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NURSING 102 EXAM 4 QUESTIONS AND CORRECT ANSWERS

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NURSING 102 EXAM 4 QUESTIONS AND CORRECT ANSWERS

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NURSING 102 EXAM 4 QUESTIONS AND
CORRECT ANSWERS
TheA2nurseA2hasA2justA2reassessedA2theA2conditionA2ofA2aA2postoperativeA2clientA2whoA2w
asA2admittedA21A2hourA2agoA2toA2theA2surgicalA2unit.A2TheA2nurseA2plansA2toA2monitorA2whi
chA2parameterA2mostA2carefullyA2duringA2theA2nextA2hour?
1.A2UrineA2outputA2ofA220ml/hour
2.A2TemperatureA2ofA299.7A2F
3.A2BloodA2pressureA2ofA2114/70
4.A2SerousA2drainageA2onA2theA2surgicalA2dressingA2-A2Ans--1.
UrineA2outputA2shouldA2beA2maintainedA2atA2aA2minimumA2ofA230mL/
hourA2forA2anA2adult.A2AnA2outputA2ofA2lessA2thanA2thatA2forA2eachA2ofA22A2consecutiveA2ho
ursA2shouldA2beA2reportedA2toA2theA2healthA2careA2provider.

AA2postoperativeA2clientA2asksA2theA2nurseA2whyA2itA2isA2soA2importantA2toA2deep-
breatheA2andA2coughA2afterA2surgery.A2WhenA2formulatingA2aA2response,A2theA2nurseA2inc
orporatesA2theA2understandingA2thatA2retainedA2pulmonaryA2secretionsA2inA2aA2postoperat
iveA2clientA2canA2leadA2toA2whichA2condition?
1.A2Pneumonia
2.A2Hypoxemia
3.A2FluidA2imbalance
4.A2PulmonaryA2embolismA2-A2Ans--1.
PostoperativeA2respiratoryA2problemsA2areA2atelectasis,A2pneumoniaA2andA2pulmonaryA2e
mboli.A2PneumoniaA2isA2theA2inflammationA2ofA2lungA2tissueA2thatA2causesA2productiveA2c
ough,A2dyspnea,A2andA2lungA2cracklesA2andA2canA2beA2causedA2byA2theA2retentionA2ofA2pu
lmonaryA2secretions.

TheA2nurseA2isA2developingA2aA2planA2ofA2careA2forA2aA2clientA2scheduledA2forA2surgery.A2T
heA2nurseA2shouldA2includeA2whichA2activityA2inA2theA2nursingA2careA2planA2forA2theA2client
A2onA2theA2dayA2ofA2surgery?
1.A2AvoidA2oralA2hygieneA2andA2rinsingA2withA2mouthwash
2.A2VerifyA2thatA2theA2clientA2hasA2notA2eatenA2forA2theA2lastA224A2hours
3.A2HaveA2theA2clientA2voidA2immediatelyA2beforeA2goingA2intoA2surgery
4.A2ReportA2immediatelyA2anyA2slightA2increaseA2inA2BPA2orA2pulseA2-A2Ans--3.A2
TheA2nurseA2wouldA2assistA2theA2clientA2toA2voidA2immediatelyA2beforeA2surgeryA2soA2thatA
2theA2bladderA2willA2beA2empty.A2OralA2hygieneA2isA2allowed,A2butA2theA2clientA2shouldA2no
tA2swallowA2anyA2water.A2TheA2clientA2usuallyA2hasA2aA2restrictionA2ofA2foodA2andA2fluidsA2f
orA26A2toA28A2hoursA2beforeA2surgeryA2insteadA2ofA224A2hours.A2AA2slightA2increaseA2inA2B
PA2andA2pulseA2isA2commonA2duringA2theA2preoperativeA2periodA2dueA2toA2anxiety.

AA2clientA2withA2aA2perforatedA2gastricA2ulcerA2isA2scheduledA2forA2surgery.A2TheA2clientA2c
annotA2signA2theA2operativeA2consentA2formA2becauseA2ofA2sedationA2fromA2opioidA2analg
esicsA2thatA2haveA2beenA2administered.A2TheA2nurseA2shouldA2takeA2whichA2mostA2appro
priateA2actionA2inA2theA2careA2ofA2thisA2client?

