NURS129 LESSON 2 PRACTICE QUESTIONS
A patient is admitted to the burn unit with second- and third-degree burns covering the face, entire right upper extremity, and right anterior trunk area. Using the rule of nines, what should the nurse calculate the extent of these burns as being? 18% 22.5% 27% 36%
22.5% face (4.5%) right arm (9%) right side anterior trunk (9%)
A patient is postoperative after a breast reduction and arrives for a follow-up appointment at the clinic. The nurse assesses excess soft pink tissue from the surgical incision site. What complication of wound healing does the nurse recognize this to be? Adhesion Contractions Keloid formation Excess granulation tissue
Excess granulation tissue
An older adult patient is being prepared for surgery. What assessment data needs to be obtained from the patient? (Select all that apply.) Fluid balance history Attitude about surgery Foods the patient dislikes Current mobility problems Current cognitive function Patient's opinion about the surgeon
Fluid balance history Current mobility problems Current cognitive function
Which intervention should the nurse include in the plan of care for a patient who is paraplegic with a stage 3 pressure injury? Keep the pressure injury clean and dry. Maintain protein intake of at least 1.25 g/kg/day. Use a 10-mL syringe to irrigate the pressure injury. Irrigate the pressure injury with hydrogen peroxide.
Maintain protein intake of at least 1.25 g/kg/day.
When reviewing the preoperative forms, the nurse notices that the informed consent form is not present or signed. What is action should the nurse to take? Have the patient sign the consent form. Have the family sign the form for the patient. Call the surgeon to obtain consent for surgery. Teach the patient about the surgery and get verbal permission.
Call the surgeon to obtain consent for surgery.
Which patient is most at risk for the development of a pressure injury? An older patient who is septic, bedridden, and incontinent An obese woman with leukemia who is receiving chemotherapy A middle-aged thin man in a halo cast after a motor vehicle accident An older adult with type 1 diabetes admitted in diabetic ketoacidosis
An older patient who is septic, bedridden, and incontinent
A patient is being prepared for a surgical procedure. What is the priority intervention by the nurse prior to the start of the procedure according to the National Patient Safety Goal (NPSG)? Prevention of infection Improved staff communication Identify patients at risk for suicide Patient, surgical procedure, and site are checked
Patient, surgical procedure, and site are checked
Early ambulation is ordered in the postoperative plan of care, but the patient refuses to get up and walk. What teaching should the nurse provide to the patient about the reason for early ambulation? "Early walking keeps your legs limber and strong." "Early ambulation will help you be ready to go home." "Early ambulation will help you get rid of your syncope and pain." "Early walking is the best way to prevent postoperative complications."
"Early walking is the best way to prevent postoperative complications."
The nurse teaches a patient with chronic kidney disease about several interventions to reduce pruritus associated with dry skin and uremia. Which statement, if made by the patient to the nurse, indicates further teaching is required? "I will avoid taking hot showers." "I can rub my skin instead of scratching." "Menthol can be used to numb the itch sensation." "A lubricating lotion right after bathing will help."
"I can rub my skin instead of scratching."
The nurse is providing discharge teaching to a patient who has had a laparoscopic cholecystectomy at an ambulatory surgery center. Which statement, if made by the patient, indicates an understanding of the discharge instructions? "I will have someone stay with me for 24 hours in case I feel dizzy." "I should wait for the pain to be severe before taking the medication." "Because I did not have general anesthesia, I will be able to drive home." "It is expected after this surgery to have a temperature up to 102.4° F."
"I will have someone stay with me for 24 hours in case I feel dizzy."
The nurse assesses small, firm, reddened raised lesions with flat, rough patches on a patient that are causing intense pruritus. What question should the nurse next ask the patient? "Have you started any new medications?" "Do you have a history of seasonal allergies?" "Have you had any lesions such as this before?" "Tell me about your activities the past 2 to 7 days."
"Tell me about your activities the past 2 to 7 days."
While the perioperative nurse is transporting a patient to the operating room for general surgery, the patient states, "I am a Jehovah's Witness, and I am worried about blood transfusions." What would be the best response by the nurse to this patient's statement? "I will make sure that you do not receive a blood transfusion during this surgery." "Would you like to sign the consent form just in case you need blood during surgery?" "Do you have someone I can contact in an emergency if you need a blood transfusion?" "Tell me what you would like done if it is determined that you need blood replacement during surgery."
"Tell me what you would like done if it is determined that you need blood replacement during surgery."
A patient tells the nurse that they are afraid to use the treatment recommended for psoriasis. What is the best response by the nurse? "You will only know if you try it and see." "You may need to get counseling to help you cope." "No treatment is medically necessary, but it can be removed." "Topical, light therapy, and systemic medications are now available."
"Topical, light therapy, and systemic medications are now available."
While performing preoperative teaching, the patient asks when he is no longer able to eat or drink. Based on the most recent practice guidelines established by the American Society of Anesthesiologists, what is the best response by the nurse? "Stay NPO after midnight." "Maintain NPO status until after breakfast." "You may drink clear liquids up to 2 hours before surgery." "You may drink clear liquids up until she is moved to the OR."
"You may drink clear liquids up to 2 hours before surgery."
A patient asks a student nurse if his family member may accompany him to the surgical area. What is the best response by the nurse? "Your family member may not enter the surgical area." "Your family can be with you in the preoperative holding area." "Your family can't be with you until the postanesthesia care unit." "Your family is only allowed in the conference room for preoperative teaching."
"Your family can be with you in the preoperative holding area."
Which patient has the highest risk of developing melanoma? A fair-skinned woman who uses a tanning booth regularly A black patient with a family history of breast and colon cancer A Hispanic man with psoriasis and eczema that did not respond to treatment An adult who had phototherapy as an infant for the treatment of hyperbilirubinemia
A fair-skinned woman who uses a tanning booth regularly
The nurse is providing preoperative teaching to a group of patients. Which patient should the nurse plan to teach coughing and deep breathing exercises? A 20-yr-old man who is scheduled for a tonsillectomy A 40-yr-old woman who is scheduled for an open cholecystectomy A 30-yr-old woman who is scheduled for a transsphenoidal hypophysectomy A 50-yr-old man who is scheduled for an evacuation of a subdural hematoma
A 40-yr-old woman who is scheduled for an open cholecystectomy
Which patient should the nurse prepare to transfer to a regional burn center? A 25-yr-old pregnant patient with a carboxyhemoglobin level of 1.5% A 39-yr-old patient with a partial-thickness burn to the right upper arm A 53-yr-old patient with a chemical burn to the anterior chest and neck A 42-yr-old patient who is scheduled for skin grafting of a burn wound
A 53-yr-old patient with a chemical burn to the anterior chest and neck
The nurse is teaching about skin cancer prevention at the community center. Which person is most at risk for developing skin cancer? A 67-yr-old bald man with psoriasis and type 2 diabetes. A 76-yr-old Hispanic man who has a latex allergy and numerous acrochordons. A 55-yr-old woman with fair skin and red hair and a family history of skin cancer. A 62-yr-old woman with chronic kidney disease who has blond hair with pale skin.
A 55-yr-old woman with fair skin and red hair and a family history of skin cancer.
Which patient would be at highest risk for hypothermia after surgery? A 42-yr-old patient who had a laparoscopic appendectomy A 38-yr-old patient who had a lumpectomy for breast cancer A 20-yr-old patient with an open reduction of a fractured radius. A 75-yr-old patient with repair of a femoral neck fracture after a fall.
A 75-yr-old patient with repair of a femoral neck fracture after a fall.
To which patient should the nurse plan to administer round-the-clock antipyretic drugs? A 76-yr-old patient with bacterial meningitis and a temperature of 104.2°F An 82-yr-old patient after hip replacement surgery and a temperature of 100.4°F A 14-yr-old patient with infectious mononucleosis and a temperature of 101.6°F A 59-yr-old patient with an acute myocardial infarction and a temperature of 99.8°F
A 76-yr-old patient with bacterial meningitis and a temperature of 104.2°F
A patient with a burn inhalation injury is receiving albuterol for the treatment of bronchospasm. What is the most important adverse effect of this medication for the nurse to monitor? Tachycardia Restlessness Hypokalemia Gastrointestinal (GI) distress
Tachycardia
The circulating nurse is caring for a patient during a colon resection. What observation made by the nurse is immediately recognized as a violation of aseptic technique? A glove contacts the leg of the table that supports the sterile field. The cuff of the scrub nurse's sterile gown contacts the sterile field. The sterile field was established at 0650, and the current time is 0900. A contaminated item is removed from the field and the area is marked off.
