GNRS 555: EXAM 1 BY M.H WITH QUESTIONS AND CORRECT
ANSWERS
Obesity cplaces cpatients cat can cincreased csurgical crisk cbecause cof cwhich cof cthe cfollowing cfactors?
1. cRisk cfor cbleeding cis cincreased.
2. cVentilatory ccapacity cis creduced.
3. cFatty ctissue chas ca cpoor cblood csupply.
4. cMetabolic cdemands care cincreased.
5. cPhysical cmobility cis coften cimpaired. c- cCORRECT cANS✔✔2, c3, c5
CH. c50
The cprimary creason cthat cyou cneed cto cinclude cfamily cmembers cwhen cyou cteach ca cpatient cpreoperative cexercises cis cso cthey
ccan:
1. cCoach cand cencourage cthe cpatient cafter csurgery.
2. cDemonstrate cto cthe cpatient cat chome.
3. cRelieve cthe cnurse cby cgetting cthe cpatient cto cdo cthe cexercises cevery c2 chours.
4. cPractice cwith cthe cpatient cwhile che cor cshe cis cwaiting cto cbe ctaken cto cthe coperating croom. c- cCORRECT cANS✔✔1
CH. c50
In cthe cpostanesthesia ccare cunit c(PACU) ca cnurse cnotes cthat ca cpatient cis chaving cdifficulty cbreathing cand csuspects can cupper-
airway cobstruction. cThe cnurse's cpriority cintervention cat cthis ctime cis:
1. cSuction cthe cpharynx cand cbronchial ctree.
2. cGive coxygen cthrough ca cmask cat c4 cL/min.
3. cAsk cthe cpatient cto cuse can cincentive cspirometer.
4. cPosition cthe cpatient con cone cside cwith cthe cface cdown cand cthe cneck cslightly cextended cso cthe ctongue cfalls cforward. c-
cCORRECT cANS✔✔4
CH. c50
Because can colder cadult cis cat cincreased crisk cfor crespiratory ccomplications cafter csurgery, cthe cnurse cneeds cto:
1. cWithhold cpain cmedications cand cambulate cthe cpatient cevery c2 chours.
2. cMonitor cfluid cand celectrolyte cstatus cevery cshift cand cvital csigns cwith ctemperature cevery c4 chours.
3. cOrient cthe cpatient cto cthe csurrounding cenvironment cfrequently cand cambulate chim cor cher cevery c2 chours.
4. cEncourage cthe cpatient cto cturn, cdeep cbreathe, cand ccough cfrequently cand censure cadequate cpain ccontrol. c- cCORRECT
cANS✔✔4
CH. c50
You care ccaring cfor ca cpatient cafter csurgery cwho chad ca cliver cresection. cHis cprothrombin ctime c(PT) cis cgreater cthan cnormal.
cHe chas clow cblood cpressure; ctachycardia; cthready cpulse; cand ccool, cclammy, cpale cskin, cand che cis crestless. cYou cassess chis
csurgical cwound, cand cthe cdressing cis csaturated cwith cblood. cWhich cimmediate cinterventions cdo cyou cperform? c(Select call cthat
capply.)
1. cNotify cthe csurgeon.
2. cMaintain cintravenous c(IV) cfluid cinfusion cand cprepare cto cgive cvolume creplacement.
3. cMonitor cthe cpatient's cvital csigns cevery c15 cminutes cor cmore cfrequently cuntil chis ccondition cstabilizes.
4. cWean coxygen ctherapy.
5. cProvide ccomfort cthrough cbathing. c- cCORRECT cANS✔✔1, c2, c3
CH. c50
,You care ca cnurse cin cthe cpostanesthesia ccare cunit c(PACU), cand cyou cnote cthat cyour cpatient chas ca cheart crate cof c130
cbeats/min cand ca crespiratory crate cof c32 cbreaths/min; cyou calso cassess cjaw cmuscle crigidity cand crigidity cof climbs, cabdomen,
cand cchest. cWhat cdo cyou csuspect, cand cwhich cintervention cis cindicated?
1. cInfection: cNotify csurgeon cand canticipate cadministration cof cantibiotics.
2. cPneumonia: cListen cto cbreath csounds, cnotify csurgeon, cand canticipate corder cfor cchest cradiography.
3. cHypertension: cCheck cblood cpressure, cnotify csurgeon, cand canticipate cadministration cof cantihypertensives.
4. cMalignant chyperthermia: cNotify csurgeon/anesthesia cprovider cimmediately, cprepare cto cadminister cdantrolene csodium
c(Dantrium), cand cmonitor cvital csigns cfrequently. c- cCORRECT cANS✔✔4
CH. c50
After ca cpatient chas cbeen cgiven cpreoperative csedatives, cwhich csafety cprecaution cdo cyou ctake?
