Advanced Cardiac Life Support (ACLS): Sepsis
questions and answers
A 68-year-old client who is admitted to the medical-surgical unit with acute cholecystitis and is
scheduled for a laparoscopic cholecystectomy in the morning. He is ambulatory without the use of an
assistive device. His medical history includes hypertension (HTN) and type 2 diabetes mellitus (DM).
His surgical history consists of an appendectomy in childhood and he reports no complications. He is
independent and lives with his spouse in a retirement community. Client reports that he has not
eaten in the last two days due to nausea, vomiting, and abdominal pain.
The nurse is aware that the older adult client is at an increased risk for surgical complications due to
normal physiological functions and comorbidities. Which risk factors place the older adult client at
increased risk for surgical complications?
- Decreased respiratory muscle strength.
- Increased glomerular filtration rate.
- Enhanced elasticity of the arterial walls.
- Rigidity of the arterial walls increases the client’s risk for complications.
Decreased respiratory muscle strength.
A decrease in respiratory muscle strength predisposes the older client to postoperative respiratory
complications.
Upon completing the client's assessment, the nurse determines that the client has which surgical risk
factors? (Select all that apply.)
- Metoprolol.
- Poor appetite.
- Diabetes Mellitus.
- Albumin 3.0 g/dL (30 g/L).
- Marital status.
Metoprolol.
Metoprolol has the potential to increase the risk of bradycardia when used in conjunction with
anesthetics.
Poor appetite.
Poor appetite places the client at risk for surgical complications due to inadequate nutrition.
Diabetes Mellitus.
Preexisting conditions, such Diabetes Mellitus (DM), increase the client’s risk for surgical complications.
Albumin 3.0 g/dL (30 g/L).
, Low albumin places the client at risk for surgical complications.
What is the priority preoperative nursing action to prevent postoperative atelectasis?
- Administer pain medication as needed.
- Instruct on incentive spirometer use.
- Obtain baseline pulse saturation.
- Turn and position every 2 hours.
Instruct on incentive spirometer use.
The nurse should teach the client how to use an incentive spirometer in the preoperative period to help
decrease risk of atelectasis. The nurse should also ensure that learning has occurred through client
verbalization and return demonstration.
See an expert-written answer!
Which is the likely reason for the elevated serum creatinine in the absence of kidney disease?
- Anemia.
- Hypertension.
- Increased pain.
- Dehydration.
Dehydration
Dehydration can temporarily increase creatinine.
The client is aware that he needs to cough, take deep breaths, and use the incentive spirometer in the
postoperative period. He is prepared for surgery and his spouse is sent to the surgical waiting area while
the client is transferred to the operating room. Upon attempting the laparoscopic cholecystectomy, the
surgeon discovers that the client's gallbladder is necrotic, resulting in the surgeon performing an open
cholecystectomy. The client is transferred to the post anesthesia care unit (PACU) where he is
extubated.
The nurse is caring for the client who has just been extubated. What should the nurse do first, after the
client is extubated?
- Administer supplemental oxygen.
- Auscultate bilateral lung sounds.
- Encourage cough and deep breathing.
- Notify the spouse of extubation.
Administer supplemental oxygen.
Administering supplemental oxygen allows for adequate perfusion.
One hour has passed since the client was extubated. Which nursing actions take priority at this time?
(Select all that apply.)
Monitor respiratory rate.
questions and answers
A 68-year-old client who is admitted to the medical-surgical unit with acute cholecystitis and is
scheduled for a laparoscopic cholecystectomy in the morning. He is ambulatory without the use of an
assistive device. His medical history includes hypertension (HTN) and type 2 diabetes mellitus (DM).
His surgical history consists of an appendectomy in childhood and he reports no complications. He is
independent and lives with his spouse in a retirement community. Client reports that he has not
eaten in the last two days due to nausea, vomiting, and abdominal pain.
The nurse is aware that the older adult client is at an increased risk for surgical complications due to
normal physiological functions and comorbidities. Which risk factors place the older adult client at
increased risk for surgical complications?
- Decreased respiratory muscle strength.
- Increased glomerular filtration rate.
- Enhanced elasticity of the arterial walls.
- Rigidity of the arterial walls increases the client’s risk for complications.
Decreased respiratory muscle strength.
A decrease in respiratory muscle strength predisposes the older client to postoperative respiratory
complications.
Upon completing the client's assessment, the nurse determines that the client has which surgical risk
factors? (Select all that apply.)
- Metoprolol.
- Poor appetite.
- Diabetes Mellitus.
- Albumin 3.0 g/dL (30 g/L).
- Marital status.
Metoprolol.
Metoprolol has the potential to increase the risk of bradycardia when used in conjunction with
anesthetics.
Poor appetite.
Poor appetite places the client at risk for surgical complications due to inadequate nutrition.
Diabetes Mellitus.
Preexisting conditions, such Diabetes Mellitus (DM), increase the client’s risk for surgical complications.
Albumin 3.0 g/dL (30 g/L).
, Low albumin places the client at risk for surgical complications.
What is the priority preoperative nursing action to prevent postoperative atelectasis?
- Administer pain medication as needed.
- Instruct on incentive spirometer use.
- Obtain baseline pulse saturation.
- Turn and position every 2 hours.
Instruct on incentive spirometer use.
The nurse should teach the client how to use an incentive spirometer in the preoperative period to help
decrease risk of atelectasis. The nurse should also ensure that learning has occurred through client
verbalization and return demonstration.
See an expert-written answer!
Which is the likely reason for the elevated serum creatinine in the absence of kidney disease?
- Anemia.
- Hypertension.
- Increased pain.
- Dehydration.
Dehydration
Dehydration can temporarily increase creatinine.
The client is aware that he needs to cough, take deep breaths, and use the incentive spirometer in the
postoperative period. He is prepared for surgery and his spouse is sent to the surgical waiting area while
the client is transferred to the operating room. Upon attempting the laparoscopic cholecystectomy, the
surgeon discovers that the client's gallbladder is necrotic, resulting in the surgeon performing an open
cholecystectomy. The client is transferred to the post anesthesia care unit (PACU) where he is
extubated.
The nurse is caring for the client who has just been extubated. What should the nurse do first, after the
client is extubated?
- Administer supplemental oxygen.
- Auscultate bilateral lung sounds.
- Encourage cough and deep breathing.
- Notify the spouse of extubation.
Administer supplemental oxygen.
Administering supplemental oxygen allows for adequate perfusion.
One hour has passed since the client was extubated. Which nursing actions take priority at this time?
(Select all that apply.)
Monitor respiratory rate.