A glove contacts the leg of the table that supports the sterile field.
The nurse recognizes that which patient is likely to have the poorest prognosis? A patient with nodular ulcerative basal cell cancer. A patient who has been diagnosed with late squamous cell cancer. A patient whose is being treated for superficial squamous cell cancer. A patient who is newly diagnosed with stage IV malignant melanoma.
A patient who is newly diagnosed with stage IV malignant melanoma.
When teaching the patient in the rehabilitation phase of a severe burn about performing range of motion (ROM), what explanations should the nurse give to the patient? (Select all that apply.) The exercises are the only way to prevent contractures. Active and passive ROM maintains function of body parts. ROM will reassure the patient that movement is still possible. Movement promotes mobilization of interstitial fluid back into the vascular bed. Active and passive ROM can only be done while the dressings are being changed.
Active and passive ROM maintains function of body parts. ROM will reassure the patient that movement is still possible. Movement promotes mobilization of interstitial fluid back into the vascular bed.
A child is about to be admitted to the pediatric intensive care unit (PICU) after surgery for removal of a tumor in the hypothalamic region of the brain. Which action by the nurse caring for the child requires the nurse manager to intervene? Obtains electronic equipment for monitoring the vital signs Adjusts the bed to the Trendelenburg position Secures a pump to administer the ordered intravenous fluids Places a hypothermia blanket at the bedside
Adjusts the bed to the Trendelenburg position
The nurse is providing emergent care for a patient with a possible inhalation injury sustained in a house fire. The patient is anxious and disoriented, and the skin is a cherry red color. What is the priority action by the nurse? Administer 100% humidified oxygen. Teach the patient deep breathing exercises. Encourage the patient to express his feelings. Assist the patient to a high Fowler's position.
Administer 100% humidified oxygen.
In planning postoperative interventions to promote repositioning, ambulation, coughing, and deep breathing, the nurse recognizes which action will best enable the patient to achieve the desired outcomes? Administering adequate analgesics to promote relief or control of pain Asking the patient to demonstrate the postoperative exercises every 1 hour Giving the patient positive feedback when the activities are performed correctly Warning the patient about possible complications if the activities are not performed
Administering adequate analgesics to promote relief or control of pain
An alert patient does not want to have a tracheostomy inserted because of extended endotracheal intubation, although family members state that they want it done. What action should the nurse take? Advocate for the patient's rights. Try to change the patient's mind. Call surgery to cancel the procedure. Tell the family they cannot interfere.
Advocate for the patient's rights.
The nurse is teaching a patient about the application of a topical medication. What should the nurse include as part of the instructions? Avoid applying medications directly onto dressings. Use a tongue blade whenever the patient's skin integrity allows. Avoid covering skin areas where a topical medication has been applied. Apply a layer of medication that is just thick enough to ensure coverage.
Apply a layer of medication that is just thick enough to ensure coverage.
To help decrease the threat of melanoma in a blonde-haired, fair-skinned patient at risk, which recommendations should the nurse provide? (Select all that apply.) Drink plenty of water. Eat plenty of foods high in vitamin K. Apply sunscreen 30 minutes prior to exposure. Wear sunglasses. Consume fish oil and vitamin E.
Apply sunscreen 30 minutes prior to exposure. Wear sunglasses. Consume fish oil and vitamin E.
When assessing a patient's surgical dressing on the first postoperative day, the nurse notes new, bright-red drainage about 5 cm in diameter. What is the priority action by the nurse? Recheck in 1 hour for increased drainage. Notify the surgeon of a potential hemorrhage. Assess the patient's blood pressure and heart rate. Remove the dressing and assess the surgical incision.
Assess the patient's blood pressure and heart rate.
A patient has been provided with a compression dressing in an attempt to facilitate rapid healing of an ankle sprain. What is a priority nursing assessment? Frequent examination of the character and quantity of exudate Monitoring for signs and symptoms of local or systemic infections Assessment of the patient's circulation distal to the location of the dressing Assessment of the range of motion of the ankle and the patient's activity tolerance
Assessment of the patient's circulation distal to the location of the dressing
In caring for the postoperative patient on the clinical unit after transfer from the postanesthesia care unit (PACU), which care can the nurse delegate to the unlicensed assistive personnel (UAP)? Monitor the patient's pain. Obtain the admission vital signs. Assist the patient to take deep breaths and cough. Change the dressing when there is excess drainage.