,1.A2ObtainA2aA2courtA2orderA2forA2theA2surgery.
2.A2HaveA2theA2chargeA2nurseA2signA2theA2informedA2consentA2immediately
3.A2SendA2theA2clientA2toA2surgeryA2withoutA2theA2consentA2formA2beingA2signed
4.A2ObtainA2aA2telephoneA2consentA2fromA2aA2familyA2member,A2followingA2agencyA2policy
A2-A2Ans--4.
EveryA2effortA2shouldA2beA2madeA2toA2obtainA2permissionA2fromA2aA2responsibleA2familyA2
memberA2toA2performA2surgeryA2ifA2theA2clientA2isA2unableA2toA2signA2theA2consentA2form.A
2AA2telephoneA2consentA2mustA2beA2witnessedA2byA2twoA2personsA2whoA2hearA2theA2famil
yA2member'sA2oralA2consent.A2TheA2twoA2witnessesA2thenA2signA2theA2consentA2withA2theA
2nameA2ofA2theA2familyA2member,A2notingA2thatA2anA2oralA2consentA2wasA2obtained.A2Con
sentA2isA2notA2informedA2ifA2itA2isA2obtainedA2fromA2aA2clientA2whoA2isA2confused,A2unconsc
ious,A2mentallyA2incompetent,A2orA2underA2theA2influenceA2ofA2sedatives.A2InA2anA2emerge
ncyA2theA2clientA2mayA2notA2beA2ableA2toA2signA2andA2familyA2membersA2mayA2notA2beA2av
ailable.A2InA2thisA2situation,A2aA2healthA2careA2providerA2isA2permittedA2legallyA2toA2perform
A2surgeryA2withoutA2consent,A2butA2tinA2thisA2caseA2itA2isA2notA2anA2emergency.A2AgencyA2
policiesA2regardingA2informedA2consentA2shouldA2alwaysA2beA2followed.

AA2preoperativeA2clientA2expressesA2anxietyA2toA2theA2nurseA2aboutA2upcomingA2surgery.A
2WhichA2responseA2byA2theA2nurseA2isA2mostA2likelyA2toA2stimulateA2furtherA2discussionA2b
etweenA2theA2clientA2andA2theA2nurse?
1.A2"IfA2it'sA2anyA2help,A2everyoneA2isA2nervousA2beforeA2surgery."
2.A2"IA2willA2beA2happyA2toA2explainA2theA2entireA2surgicalA2procedureA2withA2you."
3.A2"CanA2youA2shareA2withA2meA2whatA2you'veA2beenA2toldA2aboutA2yourA2surgery?"
4.A2"LetA2meA2tellA2youA2aboutA2theA2careA2you'llA2receiveA2afterA2surgeryA2andA2theA2amo
untA2ofA2painA2youA2canA2anticipate".A2-A2Ans--3.
ExplanationsA2shouldA2beginA2withA2theA2informationA2thatA2theA2clientA2knows.A2ByA2provi
dingA2theA2clientA2withA2individualizedA2explanationsA2ofA2careA2andA2procedures,A2theA2n
urseA2canA2assistA2theA2clientA2inA2handlingA2anxietyA2andA2fearA2forA2aA2smoothA2preoper
ativeA2experience.A2ClientsA2whoA2areA2calmA2andA2emotionallyA2preparedA2forA2surgeryA2
withstandA2anesthesiaA2betterA2andA2experienceA2fewerA2postoperativeA2complications.

TheA2nurseA2isA2conductingA2preoperativeA2teachingA2withA2aA2clientA2aboutA2theA2useA2of
A2anA2incentiveA2spirometer.A2TheA2nurseA2shouldA2includeA2whichA2pieceA2ofA2information
A2inA2discussionsA2withA2theA2client?
1.A2InhaleA2asA2rapidlyA2asA2possible
2.A2KeepA2aA2looseA2sealA2betweenA2theA2lipsA2andA2theA2mouthpiece
3.A2AfterA2maximumA2inspiration,A2holdA2theA2breathA2forA215A2secondsA2andA2exhale.A2
4.A2TheA2bestA2resultsA2areA2achievedA2whenA2sittingA2upA2orA2withA2theA2headA2ofA2theA2b
edA2elevatedA245A2toA290A2degreesA2-A2Ans--4
ForA2optimalA2lungA2expansionA2withA2theA2incentiveA2spirometer,A2theA2clientA2shouldA2as
sumeA2theA2semi-
FowlersA2orA2highA2fowlersA2position.A2TheA2mouthpieceA2shouldA2beA2coveredA2complete
lyA2andA2tightlyA2whileA2theA2clientA2inhalesA2slowly,A2withA2aA2constantA2flowA2throughA2th
eA2unit.A2TheA2breathA2shouldA2beA2heldA2forA25A2secondsA2beforeA2exhalingA2slowly.

