NUR 255 exam 1

Before admitting a patient to the operating room, which forms or results must the nurse make sure are in the chart of all patients (select all that apply)? 1. Electrocardiogram 2. Signed consent form 3. Functional status evaluation 4. Renal and liver function tests 5. A history and physical report

1,5

What patient statement indicates the need for further teaching about antiemetic medications?

"I will apply the scopolamine patch to my right or left arm and rotate sites of application."

When caring for a patient with a known latex allergy, the nurse would monitor the patient closely for a cross-sensitivity to which foods (select all that apply)? 1. Grapes 2.Oranges 3.Bananas 4.Potatoes 5. Tomatoes

1,3,4,5.

Which client would the nurse identify as having the highest risk for developing postoperative complications?

1.The 67-year-old client who is obese, has diabetes, and takes insulin.

Which action by the client indicates to the nurse preoperative teaching has been effective?

1.The client demonstrates how to use the incentive spirometer device.

Which intervention has priority for the nurse in the surgical holding area?

1.Verify the surgical checklist.

Which intraoperative nursing responsibilities should be performed by the scrub nurse (select all that apply)? 1. Documenting intraoperative care 2. Keeping track of irrigation solutions for monitoring of blood loss 3. Passing instruments and supplies to the surgeon by anticipating his or her needs 4. Coordinating the flow and activities of members of the surgical team in the surgical suite 5. Performing the count of sponges, needles, and instruments used during the surgical procedure

2,3,5

The nurse would be alerted to the occurrence of malignant hyperthermia when the patient demonstrates what manifestation? 1. Hypocapnia 2. Muscle rigidity 3. Decreased body temperature 4. Confusion upon arousal from anesthesia

2. Muscle rigidity

Activities that the nurse might perform in the role of a scrub nurse during surgery include (select all that apply):

2. preparing the instrument table. 3. passing instruments to the surgeon and assistants 5. maintaining accurate counts of sponges, needles, and instruments.

The nurse is caring for a male client scheduled for abdominal surgery. Which interventions should the nurse include in the plan of care? Select ALL that apply.

2.Discuss how to cough and deep breathe effectively. .4.Teach ways to manage postoperative pain. 5.Discuss events which occur in the post-anesthesia care uni

The unlicensed assistive personnel (UAP) can be overheard talking loudly to the scrub technologist discussing a problem which occurred during one (1) of the surgeries. Which intervention should the nurse in the surgical holding area with a female client implement?

2.Instruct the UAP and scrub tech to stop the discussion.

The circulating nurse is positioning clients for surgery. Which client has the greatest potential for nerve damage?

2.The 68-year-old client in the Trendelenburg position having a cholecystectomy.

A patient is scheduled for surgery requiring general anesthesia at an ambulatory surgical center. The nurse asks him when he ate last. He replies that he had a light breakfast a couple of hours before coming to the surgery center. What should the nurse do first?

3. Notify the anesthesia care provider when and what the patient last ate.

The nurse is assessing a client in the day surgery unit who states, "I am really afraid of having this surgery. I'm afraid of what they will find." Which statement would be the best therapeutic response by the nurse?

3."Tell me about your fears of having this surgery."

The surgical client's vital signs are T 98˚F, P 106, R 24, and BP 88/40. The client is awake and oriented times three (3) and the skin is pale and damp. Which intervention should the nurse implement first?

3.Elevate the feet and lower the head.

The circulating nurse observes the surgeon tossing a bloody gauze sponge onto thesterile field. Which action should the circulating nurse implement first?

3.Tell the surgical technologist about the sponge.

The nurse is completing the preoperative checklist on a client going to surgery. Which information should the nurse report to the surgeon?

3.The client uses the oral supplements licorice and garlic.

The nurse is changing the abdominal dressing on a client following abdominal surgery. The nurse notes that the incision line is separated and the appearance of underlying tissue is noted. Wound dehiscence is suspected. Which is the appropriate initial nursing action? 1.Leave the incision open to the air. 2.Apply a dry sterile dressing to the wound. 3.Ask the client to cough to verify the presence of dehiscence. 4.Apply a sterile dressing soaked with sterile normal saline to the wound.

4.Apply a sterile dressing soaked with sterile normal saline to the wound.

Which laboratory result would require immediate intervention by the nurse for the client scheduled for surgery?

4.Potassium 2.4 mEq/L.

The circulating nurse and the scrub technician find a discrepancy in the sponge count. Which action should the circulating nurse take first?

4.Re-count all sponges.

The nurse is checking the informed consent for a 17-year-old who has just been married and expecting her first child. She is scheduled for a cesarean section. She is still living with her parents and is on her parents health insurance. When obtaining informed consent for the cesarean section, who is legally responsible for signing? A) Her parents B) Her husband C) The patient D) The obstetrician

C) The patient

What steps are taken to prevent hip dislocation and muscle strain in the lithotomy position? A. Legs are raised quickly, one at a time. B. Legs are raised slowly, one at a time. C.Legs are raised and lowered slowly and simultaneously. D.Legs are raised and lowered quickly and simultaneously.

C.Legs are raised and lowered slowly and simultaneously.

A patient is 1 hour post-op from abdominal surgery and had lost 20% of their blood volume during surgery. The patient is experiencing signs and symptoms of hypovolemic shock. What position is best for this patient?

Modified Trendelenburg

A patient in hypovolemic shock is receiving rapid infusions of crystalloid fluids. Which patient finding requires immediate nursing action?

Patient experiences dyspnea and crackles in lung fields

The nurse would teach a patient about what antiemetic commonly used to prevent motion sickness?

Scopolamine

A patient is receiving large amounts of fluids for aggressive treatment of hypovolemic shock. The nurse makes it PRIORITY to?

Warm the fluids to prevent hypothermia

You are providing preoperative teaching to a patient scheduled for hip replacement surgery in 1 month. During the preoperative teaching, the patient gives you a list of medications she takes, the dosage, and frequency. Which of the following interventions provides the patient with the most accurate information? A) Instruct the patient to stop taking St. Johns wort at least 2 weeks prior to surgery due to its interaction with anesthetic agents .B) Instruct the patient to continue taking ephedrine prior to surgery due to its beneficial effect on blood pressure. C) Instruct the patient to discontinue Synthroid due to its effect on blood coagulation and the potential for heart dysrhythmias. D) Instruct the patient to continue any herbal supplements unless otherwise instructed, and inform the patient that these supplements have minimal effect on the surgical procedure.

a

A patient develops malignant hyperthermia. Which of the following most likely would be the first indicator of this complication? a) Tentanus-like jaw movements b) Heart rate over 150 beats per minute c) Body temperature rise of 2 degrees F d) Generalized muscle rigidity

b) Heart rate over 150 beats per minute

A patient is undergoing general anesthesia. The nurse anesthetist starts to administer the anesthesia. The patient starts giggling and kicking her legs. What stage of anesthesia would the nurse document related to the findings? a) I b) IV c) II d) III

c) II EXCITEMENT stage