Assist the patient to take deep breaths and cough.
The nurse in the skilled nursing facility is very busy and unable to answer all the call lights. Which tasks related to skin care can the nurse delegate to the nursing assistant? (Select all that apply.) Assessing a patient complaining of an itching rash Assisting the client with frequent turning to prevent pressure ulcers Covering the client who complains of being cold with more blankets Placing a sterile gauze pad over broken skin to contain drainage Applying over-the-counter lotions to skin that is not broken
Assisting the client with frequent turning to prevent pressure ulcers Covering the client who complains of being cold with more blankets Placing a sterile gauze pad over broken skin to contain drainage Applying over-the-counter lotions to skin that is not broken
The nurse determines a postoperative patient has a bronchial obstruction from retained secretions and an oxygen saturation of 87%. What condition does the nurse suspect is occurring? Atelectasis Bronchospasm Hypoventilation Pulmonary embolism
Atelectasis
A nurse is teaching a patient how to promote healing following abdominal surgery. What should be included in the teaching? (Select all that apply.) Take the antibiotic until the wound feels better. Take the analgesic every day to promote adequate rest for healing. Be sure to wash hands before changing the dressing to avoid infection. Take in more fluid, protein, and vitamins C, B, and A to facilitate healing. Notify the health care provider of redness, swelling, and increased drainage.
Be sure to wash hands before changing the dressing to avoid infection. Take in more fluid, protein, and vitamins C, B, and A to facilitate healing. Notify the health care provider of redness, swelling, and increased drainage.
An older adult patient who had surgery has signs of delirium. What priority action would benefit this patient? Review the chart for intraoperative complications. Check which medications were used for anesthesia. Assess the effectiveness of the analgesics received. Check the preoperative assessment for previous delirium or dementia.
Check the preoperative assessment for previous delirium or dementia.
The nurse practitioner orders a wet-to-dry normal saline solution (NSS) dressing for a patient who has a stage III pressure ulcer on the sacral area. The patient's daughter will be dressing the wound at home. Which steps should the nurse include in the teaching plan? (Select all that apply.) Applying a dry sterile dressing Cleansing the wound Managing pain Using cold water in the bath Hand washing
Cleansing the wound Managing pain Hand washing
A patient with hypothermia is brought to the emergency department. What treatment should the nurse anticipate? Core rewarming with warm fluids Gastric tube feedings to increase fluids Frequent oral temperature assessment Ambulation to increase metabolism
Core rewarming with warm fluids
A postoperative patient is now able to eat and is requesting a snack. What snack should the nurse recommend for the patient that will facilitate wound healing? Apple Custard Popsicle Potato chips
Custard
An older adult patient is transferred from the nursing home with a black wound on her coccyx. What immediate wound therapy does the nurse anticipate providing to this patient? Dress it with an absorbent dressing for exudate. Handle the wound gently and let it dry out to heal. Debride the nonviable, eschar tissue to allow healing. Use negative-pressure wound therapy to facilitate healing.
Debride the nonviable, eschar tissue to allow healing.
In caring for a patient with burns to the back, the nurse knows that the patient is moving out of the emergent phase of burn injury when what is observed? Serum sodium and potassium increase. Serum sodium and potassium decrease. Edema and arterial blood gases improve. Diuresis occurs and hematocrit decreases.
Diuresis occurs and hematocrit decreases.
A patient requests that the nurse give his hearing aid to a family member so it will not be lost in surgery. What is the appropriate action by the nurse? Give the hearing aid to the wife as he wishes. Tape the hearing aid to his ear to prevent loss. Encourage the patient to wear it for the surgery. Tell the surgery nurse that he has his hearing aid out.
Encourage the patient to wear it for the surgery.
The nurse is planning care for a patient with partial- and full-thickness skin destruction related to burn injury of the lower extremities. Which interventions will the nurse include in this patient's care? (Select all that apply.) Escharotomy Administration of diuretics IV and oral pain medications Daily cleansing and debridement Application of topical antimicrobial agent
Escharotomy IV and oral pain medications Daily cleansing and debridement Application of topical antimicrobial agent
The nurse is caring for a patient who is immunocompromised while receiving chemotherapy for advanced breast cancer. What signs and symptoms will the nurse teach the patient to report that may indicate an infection? Fever and chills Increased blood pressure Increased respiratory rate General malaise and fatigue
General malaise and fatigue
The surgical team in the operating room performs a surgical time-out just before starting hip replacement surgery. Which action would be part of the surgical time-out? Check the chart for a signed consent form for the procedure. Assess the patient's vital signs and oxygen saturation level. Determine if the patient has any questions about the procedure. Have the patient verify the procedure and the location of the surgery.
