NUR 206 Final Exam Questions With Verified Answers

The nurse in the PACU performs postsurgical assessments on the newly admitted patient every _________ minutes. - Answer every 15 minutes A patient is on postoperative day 2 after a nephrectomy. What is the most effective way to increase her peristalsis? - Answer Ambulation A patient is transferred from the operating room to the recovery room after undergoing an open reduction and internal fixation (ORIF) of his left ankle. Which is the first assessment to make? - Answer Check airway for patency. A postoperative patient who had a left inguinal hernia repair is ready for his discharge instructions. Which information should the nurse provide? (Select all that apply.) - Answer - Care of the wound site and any dressings - When he may operate a motor vehicle - Signs and symptoms to report to the physician - Actions and side effects of any medications Anti-embolic stockings are in place on the obese post surgical patient. Which statement accurately describes the standard of care in regards to anti-embolic stockings? - Answer should be removed approximately 20 minutes every shift. Frequent assessment of a postoperative patient is essential. What is one of the first signs and symptoms of hemorrhage? - Answer Restlessness The nurse educates the postsurgical patient about which potential effect of smoking on postsurgical recovery? - Answer Delayed healing The nurse is caring for a 90-year-old postoperative patient whose oxygen saturation is frequently dropping below 90%. Which age-related change is most likely related to this finding? - Answer weakened respiratory muscles The nurse is caring for a patient during the first postoperative day. Which goal works to prevent atelectasis and is most appropriate for the nursing care plan? - Answer Patient will "huff-cough" every 2 hours The nurse is caring for a patient following abdominal surgery. The patient asks the nurse when he will be able to eat a normal diet. Which response is best? - Answer "Once you have bowel sounds and are passing gas, you may have clear liquids, and your diet will be advanced based upon your tolerance." The nurse is caring for a patient who had spinal anesthesia. Which drink is the best choice for the nurse to offer the patient? - Answer Tea The nurse is caring for a surgical patient who complains of excessive gas. Which action should the nurse take? - Answer Ambulate the patient in the hall. The nurse is educating the patient about vitamins and wound healing. The nurse explains that which vitamin will enhance wound healing the most? - Answer Vitamin C The nurse is performing a neurological assessment on a patient who was just transferred from the PACU following abdominal surgery. Which action(s) correctly demonstrate(s) knowledge of a neurological assessment? (Select all that apply.) - Answer - Asking the patient to identify where he is. - Noting if the patient can identify the sensation of touch. - Asking the patient to move his arms and legs. - Assessing the patient's pupils for response to light. The nurse is performing the Aldrete scoring system. Which factor(s) must be assessed? (Select all that apply.) - Answer - Activity - Circulation - Level of consciousness - O2 saturation - Respiration The PACU nurse is caring for a semiconscious patient immediately following abdominal surgery. The nurse correctly places the patient in which position? - Answer Lateral The PACU nurse is caring for an unconscious patient. Assessment reveals diminished breath sounds bilaterally. Which action should the nurse take? - Answer Document "diminished breath sounds in both lower lobes." The patient is brought into PACU still unconscious. What should the nurse do when the nurse assesses an oral temperature of 94° F? - Answer Cover with a warm blanket The postoperative nursing intervention that would be contraindicated for a 45-year-old patient who has had a repair of a cerebral aneurysm and is presenting signs of increased intracranial pressure (ICP) would be: - Answer coughing every 2 hours When the postoperative patient complains of sudden chest pain combined with dyspnea, cyanosis, and tachycardia, the nurse recognizes the signs of: - Answer pulmonary embolus Which action is most important for the nurse to take prior to ambulating the postsurgical patient for the first time? - Answer Raise the head of the bed Which of the following early postoperative observations should be reported immediately? - Answer "Coffee ground" emesis While turning a patient who had a bowel resection yesterday, the wound eviscerated. What is the initial nursing intervention? - Answer Apply a warm, moist normal saline sterile dressing. During the course of surgery, the patient exhibits tachycardia, diaphoresis, and rising body temperature. The priority intervention by the circulating nurse is to: - Answer Alert the anesthesiologist and surgeon immediately. In which situation might surgery