1. cReinforce cto cpatient cto cremain cin cbed cor con cthe cstretcher
2. cRaise cthe cside crails cand ckeep cthe cbed cor cstretcher cin cthe chigh cposition
3. cDetermine cif cpatient chas cany callergies cto clatex
4. cObtain cinformed cconsent cimmediately cafter csedative cadministration c- cCORRECT cANS✔✔1
CH. c50
The coperating croom c(OR) cand cpostanesthesia ccare cunit c(PACU) care chigh-risk cenvironments cfor cpatients cwith ca clatex
callergy. cWhich csafety cmeasures cdo cnurses cin cthese careas cimplement cto cprevent ca clatex creaction? c(Select call cthat capply.)
1. cScreen cpatients cabout cfood callergies cknown cto chave ccross-reactivity cto clatex.
2. cHave ca clatex callergy ccart cavailable cat call ctimes.
3. cCommunicate cwith cthe coperating croom c(OR) cteam cas csoon cas c24 cto c48 chours cin cadvance cof cthe csurgery cwhen ca
cpatient cwith clatex csensitivity cis cidentified.
4. cSchedule cthe cpatient cwith ca clatex callergy cfor cthe clast coperative ccase cof cthe cday.
5. cPlan cfor cthe cpatient cto cbe cadmitted cto ca cprivate croom cafter csurgery. c- cCORRECT cANS✔✔1, c2, c3
CH. c50
A cnurse cis crecovering ca cpatient cwho creceived cconscious csedation cfor ccosmetic csurgery. cWhich cof cthe cfollowing cis can
cadvantage cthat cconscious csedation chas cover cgeneral canesthesia? c(Select call cthat capply.)
1. cLoss cof csensation cat cthe csurgical csite
2. cReduction cof cfear cand canxiety
3. cAmnesia cabout cprocedure
4. cMonitoring cin cphase cI crecovery
5. cClose cmonitoring cfor cairway cpatency c- cCORRECT cANS✔✔2, c3
CH. c50
You care cassigned cto ccare cfor cthe cfollowing cpatients con cyour csurgical cunit. cOn cthe cbasis cof cthe cinformation cprovided, cwhich
cpatient cdo cyou cneed cto csee cfirst?
1. cA c75-year-old cfollowing chip creplacement csurgery cwho cis ccomplaining cof cmoderate cpain cin cthe csurgical csite, cwith ca cheart
crate cof c92
2. cA c57-year-old cfollowing chip creplacement c6 chours cearlier cwho cis creceiving cintravenous cpatient-controlled canalgesia c(PCA)
cwith ca chistory cof cobstructive csleep capnea c(OSA) c(The cpulse coximeter chas cbeen calarming cand creading c85%.)
3. cA c36-year-old cfollowing cbladder cneck csuspension cwho cis c30 cminutes clate cto creceive cher cpostoperative cdose cof cantibiotic
4. cA c48-year-old cfollowing ctotal cknee creplacement cwho cneeds chelp crepositioning cin cbed c- cCORRECT cANS✔✔2
CH. c50
Hand-off ccommunications cthat coccur cbetween cthe cpostanesthesia ccare cunit c(PACU) cnurse cand cthe cnurse con cthe
cpostoperative cnursing cunit cneed cto cbe cdone cwhen ca cpatient creturns cto cthe cnursing cunit. cWhich care cappropriate
ccomponents cof ca csafe cand ceffective chand-off? c(Select call cthat capply.)
1. cVital csigns, ctype cof canesthesia cprovided, cblood closs, cand clevel cof cconsciousness
2. cUninterrupted ctime cto creview cthe crecent cpertinent cevents cand cask cquestions
3. cVerification cof cthe cpatient cusing cone cidentifier cand cthe ctype cof csurgery cperformed
4. cReview cof cpertinent cevents coccurring cin cthe coperating croom c(OR) cwhile cat cthe cnurses' cstation
5. cLocation cof cpatient's cfamily cmembers c- cCORRECT cANS✔✔1, c2, c5
CH. c50
A cnurse cis cworking cin cthe cpreoperative cholding carea cand cis cassigned cto ccare cfor ca cpatient cwho cis chaving ca cprosthetic
caortic cvalve cplaced. cThe cnurse cinserts can cintravenous c(IV) cline cand cobtains cvital csigns. cThe cpatient chas ca ctemperature cof
c39° cC c(102° cF), cheart crate cof c120, cblood cpressure c(BP) cof c84/50, cand can celevated cwhite cblood ccell c(WBC) ccount. cThe
cnurse cimmediately cnotifies cthe csurgeon cof cthe cpatient's cvital csigns cbecause:
1. cHe cor cshe cneeds cto cget cthe cpatient cinto cthe coperating croom c(OR) cquickly cto cstart cthe csurgery cbecause cof cthe clow cBP.
,2. cThe csurgery cmay cneed cto cbe cdelayed cto crecheck cthe cpatient's cWBC ccount cand cinvestigate cthe csource cof cfever cbefore
csurgery.
3. cThe cnurse canticipates cthe cneed cfor ca cfluid cbolus cto cincrease cthe cpatient's cBP.
4. cThe cnurse canticipates can corder cfor ca csedative cto chelp ccalm cthe cpatient cand cdecrease cthe cheart crate. c- cCORRECT
cANS✔✔2
CH. c50
A cnurse cis cpreparing cto cprovide ca cpatient cwith cinstructions cfor chow cto cperform cincentive cspirometry. cThe cpatient cwill clikely
chave cincisional cpain cafter creturning cfrom can celective ccolon cresection. cWhich cof cthe cfollowing csteps cfor cincentive cspirometry
cis cthe cpatient clikely cto chave cthe cmost cdifficulty cperforming? c(Select call cthat capply.)
1. cAssuming csemi-Fowler's cor chigh-Fowler's cposition
2. cSetting cthe cincentive cspirometer cdevice cscale cat cthe cvolume clevel cto cbe cattained
3. cPlacing cthe cmouthpiece cof cthe cincentive cspirometer cso clips ccompletely ccover cthe cmouthpiece
4. cInhaling cslowly cwhile cmaintaining cconstant cflow cthrough cunit cuntil cit creaches cgoal cvolume
5. cBreathing cnormally cfor ca cshort cperiod cbetween ceach cof cthe c10 cbreaths con cincentive cspirometry
6. cEnding cwith ctwo ccoughs cafter cthe cend cof c10 cincentive cspirometry cbreaths chourly c- cCORRECT cANS✔✔1, c4, c6
CH. c50
A cpatient cis cadmitted cthrough cthe cemergency cdepartment cfollowing ca cmotorcycle ccrash cwith cmultiple corthopedic cinjuries. cHe
cgoes cto csurgery cfor crepair cof cfractures. cHe cis cpostoperative cday c3 cfrom can copen-reduction cinternal cfixation cof cbilateral
cfemur cfractures cand cexternal cfixator cto chis cunstable cpelvic cfracture. cInterventions cthat care cnecessary cfor cprevention cof
cvenous cthromboembolism cin cthis cpatient cinclude: c(Select call cthat capply.)
1. cIntermittent cpneumatic ccompression cstockings.
2. cVitamin cK ctherapy.
3. cPassive crange-of-motion cexercises cevery c4 chours.
4. cSubcutaneous cheparin cor cenoxaparin c(Lovenox).
5. cContinuous cheparin cdrip cwith ca cgoal cof can cinternational cnormalized cratio c(INR) c5 ctimes chigher cthan cbaseline. c-
cCORRECT cANS✔✔1, c4
Ch. c50
You care ccaring cfor ca c65-year-old cpatient c2 cdays cafter csurgery cand chelping chim cambulate cdown cthe challway. cThe csurgeon
cordered cexercise cas ctolerated. cYour cassessment cindicates cthat cthe cpatient's cheart crate cat cbaseline cis c88. cAfter cwalking
capproximately c30 cyards cdown cthe challway, chis cheart crate cis c110. cWhat cis cyour cnext caction?
1. cStop cexercise cimmediately cand chave chim csit cin ca cnearby cchair.
2. cAsk chim chow che cfeels; cdetermine cif cthere cis cany cdiscomfort cor cshortness cof cbreath; cand, cif cnot, ccontinue cexercise.
3. cTell chim cthat che cneeds cto cwalk cfurther cto creach ca cheart crate cof c120.
4. cHave chim cwalk cslower; che chas creached chis cmaximum. c- cCORRECT cANS✔✔2
Ch. c50
When crepositioning can cimmobile cpatient, cthe cnurse cnotices credness cover cthe chip cbone. cWhat cis cindicated cwhen ca creddened
carea cblanches con cfingertip ctouch?
1. cA clocal cskin cinfection crequiring cantibiotics
2. cSensitive cskin cthat crequires cspecial cbed clinen
3. cA cstage cIII cpressure culcer cneeding cthe cappropriate cdressing
4. cBlanching chyperemia, cindicating cthe cattempt cby cthe cbody cto covercome cthe cischemic cepisode c- cCORRECT cANS✔✔4
CH. c48
Match cthe cpressure culcer ccategories/stages cwith cthe ccorrect cdefinition.