, AlendronateA2(Fosamax)A2isA2prescribedA2forA2aA2patientA2withA2osteoporosis.A2TheA2nurs
eA2teachesA2theA2patientA2that
a.A2theA2drugA2mustA2beA2takenA2withA2foodA2toA2preventA2GIA2sideA2effects.
B.A2bisphosphonatesA2preventA2calciumA2fromA2beingA2takenA2fromA2theA2bones.
C.A2lyingA2downA2afterA2takingA2theA2drugA2preventsA2light-headednessA2andA2dizziness.
D.A2takingA2theA2drugA2withA2milkA2enhancesA2theA2absorptionA2ofA2calciumA2fromA2theA2b
owel.A2-A2Ans--TheA2answerA2is:A2b

TheA2nurseA2assessA2aA2client'sA2surgicalA2incisionA2forA2signsA2ofA2infection.A2WhichA2find
ingA2byA2theA2nurseA2wouldA2beA2interpretedA2asA2aA2normalA2findingA2atA2theA2surgicalA2si
te?
1.A2Red,A2hardA2skin
2.A2SerousA2drainage
3.A2PurulentA2drainage
4.A2WarmA2tenderA2skinA2-A2Ans--2
SerousA2drainageA2isA2anA2expectedA2findingA2atA2aA2surgicalA2site.A2TheA2otherA2optionsA
2indicateA2signsA2ofA2woundA2infection.A2WoundA2infectionA2usuallyA2appearsA23A2toA26A2d
aysA2afterA2surgery.

AA2clientA2whoA2hasA2hadA2abdominalA2surgeryA2complainsA2ofA2feelingA2asA2thoughA2"so
methingA2gaveA2way"A2inA2theA2incisionalA2site.A2TheA2nurseA2removesA2theA2dressingA2an
dA2notesA2theA2presenceA2ofA2aA2loopA2ofA2bowelA2protrudingA2throughA2theA2incision.A2Wh
ichA2nursingA2interventionsA2shouldA2theA2nurseA2take?A2SelectA2allA2thatA2apply
1.A2ContactA2theA2surgeon
2.A2InstructA2theA2clientA2toA2remainA2quiet
3.A2PrepareA2theA2clientA2forA2woundA2closure
4.A2DocumentA2theA2findingsA2andA2actionsA2taken
5.A2PlaceA2aA2sterileA2salineA2dressingA2andA2icepacksA2overA2theA2wound
6.A2PlaceA2theA2clientA2inA2aA2proneA2positionA2withoutA2aA2pillowA2underA2theA2head.A2-
A2Ans--1,A22,A23A2,4A2
WoundA2dehiscenceA2isA2theA2separationA2ofA2theA2woundA2edges.A2WoundA2evisceration
A2isA2protrusionA2ofA2theA2internalA2organsA2throughA2anA2incision.A2IfA2woundA2dehiscence
A2orA2eviscerationA2occurs,A2theA2nurseA2shouldA2callA2forA2help,A2stayA2withA2theA2client,A2
andA2askA2anotherA2nurseA2toA2contactA2theA2surgeonA2andA2obtainA2neededA2suppliesA2to
A2careA2forA2theA2client.A2TheA2nurseA2placesA2theA2clientA2inA2aA2lowA2fowlersA2positionA2a
ndA2theA2clientA2isA2keptA2quiteA2andA2instructedA2notA2toA2cough.A2ProtrudingA2organsA2ar
eA2coveredA2withA2aA2sterileA2salineA2dressing.A2IceA2isA2notA2appliedA2becauseA2ofA2itsA2v
asoconstrictiveA2effect.A2TheA2treatmentA2forA2eviscerationA2isA2usuallyA2immediateA2wou
ndA2closureA2underA2localA2orA2generalA2anesthesia.A2TheA2nurseA2alsoA2documentsA2theA
2findingsA2andA2actionsA2taken.


WhichA2patientA2shouldA2NOTA2beA2prescribedA2alendronateA2(Fosamax)A2forA2osteoporo
sis?
A.A2AA2femaleA2patientA2beingA2treatedA2forA2highA2bloodA2pressureA2withA2anA2ACEA2inhib
itor.
B.A2AA2patientA2whoA2isA2allergicA2toA2iodine/shellfish.

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