Summary NURS 3205 - MedSurg Final Exam

Why does the nurse always ask the client his or her pain level after taking routine vital signs? - ANS-- To ensure that pain assessment occurs on a regular basis The nurse is caring for four clients who are complaining of pain. Based on the following assessments and histories, which client's pain is most likely chronic in nature? - ANS-- History of rheumatoid arthritis with a blood pressure of 100/70 mm Hg Which question should NOT be asked when conducting a pain assessment interview? - ANS-- "Have any members of your family ever abused drugs?" The primary role of the nurse in pain management is to advocate for the client by... - ANS-- believing the client's report of pain Which nursing diagnosis has the highest priority for the client who is receiving epidural analgesia with fentanyl (Sublimaze) for acute postoperative pain? - ANS-- Risk for Infection related to epidural catheter location The nurse is caring for a client who had surgery 24 hours ago. Which is the best indicator for the nurse to know that the client's pain is well controlled? - ANS-- The client states that she has no pain. A client with cholecystitis (inflammation of the gallbladder) has pain in the right shoulder area and asks, "What is happening to me? What did I do to my shoulder?" What is the nurse's best response? - ANS-- "Sometimes pain from a certain organ is referred elsewhere in the body." Which statement made by a nurse represents the need for further education regarding pain management in older adult clients? - ANS-- "Older clients have a different pain mechanism and do not feel it as much." Which nursing diagnosis is most appropriate for a patient during the preoperative phase of surgery? - ANS-- Anxiety related to fear of postoperative pain A client is brought to the hospital unconscious and needs emergency surgery. The client's only family member cannot come to the hospital before surgery. Which is the best option for obtaining informed consent for the client's emergent surgery? - ANS-- Contact the family member by phone and obtain verbal consent with two witnesses. What recently learned information about a client who is scheduled to have surgery within the next 12 hours is the nurse certain to communicate to the surgical team? - ANS-- Hearing problem Which is an important outcome of preoperative teaching for any patient? The patient will: - ANS-- Verbalize an understanding of perioperative routines Which patient is at increased risk for developing postoperative deep vein thrombosis? - ANS-- A 55-year-old obese woman having an abdominal hysterectomy The client will be undergoing palliative surgery to debulk an abdominal tumor, The client's daughter asks why the surgery is considered to be palliative. What is the nurse's best response? - ANS-- "The surgery will relieve the symptoms of bowel obstruction. It will not cure your father." The client undergoing preoperative assessment before an elective procedure tells the nurse that she has been taking 10 mg of prednisone (a steroid) daily for rheumatoid arthritis. What is the nurse's best action? - ANS-- Notify the surgeon and anesthesiologist. When the nurse brings the client's preoperative medications, the client responds, "I don't need that. I had a good night's sleep last night." What is the nurse's best response? - ANS-- "The medication will help prevent some complications during surgery." The nurse has just completed preoperative teaching with a female client who will be having major surgery the following day. Which statement by the client indicates that additional teaching is needed? - ANS-- "I will wear my lucky earrings tomorrow during the surgery." Which diagnostic study is generally omitted from the preoperative screening of a 54 year old male? - ANS-- Urine for C & S The nurse is caring for a client who will be undergoing emergency surgery very soon. Which information is most important for the nurse to teach the client at this time? - ANS-- What to expect in the operating and recovery rooms The preoperative client tells the nurse that he was an advanced directive with durable power of attorney for health care. The client asks how the advance directive will affect his surgery. What is the nurse's best response? - ANS-- "If you are unable to make a decision, your designee will be asked." During the preoperative assessment, the client tells the nurse that he smokes three packs of cigarettes daily. The information alerts the nurse to which potential complication that the client may experience during surgery and recovery? - ANS-- Increased risk for atelectasis The preoperative client tells the nurse that she has allergies to several substances. Which allergy presents the greatest potential problem considering the scheduled surgery? - ANS-- Bananas A client is brought to the emergency department (ED) after a motorcycle accident. The client has suffered a ruptured spleen. What is the immediate priority? - ANS-- Emergent surgery to control bleeding Four clients are scheduled for surgery. Which client does the nurse determine is at highest risk for postsurgical complications? - ANS-- 89-year-old scheduled for a knee replacement The nurse is caring for an older adult client who has just returned to the medical-surgical unit from the postanesthesia recovery unit. The client does not remember that he just had surgery. What is the nurse's best action? - ANS-- Reorienting the client as needed and check the client frequently The nurse is caring for a client who has just been brought to the PACU after surgery. What is the best indicator that the client is demonstrating adequate oxygenation? - ANS-- The client's oxygen saturation is 96%, and hemoglobin and hematocrit are within normal limits. While being transported from surgery to the PACU, a patient begins coughing and retching. What is the first thing the nurse will do? - ANS-- Roll the patient to the lateral, side-lying position The nurse assesses a client who has just been brought to the postanesthesia care unit (PACU). Which assessment finding is the best indicator that the client's circulatory status may be compromised? - ANS-- The urine output decreased from 40 to 10 mL/hr. Which activity helps minimize venous stasis and prevents development of thrombophlebitis in