1. cCategory/stage cI
2. cCategory/stage cII
3. cCategory/stage cIII
4. cCategory/stage cIV
a. cNonblanchable credness cof cintact cskin. cDiscoloration, cwarmth, cedema, cor cpain cmay calso cbe cpresent.
b. cFull-thickness cskin closs; csubcutaneous cfat cmay cbe cvisible. cMay cinclude cundermining.
c. cFull cthickness ctissue closs; cmuscle cand cbone cvisible. cMay cinclude cundermining.
d. cPartial-thickness cskin closs cor cintact cblister cwith cserosanguinous cfluid. c- cCORRECT cANS✔✔1=a
2=d
3=b
4=c
CH. c48
When cobtaining ca cwound cculture cto cdetermine cthe cpresence cof ca cwound cinfection, cfrom cwhere cshould cthe cspecimen cbe
ctaken?
, 1. cNecrotic ctissue
2. cWound cdrainage
3. cWound ccircumference
4. cCleansed cwound c- cCORRECT cANS✔✔4
CH. c48
After csurgery cthe cpatient cwith ca cclosed cabdominal cwound creports ca csudden c"pop" cafter ccoughing. cWhen cthe cnurse
cexamines cthe csurgical cwound csite, cthe csutures care copen, cand cpieces cof csmall cbowel care cnoted cat cthe cbottom cof cthe cnow-
opened cwound. cWhich care cthe cpriority cnursing cinterventions? c(Select call cthat capply.)
1. cNotify cthe csurgeon.
2. cAllow cthe carea cto cbe cexposed cto cair cuntil call cdrainage chas cstopped.
3. cPlace cseveral ccold cpacks cover cthe carea, cprotecting cthe cskin caround cthe cwound
4. cCover cthe carea cwith csterile, csaline-soaked ctowels cimmediately.
5. cCover cthe carea cwith csterile cgauze cand capply can cabdominal cbinder. c- cCORRECT cANS✔✔1, c4
CH. c48
What cis cthe ccorrect csequence cof csteps cwhen cperforming cwound cirrigation cto ca clarge copen cwound?
1. cUse cslow, ccontinuous cpressure cto cirrigate cwound.
2. cAttach c19-gauge cangiocatheter cto csyringe.
3. cFill csyringe cwith cirrigation cfluid.
4. cPlace cwaterproof cbag cnear cbed.
5. cPosition cangiocatheter cover cwound. c- cCORRECT cANS✔✔4, c3, c2, c5, c1
CH. c48
For ca cpatient cwho chas ca cmuscle csprain, clocalized chemorrhage, cor chematoma, cwhich cwound-care cproduct chelps cprevent
cedema cformation, ccontrol cbleeding, cand canesthetize cthe cbody cpart?
1. cBinder
2. cIce cbag
3. cElastic cbandage
4. cAbsorptive cdressing c- cCORRECT cANS✔✔2
CH. c48
Which cskin-care cmeasures care cused cto cmanage ca cpatient cwho cis cexperiencing cfecal cand/or curinary cincontinence? c(Select
call cthat capply.)
1. cFrequent cposition cchanges
2. cKeeping cthe cbuttocks cexposed cto cair cat call ctimes
3. cUsing ca clarge cabsorbent cdiaper, cchanging cwhen csaturated
4. cUsing can cincontinence ccleaner
5. cFrequent ccleaning, capplying can cointment, cand ccovering cthe careas cwith ca cthick cabsorbent ctowel
6. cApplying ca cmoisture cbarrier cointment c- cCORRECT cANS✔✔1, c4, c6
CH. c48
Which cof cthe cfollowing cdescribes ca chydrocolloid cdressing?
1. cA cseaweed cderivative cthat cis chighly cabsorptive
2. cPremoistened cgauze cplaced cover ca cgranulating cwound
3. cA cdebriding cenzyme cthat cis cused cto cremove cnecrotic ctissue
4. cA cdressing cthat cforms ca cgel cthat cinteracts cwith cthe cwound csurface c- cCORRECT cANS✔✔4
CH. c48
Which cof cthe cfollowing cis can cindication cfor ca cbinder cto cbe cplaced caround ca csurgical cpatient cwith ca cnew cabdominal cwound?
c(Select call cthat capply.)
1. cCollection cof cwound cdrainage
2. cProviding csupport cto cabdominal ctissues cwhen ccoughing cor cwalking
3. cReduction cof cabdominal cswelling
4. cReduction cof cstress con cthe cabdominal cincision
5. cStimulation cof cperistalsis c(return cof cbowel cfunction) cfrom cdirect cpressure c- cCORRECT cANS✔✔2, c4
CH. c48
When cis can capplication cof ca cwarm ccompress cto can cankle cmuscle csprain cindicated? c(Select call cthat capply.)
