Med-Surg 1 (Exam 2 review) Questions & Answers Already Passed!!

The postanesthesia recovery unit nurse is receiving a hand-off report from the nurse anesthetist and the circulating nurse for an 82-year-old client who had a 2-hour open reduction of a fractured elbow. For which reported information about the client or surgery does the receiving nurse ask the reporting team for more details? A. The client is Jewish. B. The estimated blood loss is 150 mL. C. The client reported an allergy to codeine. D. The total intraoperative urine output is 25 mL. - Answer-D Rationale: The total intraoperative urine output is very low. Information regarding the client's total intake, kidney function, and fluid status is needed. A postoperative client's arterial blood gas (ABG) values are pH 7.36, HCO3 21 mEq/L, Paco2 35 mm Hg, Pao2 98 mm Hg. What is the nurse's priority action? A. Compare these values with the client's preoperative ABG values. B. Assess the airway and notify the physician. C. Document the values as the only action. D. Increase the oxygen flow rate. - Answer-C Rationale: All of these ABG results are within the normal range and indicate adequacy of ventilation, gas exchange, and kidney function. Documentation is the only action that needs to be taken. The client who had neck surgery to remove the entire thyroid gland is transferred to the medical-surgical unit after 4 hours in the PACU. The client reports difficulty swallowing. What is the nurse's priority action? A. Assess the client's respiratory status. B. Inspect the client's throat with a penlight. C. Adjust the position of the drain in the incision. D. Reassure the client that this is a normal and common problem after anesthesia. - Answer-A Rationale: Most clients have a sore throat for the first 12 to 24 hours after intubation during surgery, and this is made worse when the client tries to swallow. However, it is important for the nurse to differentiate soreness from true difficulty swallowing. Surgery in the neck area can cause swelling thatreduces the lumen of the throat. This can cause respiratory impairment and swallowing difficulties. The most important action is to assess the airway and respiratory response to ensure that breathing impairment is not accompanying a swallowing problem. When changing the client's abdominal dressing on the second postoperative day, the nurse observes crusting on about half of the suture line and oozing of a small amount of serosanguineous drainage. What is the nurse's best action? A. Loosen the sutures or staples in the area where crusts have formed. B. Clean the suture line with sterile saline and apply new dressings. C. Gently remove the crusts and culture the material beneath. D. Apply pressure over the incision and notify the surgeon. - Answer-B Serosanguineous drainage and a small amount of crusting are normal incision findings on the second postoperative day. The suture line needs to be cleaned and a new dressing applied. The other actions are inappropriate. Why is it important to wear sterile gloves during a dressing change? A They protect the client from infection. B They protect the nurse from infection. C They protect both the client and the nurse from infection. D Their use prevents lawsuits. - Answer-C Standard Precautions and infection control protect both the nurse and the client from infection. The client has just undergone a surgical procedure with general anesthesia. Which finding indicates that the client needs further assessment in the postanesthesia care unit? A Pain at the surgical site B Requirement for verbal stimuli to awaken C Snoring sounds when inhaling D Sore throat on swallowing - Answer-C Snoring sounds when inhaling may indicate respiratory depression. (A sore throat on swallowing is normal post intubation., Requiring verbal stimuli to awaken is normal post sedation.Postsurgical pain at the surgical site is normal.) Which client is at greatest risk for slow wound healing? A 12-year-old healthy girl B 47-year-old obese man with diabetes C 48-year-old woman who smokes D 98-year-old healthy man - Answer-B Diabetes and obesity significantly contribute to slow wound heali