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76 terms

Final Exam 3

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the clients surgery has been delayed due to hyperkalemia, the client asks why, what is the nurses best response
by making sure your potassium level is normal before surgery, your heart will beat strong and regular during your surgery
nursing is caring for a client who will be undergoing emergency surgery what information is most important for the nurse to teach the client at the time
what to expect in the operating room recovery complications that may occur after surgery
the preoperative client tells the nurse that he has advanced directive a durable power of attorney the client asks how how the advance directive will effect his surgery what is the nurses best response
if you are unable to make a decision your signee will be asked
a client is brought to the hospital unconscious and needs emergency surgery the clients only family member cannot come to the hospital before the surgery which is the best option for obtaining informed consent for the clients emergency surgery
contact the family member by phone and obtain verbal consent with 2 witnesses
the nurse is performing preoperative teaching for the client who will be having sinus surgery the following day, which is an accurate statement for the nurse to include in preoperative teaching
you may take your digoxin in the morning with a small sip of water
the nurse is preparing to transfer a client to the OR for surgery and the client has already received preoperative medications and is becoming drowsy what is best method to verify the clients identity
check the clients medical record # and name with the chart, and id band
the nurse is caring for a client who will be having surgery on his right knee, what is the best method ensure the surgery is performed on the correct knee
have the surgeon and the client mark a yes and their initials on the knee to be operated on
the nurse is connecting a preoperative assessment for a client who will be having surgery in a few days, the client is at high risk for developing a DVT postoperatively. Which client is at high risk for developing DVT
client undergoing hip replacement surgery
Nurse applies antiembolism stockings to a preoperative client who complains that the hose are uncomfortable and he wishes to have them removed, what is the nurses best response
this will only be on your legs during the surgery and will be removed in the recovery room
Scrub nurse is observing the nursing student who will be shadowing in the OR which observed action indicates that the nursing student is performing the surgical scrub correctly
the surgical mask is put on before surgical scrub
the nurse anesthetist is caring for a client who is under general anesthesia the nurse notes the client is becoming tachycardia and the clients oxygen saturation is dropping which medication should the nurse anesthetist prepare to administer
Dantrolene Sodium and Sodium bicarb
client is having epidural anesthesia for knee replacement surgery which action will the highest priority for the nurse anesthetist during the clients surgery
monitor the respiratory rate and depth
circulating nurse is observing a new scrub nurse as she sets up the sterile field for the surgical equipment, which of the following action indicates that the scrub nurse needs additional teaching about a sterile technique
a sterile saline bottle cap is placed in the center of a sterile field
surgery is almost completed for the client and the surgeon prepares to close a large abdominal incision what will the scrub nurse prepare to do
hand the skin sutures or the staples to the surgeon
the client asks the nurse why is it best better to have a spinal anesthesia for knee surgery rather than being put to sleep which is the nurses best response
you have less risk of developing pneumonia after surgery
before the nurse brings a client to the operating room for knee surgery the client reports to the nurse that he did not initial the operative knee with the surgeon what is the priority acton
the surgeon together with the client needs to mark the site and initial it
the nurse is preparing to bring a young female client to the operating room for a total abdominal hysterectomy, the client says to the nurse i am so glad that i will still be able to have children after the surgery what is the nurses best response
i will call the surgeon to speak with you before i bring you to the operating room
the client is being positioned on the operating bed for spinal surgery after general anesthesia is administered which action is the highest priority for the nurse
ensuring the head and the neck are in good alignment
the anesthetized client must be repositioned from the supine to the prone position midway through the surgical procedure what is the priority action of the nurse
ensuring that the clients ET tube does not become dislodge or kinked
which action by the surgical nursing staff indicates that additional teaching is required about a nurses roles and responsibilities in the operating room
the circulating nurse goes to the blood bank to pick up 2 units of fresh frozen plasma for the client
which of the following statements indicate accountability by the scrub nurse during a surgical procedure
a surgical sponge is missing so i will do a recount of all surgical supplies used during the procedure
the nurse is assisting the client to the operating room when the client states i am really anxious right now ive never had an operation before what is the nurses best response
i'll ask the anesthesiologist to give you some medication to help relax
surgery is almost completed for an obese client with diabetes and the surgeon prepares to close a large abdominal incision what should the scrub nurse have ready for the surgeon
retention sutures
the nurse is caring for a client who will be having surgery shortly with spinal anesthesia the client says the nurse i changed my mind i dont want to be awake during the surgery what is the nurses best response
i'll ask the anesthesiologist to give you medication to keep you sleepy during the surgery
the circulating nurse is assisting the surgeon as he dons surgical attire in the OR, which of the following actions by the circulating nurse indicates the best practice
inspect the gloves for nicks and tears after they are on the surgeons hands
the nurse is caring for a client who has surgery 24 hours ago what is the best indicator for the nurse to kow the clients pain is well controlled
the client states she has no pain.