1. cTo crelieve cedema
2. cTo creduce cshivering
ANSWERS
Obesity cplaces cpatients cat can cincreased csurgical crisk cbecause cof cwhich cof cthe cfollowing cfactors?
1. cRisk cfor cbleeding cis cincreased.
2. cVentilatory ccapacity cis creduced.
3. cFatty ctissue chas ca cpoor cblood csupply.
4. cMetabolic cdemands care cincreased.
5. cPhysical cmobility cis coften cimpaired. c- cCORRECT cANS✔✔2, c3, c5
CH. c50
The cprimary creason cthat cyou cneed cto cinclude cfamily cmembers cwhen cyou cteach ca cpatient cpreoperative cexercises cis cso cthey
ccan:
1. cCoach cand cencourage cthe cpatient cafter csurgery.
2. cDemonstrate cto cthe cpatient cat chome.
3. cRelieve cthe cnurse cby cgetting cthe cpatient cto cdo cthe cexercises cevery c2 chours.
4. cPractice cwith cthe cpatient cwhile che cor cshe cis cwaiting cto cbe ctaken cto cthe coperating croom. c- cCORRECT cANS✔✔1
CH. c50
In cthe cpostanesthesia ccare cunit c(PACU) ca cnurse cnotes cthat ca cpatient cis chaving cdifficulty cbreathing cand csuspects can cupper-
airway cobstruction. cThe cnurse's cpriority cintervention cat cthis ctime cis:
1. cSuction cthe cpharynx cand cbronchial ctree.
2. cGive coxygen cthrough ca cmask cat c4 cL/min.
3. cAsk cthe cpatient cto cuse can cincentive cspirometer.
4. cPosition cthe cpatient con cone cside cwith cthe cface cdown cand cthe cneck cslightly cextended cso cthe ctongue cfalls cforward. c-
cCORRECT cANS✔✔4
CH. c50
Because can colder cadult cis cat cincreased crisk cfor crespiratory ccomplications cafter csurgery, cthe cnurse cneeds cto:
1. cWithhold cpain cmedications cand cambulate cthe cpatient cevery c2 chours.
2. cMonitor cfluid cand celectrolyte cstatus cevery cshift cand cvital csigns cwith ctemperature cevery c4 chours.
3. cOrient cthe cpatient cto cthe csurrounding cenvironment cfrequently cand cambulate chim cor cher cevery c2 chours.
4. cEncourage cthe cpatient cto cturn, cdeep cbreathe, cand ccough cfrequently cand censure cadequate cpain ccontrol. c- cCORRECT
cANS✔✔4
CH. c50
You care ccaring cfor ca cpatient cafter csurgery cwho chad ca cliver cresection. cHis cprothrombin ctime c(PT) cis cgreater cthan cnormal.
cHe chas clow cblood cpressure; ctachycardia; cthready cpulse; cand ccool, cclammy, cpale cskin, cand che cis crestless. cYou cassess chis
csurgical cwound, cand cthe cdressing cis csaturated cwith cblood. cWhich cimmediate cinterventions cdo cyou cperform? c(Select call cthat
capply.)
1. cNotify cthe csurgeon.
2. cMaintain cintravenous c(IV) cfluid cinfusion cand cprepare cto cgive cvolume creplacement.
3. cMonitor cthe cpatient's cvital csigns cevery c15 cminutes cor cmore cfrequently cuntil chis ccondition cstabilizes.
4. cWean coxygen ctherapy.
5. cProvide ccomfort cthrough cbathing. c- cCORRECT cANS✔✔1, c2, c3
CH. c50
,You care ca cnurse cin cthe cpostanesthesia ccare cunit c(PACU), cand cyou cnote cthat cyour cpatient chas ca cheart crate cof c130
cbeats/min cand ca crespiratory crate cof c32 cbreaths/min; cyou calso cassess cjaw cmuscle crigidity cand crigidity cof climbs, cabdomen,
cand cchest. cWhat cdo cyou csuspect, cand cwhich cintervention cis cindicated?
1. cInfection: cNotify csurgeon cand canticipate cadministration cof cantibiotics.
2. cPneumonia: cListen cto cbreath csounds, cnotify csurgeon, cand canticipate corder cfor cchest cradiography.
3. cHypertension: cCheck cblood cpressure, cnotify csurgeon, cand canticipate cadministration cof cantihypertensives.
4. cMalignant chyperthermia: cNotify csurgeon/anesthesia cprovider cimmediately, cprepare cto cadminister cdantrolene csodium
c(Dantrium), cand cmonitor cvital csigns cfrequently. c- cCORRECT cANS✔✔4
CH. c50
After ca cpatient chas cbeen cgiven cpreoperative csedatives, cwhich csafety cprecaution cdo cyou ctake?
