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Med Surg test 1
Terms in this set (70)
Ineffective individual coping related to reluctance to seek care
A 35-year-old woman comes to the local health center with a large mass in her right breast. She has felt the lump for about a year, but was afraid to come to the clinic because she was sure it was cancer. What is the most appropriate nursing diagnosis for this patient?
Cancer pain can be acute or chronic and it typically requires comparatively high doses of pain medications.
A 52-year-old female patient is receiving care on the oncology unit for breast cancer that has metastasized to her lungs and liver. When addressing the patient's pain in her plan of nursing care, the nurse should consider what characteristic of cancer pain?
When a follow-up evaluation in the clinical or home setting is done
A 77-year-old man's coronary artery bypass graft has been successful and discharge planning is underway. When planning the patient's subsequent care, the nurse should know that the postoperative phase of perioperative nursing ends at what time?
risk for Infection related to reduced immune function
A 90-year-old female patient is scheduled to undergo a partial mastectomy for the treatment of breast cancer. What nursing diagnosis should the nurse prioritize when planning this patient's postoperative care?
"What prescription and nonprescription medications do you currently take?"
A clinic nurse is conducting a preoperative interview with an adult patient who will soon be scheduled to undergo cardiac surgery. What interview question most directly addresses the patient's safety?
Demonstrate a dressing change and allow the patient to practice.
A gerontologic nurse has observed that patients often fail to adhere to a therapeutic regimen. What strategy should the nurse adopt to best assist an older adult in adhering to a therapeutic regimen involving wound care?
They increase the risk of illness.
A group of nurses are attending an educational inservice on adaptive and maladaptive responses to stress. When talking about the assessment of coping strategies in patients, the nurses discuss the use of drugs and alcohol to reduce stress. What is most important for the nurses to know about these coping behaviors?
The formal, systematic study of moral beliefs
A group of students have been challenged to prioritize ethical practice when working with a marginalized population. How should the students best understand the concept of ethics?
It provides continuity of care.
A medical nurse has obtained a new patient's health history and completed the admission assessment. The nurse has followed this by documenting the results and creating a care plan for the patient. Which of the following is the most important rationale for documenting the patient's care?
Hemorrhage and shock
An adult patient has just been admitted to the PACU following abdominal surgery. As the patient begins to awaken, he is uncharacteristically restless. The nurse checks his skin and it is cold, moist, and pale. The nurse concerned the patient may be at risk for what?
Turn the patient completely to one side.
An adult patient is in the recovery room following a nephrectomy performed for the treatment of renal cell carcinoma. The patient's vital signs and level of consciousness stabilized, but the patient then complains of severe nausea and begins to retch. What should the nurse do next?
Clinical examination findings
A newly admitted patient has gained weight steadily over the past 2 years and the nurse recognizes the need for a nutritional assessment. What assessment parameters are included when assessing a patient's nutritional status? Select all that apply.
Sterile surfaces or articles may touch other sterile surfaces.
An OR nurse is participating in an interdisciplinary audit of infection control practices in the surgical department. The nurse should know that a basic guideline for maintaining surgical asepsis is what?
"Unless there is strong evidence to the contrary, we should take the patient's report at face value.'"
An unlicensed nursing assistant (NA) reports to the nurse that a postsurgical patient is complaining of pain that she rates as 8 on a 0-to-10 point scale. The NA tells the nurse that he thinks the patient is exaggerating and does not need pain medication. What is the nurse's best response?
Stress decreases immune function.
A nurse has been studying research that examines the association between stress levels and negative health outcomes. Which relationship should underlie the educational interventions that the nurse chooses to teach?
Leg exercises improve circulation and prevent venous thrombosis.
A nurse is providing preoperative teaching to a patient who will soon undergo a cardiac bypass. The nurse's teaching plan includes exercises of the extremities. What is the purpose of teaching a patient leg exercises prior to surgery?
This is an aspect of the patient's religious practice.
A nurse on a medical unit is conducting a spiritual assessment of a patient who is newly admitted. In the course of this assessment, the patient indicates that she does not eat meat. Which of the following is the most likely significance of this patient's statement?
a mind-body method
A nurse on an oncology unit has arranged for an individual to lead meditation exercises for patients who are interested in this nonpharmacological method of pain control. The nurse should recognize the use of what category of nonpharmacological intervention?