be delayed? - Answer The patient is still taking anticoagulants The nurse clarifies the difference between regional anesthesia and procedural sedation anesthesia. Which statement about procedural sedation anesthesia is true? - Answer Procedural sedation anesthesia uses both intravenous (IV) sedation and regional anesthesia The nurse is caring for a patient who has just been given medication to reverse neuromuscular blocking agents. The nurse is aware that the patient is in which general anesthetic stage? - Answer Emergence The nurse is caring for a patient who has received epoetin alfa (Epogen) 2 to 3 weeks prior to a scheduled surgery. The nurse understands that this patient will likely: - Answer not require a blood transfusion during surgery The nurse is caring for an 82-year-old pre-surgical patient. Which abnormal finding is most important for the nurse to report immediately? - Answer Temperature of 99.8° F The nurse is caring for an Asian patient who received atropine as a preoperative drug. For which problem should the nurse should carefully monitor the patient? - Answer Tachycardia The nurse is performing a preoperative assessment on a patient scheduled for surgery today. The patient reports drinking two glasses of wine daily, smoking one pack of cigarettes daily for 20 years, completing a round of corticosteroids for asthma control 2 days ago, and taking a dose of passion flower extract yesterday. Which action should the nurse take next? - Answer Notify the physician immediately regarding the patient's recent use of corticosteroids. The nurse is reviewing the pre-surgical patient's laboratory reports and notes an elevated aspartate aminotransferase (AST) and bilirubin. The nurse understands that this patient is most at risk for which potential complication? - Answer Excessive bleeding during or after surgery The patient questions the nurse about robotics surgery. Which information should the nurse include? (Select all that apply.) - Answer - "Robotics gives the surgeon greater magnification than the human eye." - "Robotics allows the surgeon to be more precise than normal." - "Robotics allows for a smaller incision." - "Robotics procedures generally cause less postoperative pain." The patient refuses to take off her diamond wedding band before going to the op room. What action should the nurse take? - Answer Tape the ring to finger, covering the ring What are the purposes of preoperative medication? (Select all that apply.) - Answer - To reduce anxiety - To decrease mucus secretion - To counteract nausea - To synergize anesthesia What is the ideal time for preoperative teaching? - Answer 1 to 2 days before the surgery when anxiety is not as high What is the responsibility of the nurse as a witness to informed consent? - Answer Verify/obtain the patient's signature When the patient asks the nurse to make sure no one sees her with her dentures out, the nurse recognizes the common preoperative fear of: - Answer loss of control Prior to administering the preoperative medication of Demerol and atropine, the nurse should confirm that: - Answer Verify that a consent form is signed Which factor(s) may contribute to hypothermia during surgery? (Select all that apply. - Answer - Infusion of cool IV fluids - Inhalation of cool anesthetic gases - Exposure of body surfaces - Lowered metabolism Which medication would cause surgery to be delayed if it had not been discontinued several days before surgery? - Answer Anticoagulant agent Which physiological change(s) explain why the older adult is at greater surgical risk? (Select all that apply.) - Answer - Fewer physiologic reserves - Greater probability of a chronic illness - Greater vulnerability to fluid loss Which responses indicate to the nurse that the patient understands preoperative teaching? (Select all that apply.) - Answer - "I will need to sign a consent form before I am given my medications prior to my surgery." - "The surgeon will want me to ambulate as soon as possible after my surgery." - "My nurse will want me to take the deepest breaths I can tolerate following my surgery." - "I may experience some constipation if I am taking much pain medication after my surgery." Does general anesthesia prevent the patient to have any pain? - Answer No Which statement made by a patient during a preoperative assessment would be significant to report to the charge nurse and surgeon? - Answer "I have been taking an herbal product of feverfew for my migraines." Although the patient with a kidney stone denies pain, the nurse assess cues that indicate that pain is perceived. Which assessments indicate that pain may be present? - Answer - muscle tension - diaphoresis - nausea - increased pulse rate The nurse is constructing a teaching plan about fatigue management for a patient who is taking radiation treatments. Which information should the nurse include? - Answer Prioritize activities and alternate rest with periods