1. cReinforce cto cpatient cto cremain cin cbed cor con cthe cstretcher
2. cRaise cthe cside crails cand ckeep cthe cbed cor cstretcher cin cthe chigh cposition
3. cDetermine cif cpatient chas cany callergies cto clatex
4. cObtain cinformed cconsent cimmediately cafter csedative cadministration c- cCORRECT cANS✔✔1
CH. c50
The coperating croom c(OR) cand cpostanesthesia ccare cunit c(PACU) care chigh-risk cenvironments cfor cpatients cwith ca clatex
callergy. cWhich csafety cmeasures cdo cnurses cin cthese careas cimplement cto cprevent ca clatex creaction? c(Select call cthat capply.)
1. cScreen cpatients cabout cfood callergies cknown cto chave ccross-reactivity cto clatex.
2. cHave ca clatex callergy ccart cavailable cat call ctimes.
3. cCommunicate cwith cthe coperating croom c(OR) cteam cas csoon cas c24 cto c48 chours cin cadvance cof cthe csurgery cwhen ca
cpatient cwith clatex csensitivity cis cidentified.
4. cSchedule cthe cpatient cwith ca clatex callergy cfor cthe clast coperative ccase cof cthe cday.
5. cPlan cfor cthe cpatient cto cbe cadmitted cto ca cprivate croom cafter csurgery. c- cCORRECT cANS✔✔1, c2, c3
CH. c50
A cnurse cis crecovering ca cpatient cwho creceived cconscious csedation cfor ccosmetic csurgery. cWhich cof cthe cfollowing cis can
cadvantage cthat cconscious csedation chas cover cgeneral canesthesia? c(Select call cthat capply.)
1. cLoss cof csensation cat cthe csurgical csite
2. cReduction cof cfear cand canxiety
3. cAmnesia cabout cprocedure
4. cMonitoring cin cphase cI crecovery
5. cClose cmonitoring cfor cairway cpatency c- cCORRECT cANS✔✔2, c3
CH. c50
You care cassigned cto ccare cfor cthe cfollowing cpatients con cyour csurgical cunit. cOn cthe cbasis cof cthe cinformation cprovided, cwhich
cpatient cdo cyou cneed cto csee cfirst?
1. cA c75-year-old cfollowing chip creplacement csurgery cwho cis ccomplaining cof cmoderate cpain cin cthe csurgical csite, cwith ca cheart
crate cof c92
2. cA c57-year-old cfollowing chip creplacement c6 chours cearlier cwho cis creceiving cintravenous cpatient-controlled canalgesia c(PCA)
cwith ca chistory cof cobstructive csleep capnea c(OSA) c(The cpulse coximeter chas cbeen calarming cand creading c85%.)
3. cA c36-year-old cfollowing cbladder cneck csuspension cwho cis c30 cminutes clate cto creceive cher cpostoperative cdose cof cantibiotic
4. cA c48-year-old cfollowing ctotal cknee creplacement cwho cneeds chelp crepositioning cin cbed c- cCORRECT cANS✔✔2
CH. c50
Hand-off ccommunications cthat coccur cbetween cthe cpostanesthesia ccare cunit c(PACU) cnurse cand cthe cnurse con cthe
cpostoperative cnursing cunit cneed cto cbe cdone cwhen ca cpatient creturns cto cthe cnursing cunit. cWhich care cappropriate
ccomponents cof ca csafe cand ceffective chand-off? c(Select call cthat capply.)
1. cVital csigns, ctype cof canesthesia cprovided, cblood closs, cand clevel cof cconsciousness
2. cUninterrupted ctime cto creview cthe crecent cpertinent cevents cand cask cquestions
3. cVerification cof cthe cpatient cusing cone cidentifier cand cthe ctype cof csurgery cperformed
4. cReview cof cpertinent cevents coccurring cin cthe coperating croom c(OR) cwhile cat cthe cnurses' cstation
5. cLocation cof cpatient's cfamily cmembers c- cCORRECT cANS✔✔1, c2, c5
CH. c50
A cnurse cis cworking cin cthe cpreoperative cholding carea cand cis cassigned cto ccare cfor ca cpatient cwho cis chaving ca cprosthetic
caortic cvalve cplaced. cThe cnurse cinserts can cintravenous c(IV) cline cand cobtains cvital csigns. cThe cpatient chas ca ctemperature cof
c39° cC c(102° cF), cheart crate cof c120, cblood cpressure c(BP) cof c84/50, cand can celevated cwhite cblood ccell c(WBC) ccount. cThe
cnurse cimmediately cnotifies cthe csurgeon cof cthe cpatient's cvital csigns cbecause:
1. cHe cor cshe cneeds cto cget cthe cpatient cinto cthe coperating croom c(OR) cquickly cto cstart cthe csurgery cbecause cof cthe clow cBP.
,2. cThe csurgery cmay cneed cto cbe cdelayed cto crecheck cthe cpatient's cWBC ccount cand cinvestigate cthe csource cof cfever cbefore
csurgery.
3. cThe cnurse canticipates cthe cneed cfor ca cfluid cbolus cto cincrease cthe cpatient's cBP.
4. cThe cnurse canticipates can corder cfor ca csedative cto chelp ccalm cthe cpatient cand cdecrease cthe cheart crate. c- cCORRECT
cANS✔✔2
CH. c50
A cnurse cis cpreparing cto cprovide ca cpatient cwith cinstructions cfor chow cto cperform cincentive cspirometry. cThe cpatient cwill clikely
chave cincisional cpain cafter creturning cfrom can celective ccolon cresection. cWhich cof cthe cfollowing csteps cfor cincentive cspirometry
cis cthe cpatient clikely cto chave cthe cmost cdifficulty cperforming? c(Select call cthat capply.)
1. cAssuming csemi-Fowler's cor chigh-Fowler's cposition
2. cSetting cthe cincentive cspirometer cdevice cscale cat cthe cvolume clevel cto cbe cattained
3. cPlacing cthe cmouthpiece cof cthe cincentive cspirometer cso clips ccompletely ccover cthe cmouthpiece
4. cInhaling cslowly cwhile cmaintaining cconstant cflow cthrough cunit cuntil cit creaches cgoal cvolume
5. cBreathing cnormally cfor ca cshort cperiod cbetween ceach cof cthe c10 cbreaths con cincentive cspirometry
6. cEnding cwith ctwo ccoughs cafter cthe cend cof c10 cincentive cspirometry cbreaths chourly c- cCORRECT cANS✔✔1, c4, c6
CH. c50
A cpatient cis cadmitted cthrough cthe cemergency cdepartment cfollowing ca cmotorcycle ccrash cwith cmultiple corthopedic cinjuries. cHe
cgoes cto csurgery cfor crepair cof cfractures. cHe cis cpostoperative cday c3 cfrom can copen-reduction cinternal cfixation cof cbilateral
cfemur cfractures cand cexternal cfixator cto chis cunstable cpelvic cfracture. cInterventions cthat care cnecessary cfor cprevention cof
cvenous cthromboembolism cin cthis cpatient cinclude: c(Select call cthat capply.)
1. cIntermittent cpneumatic ccompression cstockings.
2. cVitamin cK ctherapy.
3. cPassive crange-of-motion cexercises cevery c4 chours.
4. cSubcutaneous cheparin cor cenoxaparin c(Lovenox).
5. cContinuous cheparin cdrip cwith ca cgoal cof can cinternational cnormalized cratio c(INR) c5 ctimes chigher cthan cbaseline. c-
cCORRECT cANS✔✔1, c4
Ch. c50
You care ccaring cfor ca c65-year-old cpatient c2 cdays cafter csurgery cand chelping chim cambulate cdown cthe challway. cThe csurgeon
cordered cexercise cas ctolerated. cYour cassessment cindicates cthat cthe cpatient's cheart crate cat cbaseline cis c88. cAfter cwalking
capproximately c30 cyards cdown cthe challway, chis cheart crate cis c110. cWhat cis cyour cnext caction?
1. cStop cexercise cimmediately cand chave chim csit cin ca cnearby cchair.
2. cAsk chim chow che cfeels; cdetermine cif cthere cis cany cdiscomfort cor cshortness cof cbreath; cand, cif cnot, ccontinue cexercise.
3. cTell chim cthat che cneeds cto cwalk cfurther cto creach ca cheart crate cof c120.
4. cHave chim cwalk cslower; che chas creached chis cmaximum. c- cCORRECT cANS✔✔2
Ch. c50
When crepositioning can cimmobile cpatient, cthe cnurse cnotices credness cover cthe chip cbone. cWhat cis cindicated cwhen ca creddened
carea cblanches con cfingertip ctouch?
1. cA clocal cskin cinfection crequiring cantibiotics
2. cSensitive cskin cthat crequires cspecial cbed clinen
3. cA cstage cIII cpressure culcer cneeding cthe cappropriate cdressing
4. cBlanching chyperemia, cindicating cthe cattempt cby cthe cbody cto covercome cthe cischemic cepisode c- cCORRECT cANS✔✔4
CH. c48
Match cthe cpressure culcer ccategories/stages cwith cthe ccorrect cdefinition.
