nursing 300 test 1
normal creatinine level
0.6-1.2
NPO
12 hours before surgery(give or take) prevents aspiration during surgery
normal sodium level
135-145
normal hemoglobin levels
W:12-16 M:14-18
fluid levels are influenced by
age gender weight
hypernatremia causes
dehydration enteral feeding with no water flushes diarrhea burns
dressing and grooming
gown, hair cap
hypochloremia management
correct underlying cause
hyperchloremia managment
correct underlying issue
As the nurse assists the postoperative client out of bed, the client reports having gas pains in the abdomen. To reduce this discomfort, what should the nurse do?
encourage the patient to ambulate
hypochloremia assessments
i/o abgs electrolytes LOC muscle strength and movement
hyponatremia assessment
i/o daily weight neuro checks monitor labs
hypokalemia assessment
i/o kidney function cardiac monitoring musculoskeletal respiratory GI
hypocalcemia causes
inadequate calcium intake acute pancreatitis medications decrease in vit d high phosphorous levels
post op pain control
most severe 24-48 hours postop opioid medications treat pain early use same scale, establish goal, observe behaviors oral pain meds when oral intake is tolerate, iv for breakthru pain assess and treat side effects
normal potassium level
3.5-5.0
normal hematocrit levels
36-48
When conducting the preoperative preparations, the nurse determines that the client does not speak English, and the nurse does not speak the client's language. The surgeon needs to obtain the client's informed consent. What is the best way for the nurse to obtain the client's informed consent?
Call the Spanish interpreter to translate the surgeon's explanation of the procedure, risks, and alternatives to obtain the client's consent and to answer the client's questions.
A client in a general hospital is to undergo surgery in 2 days and is experiencing moderate anxiety about the procedure and its outcome. What should the nurse do to help the client reduce anxiety?
Explain the surgical procedure to the client and what happens before and after surgery.
hypophosphatemia assessment
GI function muscle weakness cardiac and resp function
variables affecting surgical outcomes
age, nutritional status, lifestyle choices, chronic medical conditions, medications
hypernatremia manifestations
big and bloated skin:red and rosy, edema, low grade fever polydipsia (thirst) late serious signs:swollen dry tongue, nausea and vomiting, increased muscle tone
A client is in hypovolemic shock. To determine the effectiveness of fluid replacement therapy, the nurse should monitor the client's
blood pressure
sodium main functions
blood pressure blood volume ph balance
hyperphosphatemia assessment
bones blood heart
A client with chronic kidney disease (CKD) has a blood urea nitrogen (BUN) of 100 mg/dL, serum creatinine of 6.5 mg/dL, potassium of 6.1 mEq/L, and lethargy. What is the priority nursing assessment?
cardiac rhythm
what causes hypervolemia
caused by: fluid overload, heart failure, renal failure, cirrhosis, excessive salt intake
After abdominal surgery, a client is reluctant to turn in bed. The nurse should:
explain importance of turning to patient
main function of potassium
heart and muscle
intraoperative phase
holding room: skin prep, IV fluids/medications positioning patient to prevent injury/ensure safety
regional anesthesia
loss of sensations to region without loss of consciousness blocks specific nerve or group of nerves admin via spinal block, epidural or peripheral nerve block
how do lungs help w fluid regulation
remove 400mL of water per day thru expiration
The nurse administered morphine IV to a client after a cholecystectomy one hour ago. The nurse should contact the healthcare provider based on what assessment finding?
respiratory rate 8 breaths/min
management of hyperkalemia
restriction diet and K meds medications as ordered: kayexalate, calcium gluconate (immediately for heart), sodium bicarb, reg insulin, diuretic (loop), dialysis
what is hypervolemia what are some characteristics
retention of sodium and water in ECF moon face edema moist cough crackles distended jugular bounding pulses no appetite
how does pituitary gland regulate fluids
stores anti-diuretic hormone (ADH) regulates volume and osmolarity
hypercalcemia manifestations
swollen and slow constipation bone pain renal calculi decreased DTR severe muscle weakness
hypermagnesemia assessment
vitals cardiac and resp status DTR neuro checks
The expected outcome of withholding food and fluids from a client who will receive general anesthesia is to help prevent:
vomiting and potential aspiration during surgery
postop day 2&3 infection
water: remove cath? cauti? iv site, UTI
The registered nurse (RN) is assigned a client with stomach cancer, who has just returned from a subtotal gastrectomy. Which nursing interventions would be delegated to either a licensed practical/vocational nurse (LPN/VN) or a nursing assistant/unregistered healthcare worker (UHW)? Select all that apply.
• Document intake and output in the electronic medical record. • Reinforce tape over an abdominal incision. • Provide report for the next shift.
When administering IV replacement of 5% dextrose in water with potassium chloride, what should the nurse do first?
• Evaluate laboratory results for electrolytes.
The nurse is assigned to care for five clients. Which could be assigned by the nurse to the unlicensed assistive personnel (UAP)? Select all that apply.
• a client post-operative appendectomy with BP 110/80 mm Hg, pulse 84 bpm • a client scheduled for cataract surgery with BP 134/78 mm Hg, pulse 70 bpm
For the client who is receiving intravenous magnesium sulfate for severe preeclampsia, which assessment findings would alert the nurse to suspect hypermagnesemia?
• decreased deep tendon reflexes
skin
CHG baths, prevents infection
hyperchloremia causes
hypernatermia bicarb loss meabolic acidosis
hyperphosphatemia causes
low calcium renal failure diabetic ketoacidosis metabolic resp acidosis
diffusion
natural tendency of substance to move from area of higher to lower concentration
hypermagnesemia causes
renal failure diabetic ketoacidosis
how does adrenal gland regulate fluids
secretes aldosterone increase or decrease urinartion
how does skin help w fluid regulation
sensible perspiration (0-100 ml/day) insensible perspiration (fever burns etc) 600ml/day
hypocalcemia management
slow iv calcium vit d diet meds exercise
A nurse is reviewing a client's laboratory test results. Which electrolyte is the major cation controlling a client's extracellular fluid (ECF) osmolality?
sodium
hyperkalemia s/s
>5.0 tight and contracted hypotension bradycardia Vfib or cardiac standstill diarrhea hyperactive bowel sounds paralysis in extremities increased deep tendon reflexes profound muscle weakness MEDICAL EMERGENCY bc of cardiac effect
Which symptom is an early indication that the client's serum potassium level is below normal?
muscle weakness in legs
potassium is excreted thru
kidneys
isotonic
sodium and water leaving in same proportions treat with isotonic solution
When the nurse asks the client who is having abdominal surgery today if the client understands the procedure, the client replies, "No, not really; I talked about several different things with my surgeon, and I'm just not sure." What should the nurse do next?
notify the surgeon of the lack of understanding
normal platelet levels
140-440
normal bands level
3-5
pH of blood
7.35-7.45
normal glucose level
70-100
Which finding is an example of a variance in the critical pathway of a client 3 days after an above-the-knee amputation?
• Temperature of 102° F (38.9°C)
A client with an I.V. of normal saline at 150 mL/hour reports dyspnea and restlessness. What is the priority nursing action?
asses lung sounds
hypomagnesemia assessments
assess cardiac function DTR swallowing*
chloride main functions
blood volume blood pressure ph balance always follows sodium and does what sodium does
prostheses and belongings
dentures out, jewelry off, contacts out, lock it up
hypernatremia managment
hypotonic or isotonic non saline
normal INR level
less than 1.2 cumadin specific
hyperchloremia assessment
monitor vials ABGs (arterial blood gasses) i/o
hypercalcemia assessment
bowels pain weakness mobility
sanguineous drainage
bright red, indicates active bleed
hypermagnesemia manifestations
calm and quiet hypotension bradycardia hyporeflexia (decreased dtr) shallow respirations hypoactive bowel sounds
volume expansion
can be hypo hyper or isotonic treat w diuretics
1 L of fluid is
2lb weight gain
normal aPTT level
30-40 sec heparin specific
Normal WBC count
4000-11000 abnormal= stress, inflammation, infection
hupophosphatemia management
prevention
postop day 1&2 infection
wind- respiratory infections IS and cough and deep breathe
The nurse is reviewing laboratory data for a client with pancreatic cancer. Which finding does the nurse prioritize as requiring notification of the healthcare provider?
• potassium: 2.2 mEq/L (2.2 mmol/L)
Which outcome is expected for a client who has undergone surgical repair of an inguinal hernia?
The client will verbalize understanding of instructions to avoid lifting for 2 to 6 weeks after surgery.
