Med Surg 1 (Exam 2) questions with correct answers

One hour after admission to the post anesthesia care unit (PACU), the postoperative patient has become very restless. What is the nurse's first action? A. Assess the oxygen saturation level B. Administer pain medication as ordered C. Call the surgeon to assess the patient D. Assess for bladder distention A Patient asks nurse what does this "thing" do and why do i have to use it. Nurse explains that using this thing (incentive spirometer) A. "The spirometer will help prevent blood clots" B. "The spirometer will help your lungs expand." C. "The spirometer will improve blood flow in your lungs." D. "The spirometer will help you cough effectively." B After abdominal surgery, the patient complains of severe gas pains and states, "I have not had bowels in 3 days." What is the appropriate nursing intervention? A. Call the physician for an order for a laxative B. Reinsert a nasogastric tube C. Provide the ordered prn Morphine D. Have the patient ambulate frequently D A patient with emphysema reports social isolation. What should the nurse encourage patient to do? A. Participate in community activities B. Ask the patient's physician for an anti anxiety agent C. Verbalize his or her thoughts and feelings D. Join a support group for people with emphysema C The patient's abdominal incision is draining a small amount of pinkish color secretion. How nurse document this finding on the patient's record? A. Small amount of bloody drainage noted on dressings. B. Small amount of serosanguineous drainage noted on dressings. C. Small amount of serous drainage noted on dressings. D. Small amount of sanguineous drainage noted on dressings. B What interventions should the nurse carry out to reduce postoperative pain and promote comfort to surgical patient? (Select all that apply) A. Control or remove noxious stimuli in the environment. B. Instruct the patient in relaxation techniques. C. Use ice to reduce and prevent swelling as indicated D. Encourage activity and exercise to point of fatigue E. Use pillows to assist to a position of comfort A B C E A post-operative patient is in the post-anesthesia care unit (PACU) and reports having pain of 8 on a scale of 10. What is the best nursing action? A. Consult with the anesthesia care provider to manage the pain while the patient is still in PACU B. Have the nurses on the surgical unit to assess the patient and administer pain medication as appropriate C. Look at the routine post-operative orders and administer the pain medicine that is ordered. D. Sep up the Patient Controlled Analgesia (PCA) machine and push the button for the patient as needed. A The nurse is changing the patient's dressing on the second postoperative day and notes a small amount of serosanguineous drainage. What is the nurse's best action? A. Cover the incision with a transparent dressing B. Culture the drainage and leave the incision open to air C. Cleanse the suture line and apply a sterile dressing D. Notify the surgeon to assess the patient C What is the priority nursing intervention for the patient in the Post Anesthesia Care Unit (PACU) who reports, "I think I am going to vomit" A. Continue to monitor the vital signs B. Place a cool cloth on the patient's forehead C. Give the antiemetic as ordered D. Turn the patient on their side D A patient with a history of asthma is admitted to the emergency department with dyspnea, respiratory rate of 35 breaths per minute, nasal flaring, use of accessory muscles, and greatly diminished breath sounds. What action should the nurse take first? A. Initiate oxygen therapy and reassess the patient in 10 minutes B. Encourage the patient to relax and breathe slowly C. Draw blood for arterial blood gas analysis and send the patient for a chest X-ray D. Administer bronchodilators as ordered D The patient is 7 hours post-op and has not voided. What should the nurse do first? A. Call the surgeon stat and report the lack of voiding B. Insert an indwelling urinary catheter C. Determine when the last pain medication was given D. Palpate for presence of the bladder above the symphysis pubis D One hour after the administration of ondansetron hydrochloride (Zofran) (antiemetic), the nurse determines that the medication has been effective and documents this in the patient's record. What phase of the nursing process is illustrated? A. Diagnosis B. Evaluation C. Planning D. Assessment B The nurse is caring for several patients on the postoperative unit. Which patient does the nurse determine has the highest risk of respiratory complications after general anesthesia? A. Young adult with a body mass index of 40 B. Middle-aged woman taking a daily cholesterol lowering medication C. Middle-aged man with a deviated nasal septum D. Older woman taking a medication for hypertension A The nurse is caring for a patient who had abdominal surgery 3 days ago. The patient tells the nurse, "I felt something 'come apart' when I coughed." What is the nurse's best response? A. "That is a normal feeling in the incision whenever you are moving" B. "Be sure to splint the incision with a pillow or your hands when you cough" C. "Lie down flat on the bed with your knees u and let me examine your incision" D. "It is good you are coughing and deep-breathing to prevent pneumonia" C What is the best assessment the nurse should use to validate a patient's pain? A. Physiologic indicators, such as elevated vital signs B. A pain rating by someone who knows the patient well C. Facial grimacing and crying D. The patient's self-report of pain D A patient reports pain 8 hours after surgery. The patient has already received an opioid within the past 2 hours. What should the nurse do? A. Give the ordered pain medication early B. Call the surgeon immediately C. Assess the pain further D. Document the finding in the chart C A post-operative patient has atelectasis in the left lung confirmed by chest x-ray. What priority intervention should the nurse plan to include in the patient's care? A. Monitoring oxygen saturation hourly B. Assessing the breath sounds every two hours C. Monitoring respiratory rate rhythm twice a shift D. Encouraging use of the incentive spirometer hourly E. Changing positions every three hours D A patient is prescribed albuterol (Proventil, Ventolin) via metered-dose inhaler (MDI), two puffs every 4 hours. What should the nurse teach the patient about potential adverse effects of this drug? A. Pedal edema B. Wheezing C. Irregular Heartbeat D. Constipation C