AIIH MED-SURG 1 TEST 2

AIIH MED-SURG 1 TEST 2 AIIH MED-SURG 1 TEST 2 1. The client undergoing preoperative assessment before an elective procedure tells the nurse that she has been taking 10 mg of prednisone daily for rheumatoid arthritis. What is the nurse’s best action? 2. How does palliative surgery differ from any other type of surgery? 3. While examining the 82-year-old client's preoperative laboratory blood tests, the nurse finds the client's serum sodium level to be 139 mEq/mL. What is the nurse’s best action? 4. The client who is scheduled to have surgery cannot read or write. The surgeon obtaining the consent wants to have the client's spouse sign the consent instead. What is the nurse’s best action? 5. When asked about allergies, the preoperative client tells the nurse she has allergies to all of the following substances. Which allergy alerts the nurse to potential problems in relation to the scheduled surgery? 6. The client is NPO for surgery scheduled to occur in 4 hours. It is now 9 AM and the client's normal oral medications (consisting of digoxin, 0.125 mg, Colace, 300 mg, and Feostat, 325 mg) are due to be administered. The physician will not be available until the time of surgery. What is the nurse’s best action? 7. Twenty minutes after the client has received a preoperative injection of atropine and midazolam (Versed), the client tells the nurse that he must be allergic to the medication because his mouth is dry and his heart seems to be beating faster than normal. What is the nurse’s best first action? 8. The client scheduled to have surgery within the next 2 hours tells the nurse during the admission interview the following information. Which piece of information should the nurse be certain to communicate on the outside of the chart for the entire surgical team to know? 9. Which statement made by the client indicates a need for further teaching? 10. The client’s surgery has been delayed because of hyperkalemia. The client doesn’t understand why. What is the nurse’s best response? 11. Which nursing action or statement is most likely to reduce anxiety in a client being brought to the surgical suite? 12. Which task or function during a surgical procedure is designated as being within the scope of practice for the scrub nurse? 13. Which is the best technique to use when rinsing hands and forearms after a surgical scrub? 14. In the operating room, the client tells the circulating nurse that he is going to have the cataract in his left eye removed. The nurse notes that the consent form indicates that surgery is to be performed on the right eye. What is the nurse’s best first action? 15. The client is to undergo a gynecologic surgical procedure that requires the client to be in the lithotomy position. At what point should the circulating nurse place the client in the lithotomy position? 16. What is the priority nursing diagnosis for the client under general anesthesia during surgery? 17. During which of the following types of anesthesia should the nurse expect the client to maintain a gag reflex during surgery? 18. Which nursing intervention by the circulating nurse is most important for clients having surgery under regional anesthesia? 19. Which of the following method is the best for correctly identifying the client prior to surgery? 20. Which function or assessment finding in a client being admitted to the postanesthesia care unit after surgery is the best indication that the client's respiratory status does not require immediate attention? 21. Which assessment finding in a postoperative client indicates to the nurse that the interventions to prevent hypovolemia need to be re-evaluated? 22. The client is admitted to the postanesthesia care unit (PACU) after surgery that took place with the client in the lithotomy position. Which change in assessment findings alerts the nurse to a possible complication of this surgical position? 23. In checking the neurologic status of the client just admitted to the PACU, the nurse notes that the right eye pupil is dilated more than the left pupil. What is the nurse’s best first action? 24. Which client is at greatest risk for respiratory complications after surgery under general anesthesia? 25. One hour after admission to the PACU, the postoperative client has become very restless. What is the nurse’s best first action? 26. The postoperative client's arterial blood gas values are pH 7.22, HCO – 21 mEq/L, PCO 65 mm Hg, and PO2 58 mm Hg. What is the nurse’s best first action? 27. Two hours after abdominal surgery, the nurse auscultates the client's abdomen. No bowel sounds are present. What is the nurse’s best first action? 28.The client who is 24 hours postoperative from abdominal surgery has light brown fluid with small particles that look like coffee grounds in the NG tube drainage. What is the nurse’s best action? 29. When changing the client's abdominal dressing on the second postoperative day, the nurse notes crusting on about half of the suture line and oozing of a small amount of serosanguineous drainage. What is the nurse’s best action? 30. The client is 4 days postoperative from a bowel resection and has a large abdominal incision. When the nurse enters the client's room, he tells her that he felt the incision “pop” when he coughed just a moment ago. What is the nurse’s best response? 31. When a nurse checks a postoperative client for pain relief 30 minutes after the client started patient-controlled analgesia (PCA) with morphine, the client is sleeping and has a respiratory rate of 8 breaths/minute. What is the nurse’s best first action? Integrity 32. Which precaution or issue should the nurse reinforce to the postoperative client about correct use of the patient-controlled analgesia (PCA) device? 33. Which maneuver or technique should the nurse avoid to prevent pulmonary emboli in a postoperative client? 34. What dietary modifications should the nurse teach to the client who is going home with an extensive wound after surgery? 35. A maintenance man falls from a ladder into the unit hall, striking his head on some equipment. The man is unconscious and not breathing; the Code Team has already been paged and is on its way. The nurse should: Standing in a fast food line, the person in front, while munching on a cookie, begins to cough heavily, with deep inspirations, and waves his arms around wildly. The nurse should immediately: 36. One-person CPR principles, as taught and practiced by professional nurses, require that the initial intervention for an unconscious patient who is not breathing is to: 37. The nurse assesses that the patient is in shock based on the findings of: 38. The nurse comes upon a traffic accident. One passenger is lying on the ground by an open door. The nurse stops and begins immediate nursing interventions by proceeding with assessing: 39. The nurse finds a patient slumped to the floor and unconscious, with no pulse or respiration. The nurse should begin the protocol of: 40. As an immediate treatment for epistaxis, the nurse should give the following instructions: 41. Which condition complicates the assessment of an older adult patient with a suspected head injury? 42. The nurse is called on to assist a neighbor who needs first aid. The nurse knows that legal responsibility for this action would be that the nurse: 43. A nurse comes upon a traffic accident where there are injured, unconscious people lying on the highway. The nurse is aware that first aid interventions are sanctioned by the: 44. The nurse giving discharge instructions to the patient who is severely allergic to insect stings would caution the patient to: 45. The patient is admitted to the emergency room after having been bitten on the hand by a black widow spider. The nursing intervention that is indicated is to: 46. The nurse can cease CPR when there is: 47. When the accident victim presents to the emergency room with an open sucking chest wound, the nurse should apply to the wound: 49.A homeless person is brought to the ER after having been found asleep on a park bench under a layer of snow. He has a rectal temperature of 97 F. The nurse anticipates which of the following additional symptoms? 50.A mother brings in her 2-year-old who has drunk gasoline 1 hour ago. After initial assessment, the nurse will: