Term
An adult man is in the postanesthesia care unit (PACU) following a hemicolectomy. While in the PACU, the nurse will monitor his vital signs:
1.) continuously
2.) every 5 minutes
3.) every 15 minutes
4.) on a prn basis |
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Definition
Answer:
3.) in the PACU, vital signs are assessed every 15 minutes |
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Term
n adult who has had general anesthesia for major surgery is in the PACU. One of the signs that may indicate that his artificial airway should be removed is:
1.) gagging
2.) restlessness
3.) in increase in pain
4.) clear lungs on auscultation. |
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Definition
Answer:
1.) Gagging with the return of the gag reflex indicates that the client is able to manage his own secretions and patent airway. |
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Term
An adult is 6 days post abdominal surgery. Which sign alerts the nurse to wound evisceration?
1.) Acute bleeding
2.) Pink serous drainage
3.) Purple drainage
4.) severe pain |
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Definition
Answer:
2.) Pink serous drainage (looks like pink lemonade) suddenly gushing is usually the major symptom of wound dehiscence. |
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Term
An adult client's wound has been eviscerated. The nurse assesses his respiratory status because:
1.) dehiscence elevates the diaphragm.
2.) coughing increases the risk of evisceration.
3.) respiratory arrest commonly accompanies wound dehiscence.
4.) Splinting the wound will compromise respiratory status. |
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Definition
Answer:
2.) Coughing increases intra-abdominal pressure, which could force loops of bowel out through the open wound. |
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Term
An adult client has acute leukemia and is scheduled for a Hickman catheter insertion under local anesthesia. A MAJOR advantage of regional anesthesia is that the client:
1.) retains all reflexes
2.) remains conscious
3.) has retroactive amnesia
4.) is in the OR for a short period of time. |
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Definition
Answer:
2.)The client receiving regional anesthesia has nerve impulses blocked but does not lose consciousness. |
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Term
An adult male is scheduled for surgery and the nurse is assessing for risk factors. Which is the following are the greatest risk factors?
1.) He is 5ft 4 in tall and weighs 125 lb
2.) He expressed a fear of pain in the post-op period.
3.) He is 5ft 4 in tall, weighs 360lb, and is diabetic.
4.) He expresses fear of the unknown. |
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Definition
Answer
3.)He is 5ft 4 in tall, weighs 360lb, and is diabetic. |
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Term
The nurse in an outclient department is interviewing an adult one week prior to her scheduled elective surgery. In planning for the surgery, which of the following should the nurse include in her teaching?
1.) The client will be able to return home alone following the surgery.
2.) Limitations of oral intake the day of the procedure.
3.) The laboratory studies ordered do not need to be done until after the surgery.
4.) The client should not take any of her routine medications the morning of the surgery. |
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Definition
Answer:
2.) Instructions should be given to the client regarding limitations or oral intake to avoid nausea and vomiting for anesthesia. |
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Term
The nurse enters a woman's room to administer 10mg Valium PO, the ordered pre-op medication for her hysterectomy. During the conversation, the client tells the nurse that she and her husband are planning to have another child in the coming year. The best action for the nurse to take is which of the following?
1.) Do not administer the pre-op medication. NOtify the nursing supervisor and the physician.
2.) Go ahead and administer the medication as ordered.
3.) Check to see if the client has signed a surgical consent.
4.)Send the client to the OR without the medication. |
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Definition
Answer:
1.)no client should be administered the per-op med until the informed consent has been obtained. Even if the consent form is signed, the nurse should withhold sedating meds because this client clearly does not understand the planned procedure. |
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Term
The nurse administers 10mg IM morphine as a pre-op medication, and then discovers that there is no signed operative permit. The best action for the nurse to take is to:
1.) Send the client to surgery as scheduled.
2.) notify the nursing supervisor, the OR, and the physician.
3.) cancel surgery immediately
4.) obtain the needed constent. |
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Definition
Answer:
2.)is a narcotic, sedative, or tranquilizing drug has been administered before signing of the consent, the drug's effects must be allowed to wear off before consent can be given. |
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Term
An adult received atropine sulfate (Atropine) as a pre-op medication 30 minutes ago and is now complaining of dry mouth and her pulse rate is higher than before the medication was administered. The nurse's best interpretation of these findings is that:
1.) The client is having an allergic reaction to the drug.
2.) the client needs a higher dose of this drug
3.) this is a normal side effect of Atropine
4.) the client is anxious about the upcoming surgery. |
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Definition
Answer:
3.) These are normal side effects of an anticholinergic drug; adverse side effects would include ECG changes, constipation, and urinary retention. |
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Term
An adult with COPD is scheduled for surgery and the physician has recommended an epidural anesthetic. The nurse should know that general anesthesia was not recommended for this client because:
1.)there is too high a risk for pressure sores to develop
2.) there is less effect on the respiratory system with epidural anesthesia.
3.) CNS control of the vascular constriction would be affected with general anesthesia.
4.) there is too high a risk of lacerations to the mouth, bruising of lips, and damage to teeth. |
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Definition
Answer:
2.) Epidural anesthesia does not cause resp. depression, but general anesthesia can. especially in a client with COPD. |
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Term
An adult had a bunion removed under an epidural block. In the immediate Post-op period the nurse plans to assess the client for side effects of the epidural block that include which of the following:
1.) headache
2.) hypotension, bradycardia, nausea, vomiting
3.)hypertension, muscular rigidity, fever, and tachypnea.
4.) urinary retention |
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Definition
answer:
2.) hypotension, bradycardia, nausea and vomiting are all symptoms of sympathetic nervous system blockade, so the client should be closely monitored for these. |
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Term
An adult has just arrived on the general surgery unit from the PACU. Which of the following needs to be the initial intervention the nurse takes?
1.) assess the surgical site, noting the amount and character of drainage.
2.) assess for amount of urinary output and the presence of any distention.
3.) allow the family to visit with the client to decrease the anxiety of the client.
4.)take vital signs, assessing the first for a patient airway and the quality of respirations. |
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Definition
Answer:
4.) a specific assessment priority is the evaluation of a patent airway and respiratory and circulatory adequacy. |
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Term
In the Per-op phase, a physicial orders a patient taken off of Coumadin (warfarin) and put on IV heparin. This change in medication will:
1.) Help the patient be more relaxed before her surgical procedure.
2.) Prevent blood clots.
3.) be more quickly reversible during surgery if needed.
4.) shortens the length of recovery time for post-op patients. |
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Definition
Answer:
3.) Heparin is quickly reversible in the event of hemorrhage with Protamine sulfate, (Coumadin can be reversed with Vitamin K, but the results are much slower than with the heparin/protamine reversal) |
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