the postoperative patient? - ANS-- Having the patient ambulate as soon after the surgery as possible The nurse is caring for a client who had abdominal surgery 3 days ago and has a large abdominal incision. When the nurse enters the client's room, he tells the nurse, "I felt my incision pop when I coughed a little while ago." What is the nurse's best response? - ANS-- "Lie down with the head of the bed slightly raised and with your knees bent and let me examine your incision." Which precaution or issue should the nurse reinforce to the postoperative client about correct use of the patient-controlled (PCA) device? - ANS-- "Push the button when you feel pain beginning rather than waiting until the pain is at its worst." Two hours after colon surgery, the nurse auscultates the client's abdomen. No bowel sounds are present. What is the nurse's best action? - ANS-- Document the finding as the only action. One hour after admission to the PACU, the postoperative client has become very restless. What is the nurse's best first action? - ANS-- Check the client's oxygen saturation level. The nurse is caring for multiple postoperative clients on the medical-surgical unit. At the beginning of the shift, the nurse needs to determine which client should be seen first. The nurse should assess which of the following clients first? - ANS-- A client who has new red drainage from the nasogastric tube The nurse is caring for several clients in the postoperative unit. Which client does the nurse assess first because of their elevated risk of respiratory complications after general anesthesia? - ANS-- A young adult who is extremely obese A diabetic client underwent surgery 24 hours ago. Which precautions should the nurse take to help prevent postoperative complications for this client? - ANS-- Use sterile technique during dressing changes. The nurse is working in the PACU and receives a client from the operating room (OR) with many lines and tubes in place. Which should the nurse assess first? - ANS-- The client's endotracheal tube The client is brought to the 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 surgical position? - ANS-- The client's dorsalis pedis pulses are not palpable. The nurse receives a report that the client's Foley catheter was emptied just prior to transfer to the medical-surgical unit. Two hours later, the nurse notes that the client's urinary output is 30 mL. What is the nurse's best first action? - ANS-- Checking the patency of the Foley catheter The nurse is changing the client's dressing on the second postoperative day and notes a slight crust on the edges of the incision and a small amount of serosanguineous drainage. What is the nurse's best action? - ANS-- Cleaning the suture line gently with sterile saline and applying a new dry sterile dressing The nurse is caring for a client who has had surgery the previous day. The client tells the nurse, "Breathing in this tube thing (incentive spirometer) is a ridiculous waste of time." What is the nurse's best response? - ANS-- "The spirometer will help your lungs expand." The nurse review the initial postanesthesia care unit (PACU) flow record and notes that the client is alert and oriented x3 when stimulated, pulse is 88 per minute and regular, respirations are 12 per minute and unlabored, and oxygen saturation is 95% on 2 liters/min of nasal oxygen. What is the nurse's priority action at this time? - ANS-- Examine the surgical dressing; obtain blood pressure and temperature. A client is being transferred to the postanesthesia care unit (PACU) after surgery. The client has an endotracheal tube (ET) in place. On assessment, the client has oxygen saturation of 95%, respiratory rate of 14 breaths/min, and asymmetric chest wall expansion. What is the nurse's best action? - ANS-- Auscultate lung sounds bilaterally. When the nurse administers I.V. midazolam hydrochloride (Versed), the client demonstrates signs of an overdose. The nurse should next collaborate with the surgical team to: - ANS-- Ventilate with an oxygenated Ambu bag. Which of the following nursing interventions is most important in preventing postoperative complications? - ANS-- Early ambulation. A client who had a gastrectomy has been in the postanesthesia recovery room for 30 minutes when his vital signs suddenly change. The nurse checks the recovery room record (see chart). In addition to notifying the physician, what other action should the nurse take immediately? Vital Signs: Pulse: 70 - 80 - 90 Respiration: 12 - 14 - 20 Blood pressure: 100/60 - 110/70 - 140/90 Temp: 98 - 99 - 102 - ANS-- Administer dantrolene (Dantrium) as ordered. A client who had an esophageal hernia repair 4 hours ago has a pulse rate of 90bpm, respiration rate of 16/minute, blood pressure of 130/80 mm Hg, pulse oximeter of 91, and a temperature of 100.4 F (38 C). What should the nurse do first? - ANS-- Assist the client to a sitting position to take deep breaths. A client had a total abdominal hysterectomy and bilateral oophorectomy (removal of ovaries) for ovarian carcinoma yesterday. She received 2mg of morphine sulfate I.V. by patient-controlled analgesia (PCA) 10 minutes ago. The nurse was assisting her from the bed to a chair when the client felt dizzy and fell into the chair. The nurse should: - ANS-- Take the client's blood pressure. Which of the following assessment findings is (are) most indicative of acute pain in a client who is sincerely confused? - ANS-- Screaming Facial grimace Restlessness The nurse is conducting preoperative teaching with a client who will be undergoing pelvic surgery. The nurse explains the use of antiembolism stockings and pneumatic compression devices. Which statements by the client indicate that additional teaching is needed? - ANS-- "At least I will only have to wear the white stockings and SCD during surgery and not when I am recovering afterward." "I'm amazed that TED stockings can come as 'one size fits all' since my legs are so short." "I'm glad that the stockings and SCDs will be off during the night so I can sleep." EXTRA CREDIT Which clients are at an increased risk for postoperative nausea and vomiting? - ANS-- A middle aged client who is obese. A female client who has undergone a cholecystectomy. A male client who has a history of seasickness.