A 7-year-old has had an appendectomy on November 12. He has had pain for the last 24 hours. There is a prescription to administer acetaminophen with codeine every 3 to 4 hours as needed. The nurse is beginning the shift, and the child is requesting pain medication. The nurse reviews the chart below for pain history. Based on the information in the medical record, what should the nurse do next?
administer meds
hypomagnesemia causes
alc withdrawal * nasogastric suction diarrhea tube feeding diabetic ketoacidosis
preop phase
all care before entering OR nursing goals- inform and educate, reduce anxiety, decrease risk of complications assessment: health history, preop tests and labs, client education, consent
hypochloremia causes
alteration in acid base balance
hyponatermia management
based on why neurologic symptoms edema
phosphorus functions
bone and teeth formation helo regulate calcium calcium high=phos low calcium low=phos high
calcium funcions
bones blood (clotting) heart transmits nerve impulses inverse relation to phosophorous
assessment of hyperkalemia
cardiac muscle weakness labs
surgical team
circulating nurse: manages OR conditions, verifies consent is complete, monitors aseptic practices scrub nurse: preps hand scrub, sets up sterile tables, preps sutures and special equipment, counts all products nurse 1st assistant: handles tissues, provides exposure site, sutures, maintain hemostasis
serous drainage
clear watery plasma
post op phase
completion of procedure thru transfer or discharge takes place in PACU nursing care focused on ensuring stability or patient keep family informed of status or changes ABCs frequent vitals, focused assesment, pain control
osmolarity
concentration of solutes
hyponatremia causes
depressed and deflated seizures and coma tachycardia and weak thready pulses respiratory arrest* diarrhea diuretics GI suctioning heart failure cirrhosis excessive water intake
The nurse is caring for an infant with severe diarrhea that has lasted 3 days. The child has poor skin turgor and dry mucous membranes. What is the priority nursing diagnosis for the nurse to use when planning care for this child?
fluid volume deficit
preop medications
give 30-60 min before given for comfort and control common side effects increases effectiveness of anesthetic safety concers: dont get out of bed, stay w patient, quiet, fall risk
The nurse is assessing a client who is restless and agitated, has dry mucous membranes, and has intense thirst. The nurse should assess the client further for which electrolyte imbalance?
hypernatrimia
types of drains
penrose JP hemovac wound vac abscess drain ttube NG tube always assess and interventions
hypernatremia assessments
i/o vital signs neurological (confused, altered LOC bc brain dehydrated) fluid intake
causes of hypovolemia
inadequate intake vomiting diarrhea GI suctioning hemorrhage third spacing diabetes
informed consent
includes procedure and outcomes, risks, pt needs to have a clear understanding and repeat in own words
hypervolemia labs
labs: BUN increased urine sodium increased pulmonary congestion
management of hypokalemia
oral replacement IV replacement diet
When admitting an elderly client for nausea and vomiting that has lasted for 3 days, the nurse should assess for which clinical findings?
poor skin turgor
hypophosphatemia causes
protein calorie malnutrition
manifestations of hypovolemia
rapid weight loss decreased skin turgor oliguria (less than 30 ml/hr) concentrated urine postural hypotension tachycardia cool clammy skin dry mucous membranes altered LOC
how do kidneys regulate fluids
regulates vol and osmolarity regulate electrolyte in ECF regulate PH in ECF excretion of metabolic waste and toxic substances 170L of plasma filtered per day 1.5L of urine excrete per day
filtration
separation of liquid from undissolved particles floating in it
A client is placed on hypocalcemia precautions after removal of the parathyroid gland for cancer. The nurse should observe the client for which symptoms? Select all that apply.
• numbness • tingling • muscle twitching and spasms
The nurse is caring for a 3-year-old child with acute kidney injury. Which laboratory finding should the nurse immediately report to the healthcare provider?
• potassium level of 6.5 mEq/L (6.5 mmol/L)
hypervolemia interventions
interventions: admin diuretics, sodium restrictions, fluid restrictions, hemodialysis. teach diet. prevent
serosanguinous drainage
pale red water mix of serous and sanguinous
In an industrial accident, a client who weighs 155 lb (70 kg) sustained full-thickness burns over 40% of their body. The client is in the burn unit receiving fluid resuscitation. Which finding shows that the fluid resuscitation is benefiting the client?
• a urine output consistently above 40 ml/hour (40 mL/hour)
A client has undergone a left hemicolectomy for bowel cancer. Which activities prevent the occurrence of postoperative pneumonia in this client?
Coughing, breathing deeply, frequent repositioning, and using an incentive spirometer
The nurse has reinforced a pressure dressing on a client who is postoperative mastectomy and notes there is considerable sanguineous drainage in the hemovac. Which assessments should the nurse report to the physician? Select all that apply.
• blood pressure 86/50 mm Hg; pulse weak and thready at 120 bpm • fever of 102 degrees F, no urine output for 2 hours
A client is 2 hours postoperative after an appendectomy. The nurse recognizes a priority is to teach the client potential pulmonary postoperative complications. What action by the client demonstrates understanding of the teaching?
• diaphragmatic breathing and use of incentive spirometry 4-8 times an hour while awake
A client is diagnosed with left-sided heart failure. Which treatment should the nurse anticipate being prescribed to reduce this client's excess fluid?
diuretics
other post op nursing care
activity: purpose, restrictions, safety nutrision: promote ehaling, specific foods pain control: pharmacologic, nonpharm client edu: s/s infection, wound care, complications, when to call, restrictions, followup care
general anesthesia
acts on CNS causes loss of conciousness, sensation reflexes pain perception and memory pt cannot: be aroused or maintain own airway/breathing given inhaled or IV given by anesthesiologist of CRNA meds given to reverse effects at end
hypervolemia assessments
assess: i/o, weight daily, lung sounds, edema
hypocalcemia assessment
bones weak blood bleeding precautions beats dysrythmia
A client who is 12 hours post total thyroidectomy reports tingling around the mouth. Which assessment is the priority?
calcium level
magnesium fuctions
calming effect on muscle heart uterus DTR calcium and vit d absorption
A client with Addison's disease has fluid and electrolyte loss due to inadequate fluid intake and to fluid loss secondary to inadequate adrenal hormone secretion. As the client's oral intake increases, which fluids would be most appropriate?
chicken broth and juice
A nurse is caring for a client who just had an appendectomy. The client is receiving opioid analgesics routinely for pain. The nurse should focus the follow-up assessment on which complication?
constipation
time out
correct patient, procedure, and site informed consent signed identify any concerns
hypomagnesemia managment
diet oral meds slow iv admin
hypermagnesemia managment
discontinue all mag administer antiacids admin loop diretic if renal function allows dialysis
Upon waking up in the postanesthesia care unit and seeing a drain with bright red fluid in it exiting from his total hip incision, a client asks the nurse, "Is this the way it's supposed to be?" What should the nurse tell the client?
drainage is what needs to be drained out for healing
moderate sedation
drug induced depression of consciousness pt can: maintain airway, respond to verbal commands, faster recovery combination of sedative and opioid can be administered by RN continuous monitoring of vitals ECG O2 responsiveness
A client who had an exploratory laparotomy 3 days ago has a white blood cell (WBC) differential with a shift to the left. The nurse instructs unlicensed assistive personnel (UAP) to report which clinical manifestation of this laboratory report?
elevated temp
epidural anesthesia
epidural: injection into epidural space (thoracic or lumbar), low dose blocks sensory pathway only, high dose blocks motor&sensory can cause hypotension decreased incidence of heart attack can be continuous or 1 hr injection larger needle use increases risk of complications if dura is punctured punctured dura leads to collapse of cardiac system
A client with chronic renal failure is admitted with a heart rate of 122 beats/minute, a respiratory rate of 32 breaths/minute, a blood pressure of 190/110 mm Hg, jugular vein distention, and bibasilar crackles. Which nursing diagnosis takes highest priority for this client?
excess fluid volume
On the third day after a partial thyroidectomy, a client exhibits muscle twitching and hyperirritability of the nervous system. When questioned, the client reports numbness and tingling of the mouth and fingertips. Suspecting a life-threatening electrolyte disturbance, the nurse notifies the surgeon immediately. Which electrolyte disturbance most commonly follows thyroid surgery?
hypocalcemia
A physician orders a loop diuretic for a client. When administering this drug, the nurse anticipates that the client may develop which electrolyte imbalance?