immediately after the surgical procedure has been concluded for a client who is received a general anesthetic the client begins to shiver intensely, what will the nurse do first
apply warm blankets
the nurse is caring for an older adult client who has just returned to the medical surgical unit from the post anesthesia recovery unit the client does not remember that he just had surgery what is the nurses best action
reorientate the client as needed and check the client frequently
the nurse assess the client who has just been brought to the PACU which assessment finding is the best indicator that the clients circulatory status may be compromised
the urine output decreased from 40 to 10
the nurse is caring for a client who has just been brought to the PACU after surgery what is the best indicator that the client is demonstrating adequate oxygenation
the clients oxygen saturation is 96 and hgb and hct is within normal
the client is brought to the PACU after surgery that took place with the client in the lithotomy position...possible complications of the surgical position
the dorsal pedal pulses are not palpable
the client has undergone brain surgery and has been admitted to the PACU the nurse notes the right pupil is 5mm, and the left pupil is 3mm, what is the nurses best first action
any abnormal neurological assessment finding discovered postoperatively should be compared with the clients preop/baseline
the nurse is caring for several clients in the postoperative unit which client does the nurse assess first because of their elevated risk of respiratory complications after general anesthesia
the young adult with a BMI of 40
one hour after admission to the PACU the postoperative client has become very restless, what is the nurses best first action
checking the clients oxygen saturation
the nurse is caring for a client in PACU 2 hours after abdominal surgery the nurse auscultates the clients abdomen and notes there are no bowel sounds, what is the nurses best first action
document the findings as the only action
the nurse is changing the clients dressing on the second post operative day and notes a small amount of serosanguineous drainage, what is the nurses best action
clean the suture line gently with sterile normal saline and apply a new sterile dressing
the nurse is caring for a client with abdominal surgery 3 days ago, and has a large abdominal incision when the nurse enters the clients room he tells the nurse i felt my incision pop when i coughed a little while ago what is the nurses best response
lie down flat on the bed with your knees up and let me examine incision
the nurse administers 6 mg of morphine of subcutaneously to the client one hour ago and complains of severe pain, when the nurse returns to reassess the client the respirator rate is 8 breaths what is the nurses priority action
check the clients oxygen saturation
the nurse is teaching the client how to use the PCA to manage post operative pain, which client statement indicates that additional teaching is required
i will ask my family to push the button for me when i am sleeping
a diabetic client has undergone surgery 24 hours ago what precautions should the nurse take to help prevent postoperative complications for this client
use sterile technique during dressing changes
the nurse is providing discharge teaching for a client who will be going home with a jackson pratt, which statement indicates that the client understands how to care for drain correctly
i will measure the drainage before dumping it out
the nurse is caring for a client how has surgery the previous day the client tells the nurse breathing in this tube thing incentive spirometer is ridiculous waste of time, what is the nurses best response
the spirometer will make your lungs expand
after discharge from the PACU the client returns to the surgical nursing unit at 1000 is now 1800 the client is not experiencing any complications or difficulty, how often should the nurse assess the clients vital signs
every 4 hours
in the pacu the nurse receives a client who has just had surgery with general anesthesia, what will the nurse assess first
the clients airway and oxygen saturation
the nurse is teaching a client who has had complications for gastric surgery the client has lost weight and has a poor appetite which dietary recommendation should the nurse make for this client
take a multivitamin with small frequent meals
the nurse is caring for a client in the pacu, which client is ready to be extubated
the client who is coughing and gagging
the nurse is working the PACU and receives a client from the or with many lines and tubes in place which should the nurse assess first
the clients ET tube
the nurse is caring for a post operative client who vomits resulting in two inch opening of the abdominal incision some fatty tissue is visible and some amount of serosanguineous drainage is present what is the nurses best first action
cover the wound with sterile moist dressings
the nurse is changing a dressing on a postoperative client abdominal incision the incision has sutures and a jp drain and there is a lot of serosanguinous drainage what is the nurses best action for cleaning this incision
cleaning the incision from the center outward using sterile normal saline
the nurse is changing the dressing for clients incisions on the 3rd postoperative day the incision is intact and staples and a minminal amount of serosanguinous drainage, what is the best dressing to use for this incision
dry sterile dressing
