NUR 206 Final exam with complete vv vv vv vv vv
solutions
vv
The nurse in the PACU performs postsurgical assessments on the newly admitted patient every
vv vv vv vv vv vv vv vv vv vv vv vv vv
_________ minutes. - ANSWER-✔✔every 15 minutes
vv vv vv vv vv vv
A patient is on postoperative day 2 after a nephrectomy. What is the most effective way to increase her
vv vv vv vv vv vv vv vv vv vv vv vv vv vv vv vv vv vv
peristalsis? - ANSWER-✔✔Ambulation
vv vv vv
A patient is transferred from the operating room to the recovery room after undergoing an open
vv vv vv vv vv vv vv vv vv vv vv vv vv vv vv
reduction and internal fixation (ORIF) of his left ankle. Which is the first assessment to make? - ANSWER-
vv vv vv vv vv vv vv vv vv vv vv vv vv vv vv vv vv vv
✔✔Check airway for patency. vv vv vv
A postoperative patient who had a left inguinal hernia repair is ready for his discharge instructions.
vv vv vv vv vv vv vv vv vv vv vv vv vv vv vv
Which information should the nurse provide? (Select all that apply.) - ANSWER-✔✔- Care of the wound
vv vv vv vv vv vv vv vv vv vv vv vv vv vv vv vv
site and any dressings
vv vv vv vv vv
- When he may operate a motor vehicle
vv vv vv vv vv vv vv
- Signs and symptoms to report to the physician
vv vv vv vv vv vv vv vv
- Actions and side effects of any medications
vv vv vv vv vv vv vv
Anti-embolic stockings are in place on the obese post surgical patient. Which statement accurately
vv vv vv vv vv vv vv vv vv vv vv vv vv
describes the standard of care in regards to anti-embolic stockings? - ANSWER-✔✔should be removed
vv vv vv vv vv vv vv vv vv vv vv vv vv vv
approximately 20 minutes every shift.
vv vv vv vv vv
,Frequent assessment of a postoperative patient is essential. What is one of the first signs and symptoms
vv vv vv vv vv vv vv vv vv vv vv vv vv vv vv vv
of hemorrhage? - ANSWER-✔✔Restlessness
vv vv vv vv
The nurse educates the postsurgical patient about which potential effect of smoking on postsurgical
vv vv vv vv vv vv vv vv vv vv vv vv vv
recovery? - ANSWER-✔✔Delayed healing
vv vv vv vv
The nurse is caring for a 90-year-old postoperative patient whose oxygen saturation is frequently
vv vv vv vv vv vv vv vv vv vv vv vv vv
dropping below 90%. Which age-related change is most likely related to this finding? - ANSWER-
vv vv vv vv vv vv vv vv vv vv vv vv vv vv vv
✔✔weakened respiratory muscles vv vv
The nurse is caring for a patient during the first postoperative day. Which goal works to prevent
vv vv vv vv vv vv vv vv vv vv vv vv vv vv vv vv
atelectasis and is most appropriate for the nursing care plan? - ANSWER-✔✔Patient will "huff-cough"
vv vv vv vv vv vv vv vv vv vv vv vv vv vv
every 2 hours
vv vv vv
The nurse is caring for a patient following abdominal surgery. The patient asks the nurse when he will be
vv vv vv vv vv vv vv vv vv vv vv vv vv vv vv vv vv vv
able to eat a normal diet. Which response is best? - ANSWER-✔✔"Once you have bowel sounds and are
vv vv vv vv vv vv vv vv vv vv vv vv vv vv vv vv vv vv
passing gas, you may have clear liquids, and your diet will be advanced based upon your tolerance."
vv vv vv vv vv vv vv vv vv vv vv vv vv vv vv vv vv
The nurse is caring for a patient who had spinal anesthesia. Which drink is the best choice for the nurse
vv vv vv vv vv vv vv vv vv vv vv vv vv vv vv vv vv vv vv
to offer the patient? - ANSWER-✔✔Tea
vv vv vv vv vv vv
The nurse is caring for a surgical patient who complains of excessive gas. Which action should the nurse
vv vv vv vv vv vv vv vv vv vv vv vv vv vv vv vv vv
take? - ANSWER-✔✔Ambulate the patient in the hall.