hypokalemia
delayed complications: DVT and PE
immobility contributes to stasis of blood flow inflammation and tissue damage from surgery promote cot formation clots break free from veins in lower extremities and become lodged in pulm veins (PE) Risks: immobility, smoking, BC, increased platelets, surgery, family hx, lack of edu, dehydration Assessment: resp changes, low o2, tachycardia, anxious feeling, SOB, chest pain, doppler (DVT), redness warmth pain edema, med hx, mobility level, labs- INR aPTT Interventions:scds, ted hose, walking, ROM, hydration, nutition, medication-heparin (aPTT levels), pain meds, Evaluation:RT, pain assessment, skin assesment, labs, doppler, reassess education/understanding
A client is to have a below-the-knee amputation. Prior to the surgery, what should the circulating nurse in the operating room do?
initiate time out
spinal anesthesia
injected into subarachnoid space effective below injection site autonomic block: vasodialation, hypotention, bradycardia sensory&motor block: can affect diaphragm when block is too high: respiratory complications spinal headache: CSF leaks from puncture site, relieved by lying flat, decreased by using smaller needle, blood block
A physician orders an isotonic I.V. solution for a client. Which solution should the nurse plan to administer?
lactated ringers
how does GI tract regulate fluids
lose 100ml/day w 8 L of fluid circulating daily
what is hypovolemia
loss of ECF volume exceeds intake of fluid water and electrolytes both lost in same proportions
local anesthesia
loss of sensation without loss of consciousness given topically of injection minor procedures
hypotonic
loss of sodium exceeds loos of water treat with isotonic of hypertonic
hypertonic
loss of water exceeds loss of sodium treat with hypotonic fluid
hypokalemia s/s
low and slow flat t waves st depression and prominent u wave decreased DTR muscle cramping flaccid paralysis decreased motility constipation abdominal distension paralytic ileus hypotension and bradycardia
A nurse administers furosemide to treat a client with heart failure. Which adverse effect must the nurse watch for most carefully?
low serum potassium
infection and temp day of surgery
lower temp than normal
hypercalcemia causes
malignancy hyperparathyroidism immobilizaion
The nurse notes that a client with acute pancreatitis occasionally experiences muscle twitching and jerking. How should the nurse interpret the significance of these symptoms?
may be developing hypocalcemia
A client is receiving a bowel preparation of magnesium citrate the evening before a scheduled colonoscopy. Which factor should the nurse consider when providing care for this client?
may require fluid and electrolyte replacement
delayed complications: N&V consitpation and paralytic ileus
medications cause n&v slow peristalsis and lead to immobility increases risk of GI complications preop bowel prep and NPO status delay return of BS passage of gas and BM paralytic ileus is result of absence of peristalsis causing distension n&v and pain risks: pain meds, anesthesia, dehydration, malnutrition (low fiber diet), age Assessment: hypoactive bowel sounds, assess meds (side effects), assess i/o's, last BM, distention, diet, abdominal assessment (palpate, auscultate, peristalsis) Interventions: increase fiber intake, increase fluids, administer mirolax or other stool softener, look at medications to switch or decrease dose, CAT scan/xray, walk, i/o's, enema Evaluation: frequency, color, form, bowel sounds, abdominal appearance, hydration status and diet, medication frequency, ambulate Listen 5 min if no bowel sounds
delayed complications: urinary retention and acute renal failure
medications used during surgery and after decreased sensation prolonged hypotension decreases blood flow to kidneys state of hypovolemia will decrease the amount of urine produced Risks: medications, opioids, anesthesa, age, kidney disease, bladder infection, prostate cancer, trauma, Post Partum Assessment: monitor i/o's, bladder scan (>100mL), UA, distention, health hx Intervention: retrain bladder every 2 hours, straight cath, bladder scan, void within 8 hours of pulling catheter, education Evaluation: increased output, empty bladder on scan, clear UA, decreased/no distention, decreased/no pain Creatinine BUN GFR labs
delayed complications: atelectasis and pneumonia
meds depress resp function immobility limits lung expansion secretions become thicker and drier fluid collects in lungs pain inhibits coughing and deep breather Risks: obesity, immunocomprimised, lack of movement, copd, asthma, heart failure, aspiration, opioid use Assessment: crackles, wheezing, diminished lunch sounds, low O2, low resp rate, labs-wbc, chest xray, sputum, retractions/weak (cough), blood sugars-related to steroids Interventions: incentive spirometer, o2, breathing treatments, suction, increase mobility, antibiotics, steroids, HOB >30, education Evaluation: clear lung sounds, improved vitals, improved mobility, no further infection, education teach back
A client reports occasional numbness in the fingers and lips. Which of the following dietary choices should the nurse encourage the client eat?