the nurse receives report that the clients foley catheter was empty just prior to transfer to the medical surgical unit 2 hrs later the nurse notes the client urine output is 30 what is the nurses best first action
check the foley catheter
the nurse is ambulating a post operative client in the hallway when he coughs and says to the nurse i feel like somethings ripped in my incision a large amount of blood is suddenly apparent on the clients gown over the incision what is the best first action for the nurse
ease the client to the floor to reduce infection on the incision
in the pacu the client states concerns post operative pain mgmt to the nurse, which instructions should the nurse provide for the client so that the post op pain will be controlled more effectively
you should ask for pain medication before the pain becomes severe
the nurse is caring for multiple post operative clients on the medical surgical unit at the beginning of the shift the nurse needs to determine which client should assess which of the following clients first
the client who has new maroon drainage from the NG tube
the following post-operative pain medication orders were written by the physician on the clients chart which one is written correctly and appropriate
MS 0.5 mg subq every 1-3 hours prn for pain
the nurse is caring for a client who is complaining of severe pain at the incision site the nurse reviews the medication administration sheet and notes that the order states the client is to receive demerol 500 mg IM 3-4 hrs prn for pain which is the best action for the nurse
call the physician and clarify the order
the nurse is changing the dressing on the clients abdominal incision which of the following is an appropriate step for the nurse to perform and maintain a sterile asepsis
pouring out a small amount of sterile saline and discard it before pouring it onto the dressing
the ___client is undergoing thoracentesis which assessment finding requires immediate action by the nurse
tachycardia
the nurses assess the client after an open lung biopsy which assessment findings is matched with the correct intervention
client has reduced breath sounds nurses call the doctor immediately
which laboratory value warrants immediate intervention by the nurse
CO2 48
the nurse is calculating the clients smoking history in pack years the client has been recently diagnosed with lung cancer which will be the nurses priority intervention during the interview
maintain a nonjudgemental attitude to avoid encourage the client to feel guilty
when assessing the clients respiratory status which information is the highest priority for a nurse to obtain
occupation and hobbies
the client tells the nurse that occasionally food seems to stick in his throat and makes it hard for him to breathe what is the nurses best response
drink water when this happens
the nurse is caring for an older adult client with a pulmonary infection which nursing action is priority with this client
the nurse assesses the clients consciousness
the nurse is assessing the clients breath sounds which assessment finding has been correctly linked to the nurses primary intervention
wheezes heard in central areas administering bronchodilators
part of the clients treatment involves paralysis of the cilia in the airways which statement by the nurse indicates the higher priority teaching strategy regarding the drug
coughing every hour to help bring up mucus and secretions
the nurse is caring for several clients on a respiratory unit which client will the nurse see first
a young adults with an arterial oxygen level of 85
the client is taking vasotec and it is a ace inhibitor for htn which assessment finding with this requires immediate intervention by the nurse
persistent dry cough
the client tells the nurse that he usually expectorates about 2 ounces of thin clear colorless sputum each day mostly in the morning after getting out of bed what is the nurses initial action after gaining this information
monitor for increase in sputum production or change in color
the nurse observes that the middle age client anterior posterior chest diameter is the same as her lateral chest diameter which is the nurses most important question for the client in response to this finding
do you have any chronic breathing problems
a client with longstanding pulmonary problems is classified as having class free dysthymia based on this classification what type of assistance will highest priority as nurse provides of activity daily living
the client may complete activities of daily living without assistance but require rest periods during the performance
when measuring the clients pulse oximetry the nurse finds the client to have a reading of 85 down from 92 a hour ago what will the nurse do first
verify the assessment and apply nasal cannula oxygen
the clients scheduled to have a vq scan and is worried about contaminating his grandchildren with radioactive material
the material clears within 8 hours so your grandchildren can visit
the client is scheduled to undergo a thoracentesis what will the nurses priority intervention be
verify the informed consent has been given by the client
the nurse is assessing a client after thoracentesis which action will represents an accurate intervention by the nurse
crepitus felt at side physician notified
the client is scheduled to have a bronchoscopy which pre-procedural teaching is unique to the procedure
dont eat or drink afterwards until your gag reflex returns to prevent aspiration