vv vv vv vv vv vv vv vv
The nurse is educating the patient about vitamins and wound healing. The nurse explains that which
vv vv vv vv vv vv vv vv vv vv vv vv vv vv vv
vitamin will enhance wound healing the most? - ANSWER-✔✔Vitamin C
vv vv vv vv vv vv vv vv vv vv
The nurse is performing a neurological assessment on a patient who was just transferred from the PACU
vv vv vv vv vv vv vv vv vv vv vv vv vv vv vv vv
following abdominal surgery. Which action(s) correctly demonstrate(s) knowledge of a neurological
vv vv vv vv vv vv vv vv vv vv vv
assessment? (Select all that apply.) - ANSWER-✔✔- Asking the patient to identify where he is.
vv vv vv vv vv vv vv vv vv vv vv vv vv vv vv
, - Noting if the patient can identify the sensation of touch.
vv vv vv vv vv vv vv vv vv vv
- Asking the patient to move his arms and legs.
vv vv vv vv vv vv vv vv vv
- Assessing the patient's pupils for response to light.
vv vv vv vv vv vv vv vv
The nurse is performing the Aldrete scoring system. Which factor(s) must be assessed? (Select all that
vv vv vv vv vv vv vv vv vv vv vv vv vv vv vv
apply.) - ANSWER-✔✔- Activity
vv vv vv vv
- Circulation
vv
- Level of consciousness
vv vv vv
- O2 saturation
vv vv
- Respiration
vv
The PACU nurse is caring for a semiconscious patient immediately following abdominal surgery. The
vv vv vv vv vv vv vv vv vv vv vv vv vv
nurse correctly places the patient in which position? - ANSWER-✔✔Lateral
vv vv vv vv vv vv vv vv vv vv
The PACU nurse is caring for an unconscious patient. Assessment reveals diminished breath sounds
vv vv vv vv vv vv vv vv vv vv vv vv vv
bilaterally. Which action should the nurse take? - ANSWER-✔✔Document "diminished breath sounds in
vv vv vv vv vv vv vv vv vv vv vv vv vv
both lower lobes."
vv vv vv
The patient is brought into PACU still unconscious. What should the nurse do when the nurse assesses an
vv vv vv vv vv vv vv vv vv vv vv vv vv vv vv vv vv
oral temperature of 94° F? - ANSWER-✔✔Cover with a warm blanket
vv vv vv vv vv vv vv vv vv vv vv
The postoperative nursing intervention that would be contraindicated for a 45-year-old patient who has
vv vv vv vv vv vv vv vv vv vv vv vv vv
had a repair of a cerebral aneurysm and is presenting signs of increased intracranial pressure (ICP) would
vv vv vv vv vv vv vv vv vv vv vv vv vv vv vv vv vv
be: - ANSWER-✔✔coughing every 2 hours
vv vv vv vv vv vv
When the postoperative patient complains of sudden chest pain combined with dyspnea, cyanosis, and
vv vv vv vv vv vv vv vv vv vv vv vv vv
tachycardia, the nurse recognizes the signs of: - ANSWER-✔✔pulmonary embolus
vv vv vv vv vv vv vv vv vv vv
solutions
vv
The nurse in the PACU performs postsurgical assessments on the newly admitted patient every
vv vv vv vv vv vv vv vv vv vv vv vv vv
_________ minutes. - ANSWER-✔✔every 15 minutes
vv vv vv vv vv vv
A patient is on postoperative day 2 after a nephrectomy. What is the most effective way to increase her
vv vv vv vv vv vv vv vv vv vv vv vv vv vv vv vv vv vv
peristalsis? - ANSWER-✔✔Ambulation
vv vv vv
A patient is transferred from the operating room to the recovery room after undergoing an open
vv vv vv vv vv vv vv vv vv vv vv vv vv vv vv
reduction and internal fixation (ORIF) of his left ankle. Which is the first assessment to make? - ANSWER-
vv vv vv vv vv vv vv vv vv vv vv vv vv vv vv vv vv vv
✔✔Check airway for patency. vv vv vv
A postoperative patient who had a left inguinal hernia repair is ready for his discharge instructions.