milk products
hypophosphatemia manifestations
moans groans and stones consitpation decreased DTR severe mucle weakness decrease HR and respiratory rate increased blood pressure
active transport
movement of molecules across a membrane low to high concentration in direction against concentration gradient
osmosis
movement of water caused by concentration gradient low to high
A client who has been taking furosemide has a serum potassium level of 3.2 mEq/L. Which assessment findings by the nurse would confirm an electrolyte imbalance?
muscle weakness and weak thready pulse
hyperchloremia manifestations
nearly same as high sodium n&v swollen dry tongue confusion
hypochloremia manifestatiosn
nearly same as low sodium excessive diarrhea vomiting sweating fever (only dif)
adjunct to general anesthesia
opioids used to maintain anesthesia. analgesia during surgery, improve post op pain, can combine diff opioids can depress respers ie: fentynal morphine hydromorphone antedote: narcan benzos induce and maintain anesthesia, large doses produce unconsciousness, amnesic effect, supplemental sedation potentiates effects of opiods, resp depression, hypotension, no analgesic propertics ie: midazolam, diazepam antidote: flumazoril
hypomagnesemia manifestations
opposite of calm and quiet tachycardic v fib hyperflexia abnormal eye movement diarrhea
assessments for hypovolemia
oral fluids IV fluids, lactated ringers, isotonic rate and volume based on volume loss and hemodynamics
During a follow-up visit to the physician, a client with hyperparathyroidism asks the nurse to explain the physiology of the parathyroid glands. The nurse states that these glands produce parathyroid hormone (PTH). PTH maintains the balance between calcium and
phosphorus
delayed complications: infection and non healing wounds
preexisting conditions increase risk of complications strains on suture lines can reopen the surgical wound: dehiscence evisceration: bowel protrudes thru open wound delayed treatment, traumatic injuries and previously infected wounds at higher risk Infection Risk: wound, foley, Iv lines, nutritional status, high glucose, immunosuppressive med, low WBC, poor hygiene, increase hospital stay, lifestyle, age, chronic illness, length of surgery, dehiscence, evisceration, diabetes, Assessment: cbc-wbc, vitals-high temp, pain, redness swelling drainage, odor, skin in tact, diet, Interventions: hand hygiene, preop antibiotic, dressing changes and wound care, balanced diet, educate, foley care early removal, Evaluation: improvement of area, LOC, vitals, WBC, pain level Delayed wound healing: Risk: diabetes, nutrition, positioning, LOC, smoker, age, attitude/mentality, lack of edu, lack of resources, mobility, Assessment: size, color, skin, labs, mobility, drainage Interventions: turning, dressing change, wound care consult, hygiene, wound vac, hydration Evaluation: decreased pain, decreased drainage, decreased size, improved labs
purulent drainge
thick yellow green tan brown
hyperphophatemia management
treat underlying cause
hypercalcemia management
treat underlying cause increase mobility encourage fluids encourage fiber calcitonin dialysis
hyperphosphatemia manifestations
trousseasus sign chvosteks sign dirrhea weak bone blood and beats
hypocalcemia manifestations
trousseaus sign (hand cramp) chvosteks sign (facial nerve) diarrhea circumoral tingling (around mouth)
A nurse is caring for a client with severe burns and receiving fluid resuscitation. Which finding indicates that the client is responding to the fluid resuscitation?
urine output of 30mL/hr
post op nursing care
vitals every 5-15 min, hypothermia respers: depth, rate, effort, O2 stats cardiac: pulse rate and strength, hypotension neuro: LOC motor/sensation complications: hypoxia, hemorrhage hypovolemia control symptoms: pain, n&v discharge pacu: stable vs, orientedx4, pulmonary and cardiac function, spo2 above 90, symptoms controlled
A client is admitted on the day of surgery for an arthroscopy of the left knee. Which nursing activities should be completed prior to administering anesthesia to the client to avoid wrong-site surgery? Select all that apply.
