ATI-Perioperative MS Questions and Answers-NURS 320 : Nursing Care of Adults (NURS 320 )

A client had an open transverse colectomy 5 days ago. The nurse enters the client’s room and recognizes that the wound has eviscerated. After covering the wound with a sterile, saline-soaked dressing, which of the following actions should the nurse take? Go to the nurses’ station to seek assistance. Reinsert the organs into the abdominal cavity. Place the client in reverse Trendelenburg position. Obtain vital signs to assess for shockA nurse is caring for a client who is postoperative and has a Jackson-Pratt drain in place. Which of the following interventions should the nurse use to ensure proper functioning of the drain? Secure the drain to the client’s bed sheet. Clamp the drain when the client is ambulating. Empty and compress the drain reservoir as needed. – produces necessary suction Keep the drain higher than the surgical incisionA nurse is completing an initial PACU assessment of a client who is postoperative following a total knee arthroplasty and received spinal anesthesia. Which of the following findings indicates the need to notify the provider? The client states having numbness to the lower extremities bilaterally. –expected finding Spinal anesthesia is at the T10 level. –should still have the spinal anesthetic effect at this time, document motor and sensory function until the pt. function returns The client rouses to tactile stimuli. –moderate sedation is expected finding following surgery The client reports chest pain. –this is an indication of a PE (which total knee arthroplasty increases risk of)following observations requires an intervention? The scrub technologist is wearing a watch under his scrubs. –finger and wrist jewelry should be removed due to bacterial harboring The circulating nurse opens dressing packages before applying sterile gloves. –should be opened to maintain surgical asepsis The surgeon has her hands folded 5 cm (2 in) above the waist. –this is maintaining surgical asepsis The holding area nurse is performing client education. –this is a role of the holding area nurseA nurse is caring for a client who is postoperative. To prevent formation of thrombi in the postoperative period, the nurse should do which of the following? Change the client's position every 4 hr. –should change position every 2 hrs. Have the client perform dorsal and plantar flexion of the feet every hour. –exercise helps prevent venous stasis in lower legs and decreases the likelihood of thrombophlebitis Place the client in bed with a pillow under the knees. –can increase thromboembolism formation Assess pedal and posterior tibial pulses every 2 hr. –this is not preventio Choose a title that best describes your document