Reprioritizing needs and roles
A patient is experiencing intense stress during his current hospital admission for the exacerbation of chronic obstructive pulmonary disease (COPD). Which of the patient's actions best demonstrates adaptively coping?
Preventing potential contamination of the peritoneum
A patient is scheduled for a bowel resection in the morning and the patient's orders include a cleansing enema tonight. The patient wants to know why this is necessary. The nurse should explain that the cleansing enema will have what therapeutic effect?
By implementing an interdisciplinary approach to care
A patient is scheduled for surgery the next day and the different phases of the patient's surgical experience will require input from members of numerous health disciplines. How should the patient's care best be coordinated?
A patient's intractable neuropathic pain is being treated on an inpatient basis using a multimodal approach to analgesia. After administering a recently increased dose of IV morphine to the patient, the nurse has returned to assess the patient and finds the patient unresponsive to verbal and physical stimulation with a respiratory rate of five breaths per minute. The nurse has called a code blue and should anticipate the administration of what drug?
The patient has vomited three times in the past 12 hours.
A patient underwent an open bowel resection 2 days ago and the nurse's most recent assessment of the patient's abdominal incision reveals that it is dehiscing. What factor should the nurse suspect may have caused the dehiscence?
The tube provides an airway for ventilation
A patient waiting in the presurgical holding area asks the nurse, "Why exactly do they have to put a breathing tube into me? My surgery is on my knee." What is the best rationale for intubation during a surgical procedure that the nurse should describe?
By maintaining each of your patients' privacy
As an intraoperative nurse, you are the advocate for each of the patients who receives care in the surgical setting. How can you best exemplify the principles of patient advocacy?
Sufficient oxygen saturation
Adequate respiratory function
Stable blood pressure
A surgical patient has been in the PACU for the past 3 hours. What are the determining factors for the patient to be discharged from the PACU? Select all that apply.
Hypoxia to the brain
A teenage boy who was the victim of a near drowning has been admitted to the emergency department. The patient was submerged for several minutes and remains unconscious. What pathophysiological process has occurred as a result of the submersion?
Trace the outline of the drainage on the dressing for future comparison.
The dressing surrounding a mastectomy patient's Jackson-Pratt drain has scant drainage on it. The nurse believes that the amount of drainage on the dressing may be increasing. How can the nurse best confirm this suspicion?
The nurse should assess the patient's blood glucose levels vigilantly.
The nurse admitting a patient who is insulin dependent to the same-day surgical suite for carpal tunnel surgery. How should this patient's diagnosis of type 1 diabetes affect the care that the nurse plans?
The mindful use of a word, phrase, or visual, which allows oneself to be distracted and temporarily escape from stressful situations
The nurse at the student health center is seeing a group of students who are interested in reducing their stress level. The nurse identifies guided imagery as an appropriate intervention. What will be included in the nurse's intervention?
Severity of Infection
condition of the host
nature of the injury
The nurse is admitting a 51-year-old patient to the medical-surgical unit after a diagnosis of cellulitis of the calf. What factors does the nurse know impact the processes of inflammation, repair, and replacement? Select all that apply.
Encourage the patient to use the incentive spirometer every 2 hours.
The nurse is admitting a patient to the medical-surgical unit from the PACU. What should the nurse do to help the patient clear secretions and help prevent pneumonia?
Stand upright for 2 to 3 minutes prior to ambulating.
The nurse is caring for a 78-year-old man who has had an outpatient cholecystectomy. The nurse is getting him up for his first walk postoperatively. To decrease the potential for orthostatic hypotension and consequent falls, what should the nurse have the patient do?
The nurse is caring for a 79-year-old man who has returned to the postsurgical unit following abdominal surgery. The patient is unable to ambulate and is now refusing to wear an external pneumatic compression stocking. The nurse should explain that refusing to wear external pneumatic compression stockings increases his risk of what postsurgical complication?
the patient is in pain
The nurse is caring for a patient after abdominal surgery in the PACU. The patient's blood pressure has increased and the patient is restless. The patient's oxygen saturation is 97%. What cause for this change in status should the nurse first suspect?
"You will move more easily and heal more quickly with decreased pain. Dependence only occurs when it is administered for an extended period of time."
The nurse is caring for a patient in the postoperative period following an abdominal hysterectomy. The patient states, "I don't want to use my pain meds because they'll make me dependent and I won't get better as fast." Which response is most important when explaining the use of pain medication?