• Verify that the surgeon has marked with a permanent marker the correct knee for the surgical site. • Verbally ask the client to state his or her name, surgical site, and procedure. • Verify the correct client with the correct operative site from medical records and diagnostic reports. • Call a "time-out" in the operating room to have the surgeon verify the correct knee before making the incision.
post op day 4&5+ infection
wound: surgical wound infection
normal neutrophil levels
50-70
A nurse is caring for a client with a postoperative wound evisceration. Which action should the nurse perform first?
Cover the protruding internal organs with sterile gauze, moistened with sterile saline solution.
The nurse is caring for a 5-year-old child who had a hernia repair 1 day ago. The child is vomiting, has a nasogastric (NG) tube to low intermittent suction, and has diarrhea. Which of the following laboratory results would be the immediate priority for the nurse to assess?
potassium level
A client who had transurethral resection of the prostate has dribbling urine after his Foley catheter is removed on the second postoperative day. The nurse notes that the client had 200 mL of urine output in the last 8 hours with a 1,000-mL intake. What should the nurse do first?
assess for bladder distention
A client with acute renal failure has a serum potassium level of 6.5 mEq/L (6.5 mmol/L). The nurse should monitor the client for which potential complication?
cardiac arrest
The nurse is assessing a client's abdominal incision 48 hours after surgery. Which finding indicates that the wound is inflamed?
• Localized warmth over the incisional area.
purpose of surgery
diagnostic- biopsy curative- appendix removal palliative-rid of pain cosmetic-facelift preventative-mole removal for skin cancer
A client is scheduled to have surgery to relieve an intestinal obstruction. Prior to surgery, the nurse should verify that the client has followed which preoperative instructions?
discontinue use of blood thinners
The nurse is taking a nursing history from a client prior to surgery. Which information in the client's history would have a significant impact on the client's recovery postoperatively? The client:
has smoked 1 pack of cigarettes a day for 12 years.
bowel prep
helps with visability
A client with cirrhosis begins to develop ascites. Spironolactone is prescribed to treat the ascites. The nurse should monitor the client closely for which drug-related adverse effect?
hyperkalemia
A client has had an exacerbation of ulcerative colitis with cramping and diarrhea persisting longer than 1 week. The nurse should assess the client for which complication?
hypokalemia
A multigravid client thought to be at 14 weeks' gestation reports that she is experiencing such severe morning sickness that she "has not been able to keep anything down for a week." The nurse should assess for signs and symptoms of which condition?
hypokalemia
Which nursing intervention is the highest priority during the first 24 hours postoperatively for the client who had a total laryngectomy due to cancer of the larynx?
keep airway open
The nurse is caring for a client postoperatively who received an inhalation anesthetic during GI surgery. The client complains of being very cold and is shivering. The nurse provides extra blankets. What additional intervention is needed?
provide oxygen as ordered
A nurse completes preoperative teaching for a client scheduled for a cholecystectomy. The client states, "If I lie still and avoid turning, I will avoid pain. Do you think this is a good idea?" What is the nurse's best response?
• "Turn from side to side every 2 hours, and the nurse will administer pain medication to assist in movement."
Which of the following statements heard during shift report identifies an important priority for action?
• A postoperative client's pulse has been increasing, and the blood pressure is decreasing.
A complete blood count is commonly performed before a client goes into surgery. What does this test seek to identify?
• Abnormally low hematocrit (HCT) and hemoglobin (Hb) levels
The nurse is providing preoperative instructions to a client who is deaf. Which strategy is most effective in assuring that the client understands the information?
• Give the client written material to read, and follow up with time for questions.
A nurse is caring for a client who had a thyroidectomy and is at risk for hypocalcemia. What should the nurse do?
• Observe for muscle twitching and numbness or tingling of the lips, fingers, and toes.
normal BUN level
6-20
A client has been experiencing abdominal cramps, diarrhea, and concentrated urine for the past 2 days. Which signs would be included in a focused assessment?
• signs of dehydration, including loss of weight; poor tissue turgor; and dry, cracked mucous membranes
The nurse is caring for a client who had an open cholecystectomy 24 hours ago. The client's vital signs have been stable over the last 24 hours, with most recent temperature 98.6°F (37°C), blood pressure (BP) 118/76 mm Hg, respiratory rate (RR) 16 breaths/minute, and heart rate (HR) 78 bpm, but these signs are now changing. Which set of vital signs indicates that the nurse should contact the health care provider (HCP)?