Have the patient verify the procedure and the location of the surgery.
The nurse is caring for a patient with partial- and full-thickness burns to 65% of the body. When planning nutritional interventions for this patient, what dietary choices should the nurse implement? Full liquids only Whatever the patient requests High-protein and low-sodium foods High-calorie and high-protein foods
High-calorie and high-protein foods
A patient having abdominal surgery had an estimated blood loss of 400 mL and received 300 mL of 0.9% normal saline. Postoperatively, the patient's blood pressure is 70/48 mm Hg. What priority treatment does the nurse anticipate administering? Blood administration IV fluid administration An ECG to check circulatory status Return to surgery to check for internal bleeding
IV fluid administration
The nurse is caring for a Native American patient 2 days after a thoracotomy for a tumor resection. What would be the most appropriate action if the patient does not report any pain? Contact the health care provider. Identify possible reasons for denying pain. Administer the prescribed pain medication. Assess the renal and liver function test results.
Identify possible reasons for denying pain.
A patient is admitted to the postanesthesia care unit (PACU) after abdominal surgery. Which assessment, if made by the nurse, is the best indicator of respiratory depression? Increased respiratory rate Decreased oxygen saturation Increased carbon dioxide pressure Frequent premature ventricular contractions (PVCs)
Increased carbon dioxide pressure
A patient arrives in the emergency department reporting fever for 24 hours and lower right quadrant abdominal pain. After laboratory studies are performed, what does the nurse determine indicates the patient has a bacterial infection? Increased platelet count Decreased blood urea nitrogen Increased number of band neutrophils Increased number of segmented myelocytes
Increased number of band neutrophils
What clinical indicator will the nurse likely identify when assessing a patient with pyrexia? Elevated blood pressure Increased pulse rate Precordial pain Dyspnea
Increased pulse rate
A patient being admitted to the same-day surgery unit informs the nurse they took kava last evening to sleep. Which nursing action would be most appropriate? Tell the patient that using kava to help sleep is often helpful. Inform the anesthesia care provider of the patient's recent use of kava. Tell the patient that the kava should continue to help the patient to relax before surgery. Inform the patient about the dangers of taking herbal medicines without consulting a health care provider.
Inform the anesthesia care provider of the patient's recent use of kava.
The nurse is teaching the residents of an independent living facility about preventing skin infections and infestations. What should be included in the teaching? Use cool compresses if an infection occurs. Oral antibiotics are needed for any skin changes. Antiviral agents will be needed to prevent outbreaks. Inspect skin for changes when bathing with mild soap.
Inspect skin for changes when bathing with mild soap.
An older adult is moving into an independent living facility. What teaching will prevent this patient from being accidently burned in the new home? Encourage her to stop smoking. Install tap water anti-scald devices. Ensure all meals are cooked for her. Be sure she uses an open space heater.
Install tap water anti-scald devices.
A patient is ordered to receive acetaminophen 650 mg per rectum every 6 hours as needed for fever greater than 102° F. Which priority parameter would the nurse monitor, other than temperature, if the patient requires this medication? Pain level Intake and output Oxygen saturation Level of consciousness
Intake and output
The patient in the emergent phase of a burn injury is being treated for severe pain. What medication should the nurse anticipate administering to the patient? Subcutaneous (SQ) tetanus toxoid Intravenous (IV) morphine sulfate Intramuscular (IM) hydromorphone Oral oxycodone and acetaminophen
Intravenous (IV) morphine sulfate
The patient is having a mole removed that has changed appearance. What does the nurse teach the patient about the reason for this surgical procedure? It will prevent cancer. It will alleviate symptoms. It will cure the patient's cancer. It will provide cosmetic improvement.
It will prevent cancer.