Red, warm, tender incision
The nurse is caring for a patient on the medical-surgical unit postoperative day 5. During each patient assessment, the nurse evaluates the patient for infection. Which of the following would be most indicative of infection?
maintaining a patent airway
The nurse is caring for a patient who has just been transferred to the PACU from the OR. What is the highest nursing priority?
Elderly patients have less physiologic reserve than younger patients.
The nurse is doing a preoperative assessment of an 87-year-old man who is slated to have a right lung lobe resection to treat lung cancer. What underlying principle should guide the nurse's preoperative assessment of an elderly patient?
The nurse is preparing to send a patient to the OR for a scheduled surgery. What should the nurse ensure is on the chart when it accompanies the patient to surgery? Select all that apply.
I'll eat plenty of fruits and vegetables
The nurse is providing teaching about tissue repair and wound healing to a patient who has a leg ulcer. Which of the following statements by the patient indicates that teaching has been effective?
You are the emergency department (ED) nurse caring for an adult patient who was in a motor vehicle accident. Radiography reveals an ulnar fracture. What type of pain are you addressing when you provide care for this patient?
Chronic pain can cause intense emotional responses.
You are the nurse coming on shift in a rehabilitation unit. You receive information in report about a new patient who has fibromyalgia and has difficulty with her ADLs. The off-going nurse also reports that the patient is withdrawn, refusing visitors, and has been vacillating between tears and anger all afternoon. What do you know about chronic pain syndromes that could account for your new patient's behavior?
Assessment for respiratory depression.
Your patient is receiving postoperative morphine through a patient-controlled analgesic (PCA) pump and the patient's orders specify an initial bolus dose. What is your priority assessment?
Patient will adopt coping mechanisms to reduce stress.
You walk into your patient's room and find her sobbing uncontrollably. When you ask what the problem is, your patient responds, "I am so scared. I have never known anyone who goes into a hospital and comes out alive." On this patient's care plan you note a pre-existing nursing diagnosis of Ineffective Coping related to stress. What is the best outcome you can expect for this patient?
the abnormal reorganization of the nervous system.
A 60-year-old patient who has diabetes had a below-knee amputation 1 week ago. The patient asks "why does it still feel like my leg is attached, and why does it still hurt?" The nurse explains neuropathic pain in terms that are accessible to the patient. The nurse should describe what pathophysiologic process?
Enhancing the nurse's clinical decision making
helping identify the patient's priority needs
planning the best nursing actions to assist the patient increasing the accuracy of the nurse's judgments.
Achieving adequate pain management for a postoperative patient will require sophisticated critical thinking skills by the nurse. What are the potential benefits of critical thinking in nursing? Select all that apply.
A 74-year-old woman with a low body mass index
A circulating nurse provides care in a surgical department that has multiple surgeries scheduled for the day. The nurse should know to monitor which patient most closely during the intraoperative period because of the increased risk for hypothermia?
By adhering to EBP guidelines
A hospital's current quality improvement program has integrated the principles of the Institute for Healthcare Improvement (IHI) 5 Million Lives Campaign. How can the hospital best achieve the campaign goals of reducing preventable harm and death?
The pain, redness and swelling are part of the inflammatory process, but it is probably too early for infection
A mother has brought her young son to the emergency department (ED). The mother tells the triage nurse that the boy was stung by a bee about an hour ago. The mother explains to the nurse, "It hurts him so bad and it looks swollen, red, and infected." What can the triage nurse teach the mother?
Absence of reflexes
diminished ability to communicate
loss of pain sensations.
An intraoperative nurse is applying interventions that will address surgical patients' risks for perioperative positioning injury. Which of the following factors contribute to this increased risk for injury in the intraoperative phase of the surgical experience? Select all that apply.
Mask covering the nose and mouth.
An OR nurse is teaching a nursing student about the principles of surgical asepsis as a requirement in the restricted zone of the operating suite. What personal protective equipment should the nurse wear at all times in the restricted zone of the OR?
Verifying the surgical site with the patient
establishing an IV
taking measures to ensure the patient's comfort.
A nurse in the preoperative holding area is admitting a woman prior to reduction mammoplasty. What should the nurse include in the care given to this patient? Select all that apply.
Risk for ineffective health maintenance related to non adherence to therapeutic regimen.
