Vsim: Sarah Lin
The nurse knows Sara Lin has understood the discharge education on how to monitor her incision for signs of infection when she reports that she will monitor her incision for which of the following?
Increased drainage, redness, and swelling around the incision site.
A patient in the postoperative section of a same-day surgery center asks, "Why do you need to perform an assessment? I feel fine and am going home soon." What is the best response by the nurse?
An assessment assists with risk detection and control.
A patient reports to the emergency department with complaints of abdominal pain. After assessing the patient's pain, the nurse should complete which assessment first?
Auscultation of the abdomen
Sara Lin is a patient who had an appendectomy two days ago. Nurses caring for her are utilizing standard precautions in her care to prevent infection. The nursing student understands that, in order to meet standards, which of the following is most appropriate in the care of this patient?
Clean, nonsterile gloves should be worn if there is risk of touching blood or body fluids.
Sara Lin is a patient who had an appendectomy two days ago. The nursing assistant reports to the nurse that the patient's vital signs (blood pressure, respiration, and pulse) are all slightly elevated. What should the nurse do next?
Complete a pain assessment on the patient.
A nurse is preparing to administer 1 mg of a controlled substance via intravenous push for pain relief. The medication is available in 2 mg syringes. What should the nurse do with the extra medication?
Dispose of the extra 1 mg with a second nurse as witness and both nurses document it.
A patient who is in intense pain expresses concern about taking oxycodone hydrochloride tablets. What is the best response by the nurse?
Explain that the medication will likely provide the best relief for the patient's pain.
The nurse notices that the patient who had surgery earlier in the day is now pale and restless with low blood pressure, tachycardia, and tachypnea. What is the nurse's priority action based on these findings?
Notify the provider of assessment findings immediately.
A postoperative patient begins to complain of pain, redness, and swelling in her left calf. What should the nurse do for the patient?
Notify the surgeon immediately.
A nurse notes that there are two patients on the unit who are prescribed different medications with similar sounding names. The patients are assigned to different nurses. The nurse knows medication administration safety will be enhanced by which of the following?
Preparing medication using three checks
A nurse rounding on a patient in the postanesthesia recovery unit notices the bandage covering the incision site shows evidence of bleeding through the dressing. What is the priority action that the nurse should take?
Reinforce the dressing.
A nurse is caring for a patient who had an appendectomy. The patient is having difficulty breathing, is nauseated, and does not want to use the incentive spirometer because it hurts the incision. What is the nurse's priority intervention at this time?
Reposition the patient in bed to improve breathing.
A patient appears restless, and is grimacing and moaning after surgery. The patient denies the need for pain medication at this time. What is the best response by the nurse?
Teach the patient about the importance of effective pain management.
The nurse received an order for a postoperative patient in an acute care facility. The order stated: Morphine, 1-6 mg IV every 2 hours as needed for pain. What should the nurse question about this order?
The medication range of 1-6 mg
A patient is at the hospital being prepared for a surgical procedure. Which of the following is a priority for the nurse to teach at this time?
The plan for assessing and treating postoperative pain
Which of the following postoperative assessments should have been completed when Sara Lin arrived on inpatient after surgery? (Select all that apply.)
● Assessment of the surgical site ● Vital signs and oxygen saturation ● Type, amount, and flow rate of intravenous fluids ● Orientation to time, place, and person
Sara Lin is concerned about pain management when she transitions to oral pain medication. What should the nurse include in the teaching? (Select all that apply.)
● PRN medications are given as needed. ● Please ask for pain medications before the pain is severe. ● You can use complementary therapy in conjunction with pain medication.
A nurse is caring for a cognitively impaired nonverbal patient on a medical-surgical unit. In what ways should the nurse assess the patient's pain? (Select all that apply.)
● The behavioral pain scale ● Nonverbal pain assessment tool ● A pain estimate made by a family member