When caring for a patient with an electrical burn injury, which order from the health care provider should the nurse question? Mannitol 75 gram IV Urine for myoglobulin Lactated Ringer's solution at 25 mL/hr Sodium bicarbonate 24 mEq every 4 hours
Lactated Ringer's solution at 25 mL/hr
The nurse is positioning a patient after a surgical procedure. What is the best position unless contraindicated, for this patient to be placed in to prevent respiratory complications? Supine Lateral Semi-Fowler's High-Fowler's
Lateral
A nurse is caring for an unconscious patient who has just been admitted to the postanesthesia care unit (PACU) after an abdominal hysterectomy. How should the nurse position the patient? Left lateral position with head supported on a pillow Prone position with a pillow supporting the abdomen Supine position with head of bed elevated 30 degrees Semi-Fowler's position with the head turned to the right
Left lateral position with head supported on a pillow
A patient with type 2 diabetes is in the acute phase of burn care with electrical burns on the left side of the body and a serum glucose level of 485 mg/dL. What is the nurse's priority intervention for this patient? Replace the blood lost. Maintain a neutral pH. Maintain fluid balance. Replace serum potassium.
Maintain fluid balance.
A patient is having elective facial cosmetic surgery and will be staying in the facility for 24 hours after surgery. What is the nurse's postoperative priority for this patient? Manage patient pain. Control the bleeding. Maintain fluid balance. Manage oxygenation status.
Manage oxygenation status.
The postoperative patient has dry skin and reports pruritus on both legs. What nursing actions can help stop the itch-scratch cycle? (Select all that apply.) Moisturize the skin on the legs. Provide a warm blanket and room. Administer antihistamines at bedtime. Vigorously rub the patient's legs after bathing. Cleanse the legs with a saline solution twice daily.
Moisturize the skin on the legs. Administer antihistamines at bedtime.
The nurse is planning care for the patient in the acute phase of a burn injury. What nursing action is important for the nurse to perform after the progression from the emergent to the acute phase? Begin IV fluid replacement. Monitor for signs of complications. Assess and manage pain and anxiety. Discuss possible reconstructive surgery.
Monitor for signs of complications.
The nurse is planning to change the dressing that covers a deep partial-thickness burn of the right lower leg. Which prescribed medication should the nurse administer to the patient 30 minutes before the scheduled dressing change? Morphine Sertraline Zolpidem Alprazolam
Morphine
The nurse is circulating for a surgical procedure. What assessment finding would indicate to the nurse that the patient may be experiencing malignant hyperthermia? Hypocapnia Muscle rigidity Decreased body temperature Confusion upon arousal from anesthesia
Muscle rigidity
A patient arrives in the emergency department after sustaining a full-thickness thermal burn to both arms while putting lighter fluid on a grill. What manifestations should the nurse expect? Severe pain, blisters, and blanching with pressure Pain, minimal edema, and blanching with pressure Redness, evidence of inhalation injury, and charred skin No pain, waxy white skin, and no blanching with pressure
No pain, waxy white skin, and no blanching with pressure
The patient with a stage 4 pressure injury on the coccyx will need a skin graft to close the wound. Which postoperative care should the nurse expect to use to facilitate healing? No straining of the grafted site. The wound will be exposed to air. Soft tissue expansion will be done daily. The pressure dressing will not be removed.
No straining of the grafted site.
A patient informs the nurse prior to the surgical procedure that she is so nervous about the procedure and had to take alprazolam (Xanax) last night, but it did not relieve the anxiety. What is the priority action by the nurse? Review the surgery with the patient. Notify the anesthesia care provider (ACP). Administer another dose of alprazolam (Xanax). Tell the patient that everything will be okay with the surgery.
Notify the anesthesia care provider (ACP).
The nurse is working on a surgical floor and is preparing to receive a postoperative patient from the postanesthesia care unit (PACU). What should the nurse's initial action be upon the patient's arrival? Assess the patient's pain. Obtain the patient's vital signs. Check the rate of the IV infusion. Review the surgeon's postoperative orders.
Obtain the patient's vital signs.
Five minutes after receiving a preoperative sedative medication by IV injection, a patient asks to get up to go to the bathroom to urinate. What is the most appropriate action for the nurse to take? Offer the patient to use a urinal or bedpan after explaining the need to maintain safety. Assist the patient to the bathroom and stay next to the door to assist patient back to bed when done. Allow the patient to go to the bathroom since the onset of the medication will be more than 5 minutes. Ask the patient to hold the urine for a short period since a urinary catheter will be placed in the operating room.