A nurse is planning care for an older adult who lives with a number of chronic health problems. For which of the following nursing diagnoses would education of the patient be the nurse's highest priority?
A patient is experiencing severe pain after suffering an electrical burn in a workplace accident. The nurse is applying knowledge of the pathophysiology of pain when planning this patient's nursing care. What is the physiologic process by which noxious stimuli, such as burns, activate nociceptors?
Dysplasia cells have a high potential to become malignant.
A patient who has a 40 pack-year history of smoking may have dysplasia of the epithelial cells in her bronchi. What would the nurse tell the patient about dysplastic cells in the bronchi?
The patient should take a deep breath in through the mouth and exhale through the mouth, take short breath and cough from deep in the lungs.
In anticipation of a patient's scheduled surgery, the nurse is teaching her to perform deep breathing and coughing to use postoperatively. What action should the nurse teach the patient?
Maintaining an aseptic environment in the OR is essential to patient safety and infection control. When moving around surgical areas, what distance must the nurse maintain from the sterile field?
"You will need to have food and fluid restricted before surgery so you are not at risk of choking."
One of the things a nurse has taught to a patient during preoperative teaching is to have nothing by mouth for the specified time before surgery. The patient asks the nurse why this is important. What is the most appropriate response for the patient?
The patient expresses interest in the dressing change the patient is willing to look at the incision during a dressing change
the patient assists in opening the packages of dressing material for the nurse.
The nurse is caring for a postoperative patient who needs daily dressing changes. The patient is 3 days postoperative and is scheduled for discharge the next day. Until now, the patient has refused to learn how to change her dressing. What would indicate to the nurse the patient's possible readiness to learn how to change her dressing? Select all that apply.
The nurse is checking the informed consent for a 17-year-old who has just been married and expecting her first child. She is scheduled for a cesarean section. She is still living with her parents and is on her parents' health insurance. When obtaining informed consent for the cesarean section, who is legally responsible for signing?
Provide the nurse's or surgeon's contact information, give prescriptions to the patient and provide all the discharge instructions in writing.
The nurse is discharging a patient home from an outpatient surgery center. The nurse has reviewed all of the discharge instructions with the patient and her caregiver. What else should the nurse do before discharging the patient from the facility? Select all that apply.
Prevention is emphasized as the link between personal behavior and health.
The nurse is teaching a local community group about the importance of disease prevention. Why is the nurse justified in emphasizing disease prevention as a component of health promotion?
The patient may be at risk for malignant hyperthermia
The OR nurse is taking the patient into the OR when the patient informs the operating nurse that his grandmother spiked a 104°F temperature in the OR and nearly died 15 years ago. What relevance does this information have regarding the patient?
The PACU nurse is caring for a 45-year-old male patient who had a left lobectomy. The nurse is assessing the patient frequently for airway patency and cardiovascular status. The nurse should know that the most common cardiovascular complications seen in the PACU include what? Select all that apply.
Disturbed sensory perception related to anesthetic
risk of latex allergy response related to surgical exposure
disturbed body image related to anesthesia.
When creating plans of nursing care for patients who are undergoing surgery using general anesthetic, what nursing diagnoses should the nurse identify? Select all that apply.
Identifying the immediate needs of the patient.
You are admitting a patient to your medical unit after the patient has been transferred from the emergency department. What is your priority nursing action at this time?
Changes in neurologic function due to the procedure
prior effectiveness in relieving the pain
type of procedure being performed.
You are caring for a 20-year-old patient with a diagnosis of cerebral palsy who has been admitted for the relief of painful contractures in his lower extremities. When creating a nursing care plan for this patient, what variables should the nurse consider? Select all that apply.
How the presence of pain affects patients and families the advantages and disadvantages of available pain-relief strategies
resources that can assist the patient with pain management.
You are caring for a patient admitted to the medical-surgical unit after falling from a horse. The patient states "I hurt so bad. I suffer from chronic pain anyway, and now it is so much worse." When planning the patient's care, what variables should you consider? Select all that apply.
The patient's allergy status
Your patient has just returned from the postanesthetic care unit (PACU) following left tibia open reduction internal fixation (ORIF). The patient is complaining of pain, and you are preparing to administer the patient's first scheduled dose of hydromorphone (Dilaudid). Prior to administering the drug, you would prioritize which of the following assessments?
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