of activity. A 32-year-old mother is undergoing radiation from a sealed-source modality and has been isolated in a private room for 3 days. How should the nurse best prepare for the patient's 8-year-old twins to visit? - Answer Put chairs in the hall for "long-distance" visitation. Which description(s) is/are characteristic of a malignant neoplasm? (Select all that apply.) - Answer -Disorganization -Altered DNA -Invasion of nearby organs -Travel through body fluid The nurse is instructing a patient who is on a biologic response modifier (BRM) colony-stimulating drug. The nurse teaches that about which desired action from this medication? - Answer Enhanced recovery of bone marrow A patient who has malignant cancer secondary to a high-grade lymphoma has been admitted with muscle weakness, tetany, paresthesia, and convulsion. Lab studies reveal hyperkalemia and Hyperuricemia the nurse recognizes that the patient is most likely suffering from? - Answer Tumor Lysis Syndrome (TLS) A patient receiving chemotherapy has thrombocytopenia. What is the most appropriate that the nurse should teach the patient? - Answer Do not take aspirin for a headache The 52-year-old male who was diagnosed with a benign growth in her colon is concerned about the growth spreading. Which explanation best allays the patient's anxiety? - Answer "Benign growths are surrounded by fibrous tissue that prevents spread." The nurse assesses several patients in the outpatient clinic. Which patient has the greatest risk for developing cancer? - Answer 45-year-old farmer from Texas who has worked on his family's cotton farm since the age of 12 The nurse assesses a man who is scheduled for a prostate-specific antigen (PSA) test. The nurse understands that which situation could delay the test? - Answer The patient reports having a recent urinary tract infection (UTI). The nurse is educating the 40-year-old female patient about the American Cancer Society (ACS) recommendations for early detection of cancer. Which information should she include when teaching? - Answer Obtain a mammogram every year The 26-year-old patient with a malignant neoplasm has experienced a 10-pound weight loss in 3 weeks. To which factor is this patient's rapid weight loss most likely related? - Answer The malignancy's high nutritional demand The nurse cautions that the most common site of cancer in adult men is the: - Answer Prostate A patient has developed stomatitis from chemotherapy. What should the appropriate intervention for this condition include? - Answer Using a soft toothbrush A patient is undergoing external radiation and helping the patient with effects the nurse would? - Answer Instruct the patient to wear loose fitting, cotton clothing Which viruses are responsible for specific cancers? (Select all that apply.) - Answer -Liver cancer from hepatitis B virus -Burkitt lymphoma from Epstein-Barr virus -Cervical cancer from human papillomavirus -Kaposi sarcoma from human immunodeficiency virus The patient has terminal cancer of the prostate and screams at you. What type of emotion he he experiencing? - Answer Anger The nurse reinforces patient instructions regarding neutropenic precautions. Important topics should include which of the following? - Answer - No fresh fruit - No raw vegetables or salads - Encourage hand hygiene The nurse is teaching a 50-year-old male patient who is taking estrogens as treatment of prostate cancer. The nurse should educate the patient about which expected side effect? - Answer Gynecomastia The nurse is caring for a terminally ill cancer patient who is receiving palliative care. The patient's wife asks how her husband's pain will be controlled as he nears death. Which is the nurse's best response? - Answer "Most of the time we can manage the pain with oral morphine and transdermal pain medication." The nurse explains that metastasis from the original site to a new site can occur in a variety of ways. Which mechanisms do malignant cells use to metastasize? (Select all that apply.) - Answer -"Transplantation" via surgical instruments during surgery. -Entering a body cavity and attaching to an organ. -Traveling through the lymphatic system. -"Relocation" from contaminated gloves during surgery. The nurse found a pellet in the bed of a patient receiving sealed internal radiation. What should the nurse do? - Answer Pick it up with a long handled lead tong and place it in lead container. Radiation has an immediate and delayed effect on cells. What statement holds true? - Answer The delayed effect is that it alters the DNA and impairs the ability to replicate or reproduce Using the TNM staging classification system, what does a tumor staged as T2N2M2 mean? - Answer large tumor, with lymph node involvement, and metastases Tumors originating from epithelial tissues and epithelial cells are? - Answer melanomas Which of the following are thrombocytopenic precautions? - Answer Using an electric razor