Offer the patient to use a urinal or bedpan after explaining the need to maintain safety.
A nurse is instructing a nursing assistant on how to prevent pressure ulcers for frail elderly clients. The action by the nursing assistant indicates understanding of the instructions? (Select all that apply.) Maintains a cooler environment when bathing Bathes and dries the skin vigorously to stimulate circulation Offers nutritional supplements and frequent snacks Keeps the head of the bed elevated 45 degrees Turns the patient at least every 2 hours
Offers nutritional supplements and frequent snacks Turns the patient at least every 2 hours
A nurse is caring for a patient with second- and third-degree burns to 50% of the body. The nurse prepares fluid resuscitation based on knowledge of the Parkland (Baxter) formula that includes which recommendation? The total 24-hour fluid requirement should be administered in the first 8 hours. One half of the total 24-hour fluid requirement should be administered in the first 4 hours. One half of the total 24-hour fluid requirement should be administered in the first 8 hours. One third of the total 24-hour fluid requirement should be administered in the first 4 hours.
One half of the total 24-hour fluid requirement should be administered in the first 8 hours.
The nurse should explain to a patient that which are effective treatments for atopic pruritus? (Select all that apply.) Topical antihistamines Oral steroids Topical steroids Topical petroleum ointment Oral antihistamines
Oral steroids Topical steroids
The nurse notes a patient has chills related to an infection. What is the priority action by the nurse? Provide a light blanket. Encourage a hot shower. Monitor temperature every hour. Turn up the thermostat in the patient's room.
Provide a light blanket.
A patient with pneumonia has a fever of 103° F. What nursing actions will assist in managing the patient's febrile state? Administer aspirin on a scheduled basis around the clock. Provide acetaminophen every 4 hours to maintain consistent blood levels. Administer acetaminophen when the patient's oral temperature exceeds 103.5° F. Provide drug interventions if complementary and alternative therapies have failed.
Provide acetaminophen every 4 hours to maintain consistent blood levels.
A patient had abdominal surgery last week and returns to the clinic for follow-up. The nurse assesses thick, white, malodorous drainage. How should the nurse document this drainage? Serous Purulent Fibrinous Catarrhal
Purulent
The nurse is caring for a patient with superficial partial-thickness burns of the face sustained within the last 12 hours. Upon assessment the nurse would expect to find which manifestation? Blisters Reddening of the skin Destruction of all skin layers Damage to sebaceous glands
Reddening of the skin
Which is the priority nursing invention for a patient with hyperthermia? Initiating seizure precautions Limiting oral intake Removing excess clothing Providing a blanket
Removing excess clothing
After the unlicensed assistive personnel (UAP) bathed the patient, she reported a reddened area on the patient's coccyx to the nurse. After assessing the area, what should be included in the plan of care? Reposition every 2 hours. Measure the size of the reddened area. Massage the area to increase blood flow. Evaluate the area later to see if it is better.
Reposition every 2 hours.
The nurse is preparing a patient for a surgical procedure. Before admitting the patient into the perioperative suite, what documents must the nurse make sure are in the patient's chart? (Select all that apply.) Electrocardiogram Signed consent form Functional status evaluation Renal and liver function tests A history and physical examination report
Signed consent form A history and physical examination report
A patient is admitted to the emergency department with first- and second-degree burns after being involved in a house fire. Which assessment findings would alert the nurse to the presence of an inhalation injury? (Select all that apply.) Singed nasal hair Generalized pallor Painful swallowing Burns on the upper extremities History of being involved in a large fire
Singed nasal hair Painful swallowing History of being involved in a large fire
An older adult patient is having surgery. What risk area will the nurse need to be especially aware of for this patient during surgery? Sterility Paralysis Urine output Skin integrity
Skin integrity
The nurse is caring for a patient who sustained a deep partial-thickness burn to the anterior chest area during a workplace accident 6 hours ago. Which assessment findings would the nurse identify as congruent with this type of burn? Skin is hard with a dry, waxy white appearance. Skin is shiny and red with clear, fluid-filled blisters. Skin is red and blanches when slight pressure is applied. Skin is leathery with visible muscles, tendons, and bones.
Skin is shiny and red with clear, fluid-filled blisters.