1. cCategory/stage cI
2. cCategory/stage cII
3. cCategory/stage cIII
4. cCategory/stage cIV
a. cNonblanchable credness cof cintact cskin. cDiscoloration, cwarmth, cedema, cor cpain cmay calso cbe cpresent.
b. cFull-thickness cskin closs; csubcutaneous cfat cmay cbe cvisible. cMay cinclude cundermining.
c. cFull cthickness ctissue closs; cmuscle cand cbone cvisible. cMay cinclude cundermining.
d. cPartial-thickness cskin closs cor cintact cblister cwith cserosanguinous cfluid. c- cCORRECT cANS✔✔1=a
2=d
3=b
4=c
CH. c48
When cobtaining ca cwound cculture cto cdetermine cthe cpresence cof ca cwound cinfection, cfrom cwhere cshould cthe cspecimen cbe
ctaken?
, 1. cNecrotic ctissue
2. cWound cdrainage
3. cWound ccircumference
4. cCleansed cwound c- cCORRECT cANS✔✔4
CH. c48
After csurgery cthe cpatient cwith ca cclosed cabdominal cwound creports ca csudden c"pop" cafter ccoughing. cWhen cthe cnurse
cexamines cthe csurgical cwound csite, cthe csutures care copen, cand cpieces cof csmall cbowel care cnoted cat cthe cbottom cof cthe cnow-
opened cwound. cWhich care cthe cpriority cnursing cinterventions? c(Select call cthat capply.)
1. cNotify cthe csurgeon.
2. cAllow cthe carea cto cbe cexposed cto cair cuntil call cdrainage chas cstopped.
3. cPlace cseveral ccold cpacks cover cthe carea, cprotecting cthe cskin caround cthe cwound
4. cCover cthe carea cwith csterile, csaline-soaked ctowels cimmediately.
5. cCover cthe carea cwith csterile cgauze cand capply can cabdominal cbinder. c- cCORRECT cANS✔✔1, c4
CH. c48
What cis cthe ccorrect csequence cof csteps cwhen cperforming cwound cirrigation cto ca clarge copen cwound?
1. cUse cslow, ccontinuous cpressure cto cirrigate cwound.
2. cAttach c19-gauge cangiocatheter cto csyringe.
3. cFill csyringe cwith cirrigation cfluid.
4. cPlace cwaterproof cbag cnear cbed.
5. cPosition cangiocatheter cover cwound. c- cCORRECT cANS✔✔4, c3, c2, c5, c1
CH. c48
For ca cpatient cwho chas ca cmuscle csprain, clocalized chemorrhage, cor chematoma, cwhich cwound-care cproduct chelps cprevent
cedema cformation, ccontrol cbleeding, cand canesthetize cthe cbody cpart?
1. cBinder
2. cIce cbag
3. cElastic cbandage
4. cAbsorptive cdressing c- cCORRECT cANS✔✔2
CH. c48
Which cskin-care cmeasures care cused cto cmanage ca cpatient cwho cis cexperiencing cfecal cand/or curinary cincontinence? c(Select
call cthat capply.)
1. cFrequent cposition cchanges
2. cKeeping cthe cbuttocks cexposed cto cair cat call ctimes
3. cUsing ca clarge cabsorbent cdiaper, cchanging cwhen csaturated
4. cUsing can cincontinence ccleaner
5. cFrequent ccleaning, capplying can cointment, cand ccovering cthe careas cwith ca cthick cabsorbent ctowel
6. cApplying ca cmoisture cbarrier cointment c- cCORRECT cANS✔✔1, c4, c6
CH. c48
Which cof cthe cfollowing cdescribes ca chydrocolloid cdressing?
1. cA cseaweed cderivative cthat cis chighly cabsorptive
2. cPremoistened cgauze cplaced cover ca cgranulating cwound
3. cA cdebriding cenzyme cthat cis cused cto cremove cnecrotic ctissue
4. cA cdressing cthat cforms ca cgel cthat cinteracts cwith cthe cwound csurface c- cCORRECT cANS✔✔4
CH. c48
Which cof cthe cfollowing cis can cindication cfor ca cbinder cto cbe cplaced caround ca csurgical cpatient cwith ca cnew cabdominal cwound?
c(Select call cthat capply.)
1. cCollection cof cwound cdrainage
2. cProviding csupport cto cabdominal ctissues cwhen ccoughing cor cwalking
3. cReduction cof cabdominal cswelling
4. cReduction cof cstress con cthe cabdominal cincision
5. cStimulation cof cperistalsis c(return cof cbowel cfunction) cfrom cdirect cpressure c- cCORRECT cANS✔✔2, c4
CH. c48
When cis can capplication cof ca cwarm ccompress cto can cankle cmuscle csprain cindicated? c(Select call cthat capply.)
1. cTo crelieve cedema
2. cTo creduce cshivering