• temperature 101.8° F (38.8° C), BP 140/86 mm Hg, HR 94 bpm, RR 24 breaths/min Explanation: This client is exhibiting signs of sepsis, and the nurse should notify the health care provider. The client has three signs indicating sepsis: temperature >101.0°F (38.3°C) (or <96.8°F [36°C]), HR >90 bpm, and RR >20 breaths/min. At least two of these variables are required to diagnose sepsis
A client has a serum calcium level of 7.2 mg/dl (1.8 mmol/L). During the physical examination, the nurse expects to assess
• Trousseau's sign.
A client who is 1 day postoperative is using a morphine patient-controlled analgesia (PCA) pump. The client is confused and disoriented. What is the priority intervention by the nurse?
• Check respiratory rate and depth as well as oxygen saturation levels.
The nurse is working with a licensed practical nurse (LPN) and delegating the taking of vital signs for a preoperative client. Upon review of the chart as the client is leaving for the operating room, the nurse notes that the temperature is 101.1°F (38.4°C) and the pulse is 110 bpm. What are the nurse's initial actions?
• Notify the surgeon and await the surgeon's decision; reinforce with the LPN the importance of reporting abnormal preoperative vital signs.
A client had surgery for a bowel obstruction 4 days ago. The nurse assesses that the client has not passed any flatus, and there are no bowel sounds. Even though the abdomen has become more distended, the client feels little discomfort. In considering the plan of care, what is the most appropriate first step for the nurse to take?
• Obtain an order for nasogastric tube insertion.
The nurse is caring for a client who is post-operative cholecystectomy. When assessing the respiratory status after general anesthesia, which of the following clinical findings would the nurse view as a concern? Select all that apply.
• PAO2 of 76 mm Hg • cyanosis around the mouth and fingertips
A nurse is administering 50 mEq potassium chloride (KCl) in 250 mL 0.9 normal saline (NS) intravenously piggyback (I.V.PB) to a client with hypokalemia. Which action should the nurse take?
• Provide continuous cardiac monitoring during the infusion.
A client is receiving chemotherapy to treat breast cancer. Which assessment finding indicates a chemotherapy-induced complication?
• Serum potassium level of [2.6 mEq/L (2.6 mmol/L)}
The surgeon prescribes cefazolin 1 g to be given IV at 0730 when the client's surgery is scheduled at 0800. What is the primary reason to start the antibiotic exactly at 0730?
• The antibiotic is most effective in preventing infection if it is given 30 to 60 minutes before the operative incision is made.
A 250-lb (113-kg) male client is recovering from general anesthesia. The client's vital signs are: pulse, 150 bpm; blood pressure, 90/50 mm Hg; respiratory rate, 28 breaths/min; tympanic temperature, 99.8°F (37.7°C); The client has rigid muscles. How should the nurse interpret these findings?
• The client is in the early stages of malignant hyperthermia; the nurse should obtain emergency medications and notify the anesthesiologist. Explanation: A heart rate of 150 bpm or greater, hypotension, and muscle rigidity are early signs of malignant hyperthermia. The nurse should quickly assemble emergency supplies and personnel because malignant hyperthermia is potentially and rapidly fatal in more than 50% of cases. Rapid, extreme rise in temperature is a late sign. Another factor influencing the analysis is that the client has a large body frame, and having large, bulky muscles is a risk factor for malignant hyperthermia. The client's vital signs are well out of the range of normal; analysis of the data and swift intervention are indicated. Excessive blood loss is unlikely, and the data do not support this conclusion. Although clients do have changes in vital signs when in acute pain, the nurse would expect the client to be hypertensive, not hypotensive.
A client is in the operating room having surgery to replace a hip. Prior to starting the surgery, there is confusion about the view of the hip on the X-ray The surgical team requests a "time out" and stops the surgery. When can surgery continue? Select all that apply.
• The surgeon verifies the correct procedure. • The surgeon verifies correct surgical site. • The surgical team identifies the client using two sources of identification.
The nurse is evaluating the effectiveness of fluid resuscitation during the emergency period of burn management. Which finding indicates that adequate fluid replacement has been achieved?
• The urine output is greater than 35 mL/h.
A nurse is caring for a client with chronic renal failure. The laboratory results indicate hypocalcemia and hyperphosphatemia. When assessing the client, the nurse would be alert for which signs and symptoms? Select all that apply.
• Trousseau's sign • cardiac arrhythmias • fractures