The nurse is admitting a patient to the emergency room on a cold winter night. Which assessment finding would cause the nurse to suspect hypothermia? Slow capillary refill Red, sweaty skin Rapid pulse rate Increased respirations
Slow capillary refill
The nurse is performing a preoperative assessment for a patient scheduled for a surgical procedure. What is the rationale for the nurse's careful documentation of the patient's current medication list? Some medications may alter the patient's perceptions about surgery. Many anesthetics alter renal and hepatic function, causing toxicity of other drugs. Some medications may interact with anesthetics, altering the potency and effect of the drugs. Routine medications are withheld the day of surgery, requiring dosage and schedule adjustments after surgery.
Some medications may interact with anesthetics, altering the potency and effect of the drugs.
A homeless person is brought to the emergency department after prolonged exposure to cold weather. What clinical manifestation would the nurse expect? Rapid respirations Increased anxiety Erythema Stupor
Stupor
The patient has inflammation and reports feeling tired, nausea, and anorexia. The nurse explains to the patient that these manifestations are related to inflammation in what way? Local response Systemic response Infectious response Acute inflammatory response
Systemic response
The perioperative nurse is reviewing the chart of a patient who is being admitted into the operating room for a laminectomy. What information obtained from the chart review should the nurse discuss with the anesthesia care provider? The patient's mother has contact dermatitis related to a latex allergy. The patient's grandmother developed hypothermia during a craniotomy. The patient's father developed a high temperature during a recent surgery. The patient's brother developed nausea after surgery with general anesthesia.
The patient's father developed a high temperature during a recent surgery.
The nurse is performing a skin assessment for an older adult patient. What finding should the nurse immediately report to the health care provider? The presence of wrinkles on the face and hands. The patient's report of dry skin that is frequently itchy. The presence of an irregularly shaped mole that the patient states is new. The presence of veins on the back of the patient's leg that are blue and tortuous.
The presence of an irregularly shaped mole that the patient states is new.
The nurse is providing care to a patient with an open abdominal wound after surgery. What teaching should the nurse provide to the patient regarding the healing process? The wound will be stapled together until it heals. The healing will contract the area to close the wound. The wound will be left open and heal from the edges inward. The wound will be sutured after the current infection is controlled.
The wound will be left open and heal from the edges inward.
The nurse is caring for a 71-kg patient during the first 12 hours after a thermal burn injury. Which outcomes indicate adequate fluid resuscitation? (Select all that apply.) Urine output is 46 mL/hr. Heart rate is 94 beats/min. Urine specific gravity is 1.040. Mean arterial pressure is 54 mm Hg. Systolic blood pressure is 88 mm Hg.
Urine output is 46 mL/hr. Heart rate is 94 beats/min.
A patient had surgery at an ambulatory surgery center. Which criteria support that this patient is ready for discharge? (Select all that apply.) Vital signs baseline or stable Minimal nausea and vomiting Wants to wait to void at home Responsible adult taking patient home Comfortable after IV opioid 15 minutes ago
Vital signs baseline or stable Minimal nausea and vomiting Responsible adult taking patient home
The nurse is caring for a patient admitted for uncontrolled seizures who also has impetigo on the face and neck. Which action is appropriate for the nurse to take? Put on a protective gown before entering the room. Wash hands for 1 to 2 minutes when leaving the room. Wear gloves to leave a diet menu on the patient's table. Wear a particulate mask when within 3 feet of the patient.
Wash hands for 1 to 2 minutes when leaving the room.
An older adult patient has been admitted before having surgery for a bilateral mastectomy and breast reconstruction. What information should the nurse include in the patient's preoperative teaching? (Select all that apply.) Various options for reconstructive surgery The risks and benefits of her particular surgery Risk factors for breast cancer and the role of screening Where in the hospital she will be taken after surgery is over How to perform postoperative deep-breathing and coughing exercises
Where in the hospital she will be taken after surgery is over How to perform postoperative deep-breathing and coughing exercises
When assessing a patient who is receiving cefazolin for the treatment of a bacterial infection, which data suggest that treatment has been effective? White blood cell (WBC) count of 8000/ìL; temperature of 101° F White blood cell (WBC) count of 4000/ìL; temperature of 100° F White blood cell (WBC) count of 8500/ìL; temperature of 98.4° F White blood cell (WBC) count of 16,500/ìL; temperature of 98.8° F
White blood cell (WBC) count of 8500/ìL; temperature of 98.4° F
