, and would be aware of possible postoperative complications for this client.
An RN and an LPN/LVN are working together in caring for a client who needs all of these interventions after orthopedic surgery. Which action(s) would be best for the RN to accomplish? Reinforce the need to cough and deep-breathe every 2 to 4 hours. Develop the discharge teaching plan in conjunction with the client. Administer narcotic pain medications before assisting the client with ambulation. Listen for bowel sounds and monitor the abdomen for distention and pain.
The best and most appropriate action for the nurse to take is to develop the discharge teaching plan with the client. Education and preparation for discharge are within the scope of practice of the RN, but not within that of the LPN/LVN.
Which staff member will be best for the nurse manager to assign to update standard nursing care plans and policies for care of the client in the operating room (OR)? Surgical technologist with 10 years of experience in the OR at this hospital Certified registered nurse first assistant (CRNFA) who has worked for 5 years in the ORs of multiple hospitals Holding room RN who has worked in the hospital holding room for longer than 15 years Circulating RN who has been employed in the hospital OR for 7 years
The circulating RN is the best staff member for the nurse manager to assign. This nurse has the experience and background to write OR policy, has been employed in the hospital for 7 years, and is aware of hospital policy and procedures.A surgical technologist does not have the background to write policy for nurses.
Who is the most likely person to administer blood products in an operating suite? Circulating nurse Holding area nurse Scrub nurse Specialty nurse
The circulating nurse is the most likely person to administer blood products to a client in the operating suite. Circulating nurses or "circulators" are registered nurses who coordinate, oversee, and are involved in the client's nursing care in the operating room. Scrub nurses set up the sterile field, drape the client, and hand sterile supplies, sterile equipment, and instruments to the surgeon and the assistant. Specialty nurses may be in charge of a particular type of surgical specialty.
The nurse is educating a client who is about to undergo cardiac surgery with general anesthesia. Which statement by the client indicates the need for further instruction? "I will wake up with a tube in my throat." "I will have a bandage on my chest." "My family will not be able to see me right away." "Pain medication will take away my pain."
The client statement about waking up with a tube in the throat is accurate, because the client will be intubated. Following heart surgery, a dressing is placed on the chest. The client will not be able to see family immediately because he or she will go to recovery first.
The charge nurse for a hospital operating room is making client assignments for the day. Which client is most appropriate to assign to the least-experienced circulating nurse? The 20-year-old client who has a ruptured appendix and is having an emergency appendectomy The 28-year-old client with a fractured femur who is having an open reduction and internal fixation The 45-year-old client with coronary artery disease who is having coronary artery bypass grafting The 52-year-old client with stage I breast cancer who is having a tunneled central venous catheter placed
The client with stage I breast cancer who is having a tunneled central venous catheter placed is the most stable client among all scheduled procedures.
The nurse completes the preoperative checklist on a client scheduled for general surgery. Which factor contributes the greatest risk for the planned procedure? Age 59 years General anesthesia complications experienced by the client's brother Diet-controlled diabetes mellitus Ten pounds (4.5 kg) over the client's ideal body weight
The client's greatest risk factor is diabetes mellitus. Diabetes contributes an increased risk for surgery or postsurgical complications.Older adults are at greater risk for surgical procedures, but this client is not classified as an older adult. Family medical history and problems with anesthetics may indicate possible reactions to anesthesia, but this is not the best answer.
The nurse is assessing a client who comes to the emergency department with acute abdominal pain. The nurse notes a bulging, pulsating mass when inspecting the abdomen. Which action by the nurse is correct? Auscultate the abdomen to determine the presence of bowel sounds. Notify the provider about this finding immediately. Palpate the client's abdomen to determine the outlines of the mass. Question the client about recent stool habits.
The nurse needs to immediately notify the health care provider because a bulging, pulsating mass may indicate an abdominal aortic aneurysm requiring emergency actions.
An older client's adult child tells the nurse that the client does not want life support. What does the nurse do first? Call the legal department to draft the paperwork. Document this in the chart. Thank the person and do nothing else. Talk to the client.
The nurse would first talk to the client in order to determine the client's wishes and state of mind.The nurse should not call the legal department or document in the client's chart before speaking with the client. Doing nothing is not appropriate.
A preoperative client smokes a pack of cigarettes a day. What is the nurse's teaching priority for the best physical outcomes? Instruct the client to quit smoking. Teach about the dangers of tobacco. Teach the importance of incentive spirometry. Tell the client that smoking increases postoperative complications.
The nurse would first teach the importance of incentive spirometry. Incentive spirometry is good for lung hygiene and it encourages deep breathing.The nurse can suggest quitting or advice about the dangers of tobacco, but it is not therapeutic to instruct it at this time. Telling the client that smoking causes increased complications is not helpful or therapeutic just prior to surgery.