vv vv vv vv vv vv vv vv vv vv vv vv vv vv vv
Which information should the nurse provide? (Select all that apply.) - ANSWER-✔✔- Care of the wound
vv vv vv vv vv vv vv vv vv vv vv vv vv vv vv vv
site and any dressings
vv vv vv vv vv
- When he may operate a motor vehicle
vv vv vv vv vv vv vv
- Signs and symptoms to report to the physician
vv vv vv vv vv vv vv vv
- Actions and side effects of any medications
vv vv vv vv vv vv vv
Anti-embolic stockings are in place on the obese post surgical patient. Which statement accurately
vv vv vv vv vv vv vv vv vv vv vv vv vv
describes the standard of care in regards to anti-embolic stockings? - ANSWER-✔✔should be removed
vv vv vv vv vv vv vv vv vv vv vv vv vv vv
approximately 20 minutes every shift.
vv vv vv vv vv
,Frequent assessment of a postoperative patient is essential. What is one of the first signs and symptoms
vv vv vv vv vv vv vv vv vv vv vv vv vv vv vv vv
of hemorrhage? - ANSWER-✔✔Restlessness
vv vv vv vv
The nurse educates the postsurgical patient about which potential effect of smoking on postsurgical
vv vv vv vv vv vv vv vv vv vv vv vv vv
recovery? - ANSWER-✔✔Delayed healing
vv vv vv vv
The nurse is caring for a 90-year-old postoperative patient whose oxygen saturation is frequently
vv vv vv vv vv vv vv vv vv vv vv vv vv
dropping below 90%. Which age-related change is most likely related to this finding? - ANSWER-
vv vv vv vv vv vv vv vv vv vv vv vv vv vv vv
✔✔weakened respiratory muscles vv vv
The nurse is caring for a patient during the first postoperative day. Which goal works to prevent
vv vv vv vv vv vv vv vv vv vv vv vv vv vv vv vv
atelectasis and is most appropriate for the nursing care plan? - ANSWER-✔✔Patient will "huff-cough"
vv vv vv vv vv vv vv vv vv vv vv vv vv vv
every 2 hours
vv vv vv
The nurse is caring for a patient following abdominal surgery. The patient asks the nurse when he will be
vv vv vv vv vv vv vv vv vv vv vv vv vv vv vv vv vv vv
able to eat a normal diet. Which response is best? - ANSWER-✔✔"Once you have bowel sounds and are
vv vv vv vv vv vv vv vv vv vv vv vv vv vv vv vv vv vv
passing gas, you may have clear liquids, and your diet will be advanced based upon your tolerance."
vv vv vv vv vv vv vv vv vv vv vv vv vv vv vv vv vv
The nurse is caring for a patient who had spinal anesthesia. Which drink is the best choice for the nurse
vv vv vv vv vv vv vv vv vv vv vv vv vv vv vv vv vv vv vv
to offer the patient? - ANSWER-✔✔Tea
vv vv vv vv vv vv
The nurse is caring for a surgical patient who complains of excessive gas. Which action should the nurse
vv vv vv vv vv vv vv vv vv vv vv vv vv vv vv vv vv
take? - ANSWER-✔✔Ambulate the patient in the hall.
vv vv vv vv vv vv vv vv
The nurse is educating the patient about vitamins and wound healing. The nurse explains that which
vv vv vv vv vv vv vv vv vv vv vv vv vv vv vv
vitamin will enhance wound healing the most? - ANSWER-✔✔Vitamin C
vv vv vv vv vv vv vv vv vv vv
The nurse is performing a neurological assessment on a patient who was just transferred from the PACU
vv vv vv vv vv vv vv vv vv vv vv vv vv vv vv vv
following abdominal surgery. Which action(s) correctly demonstrate(s) knowledge of a neurological
vv vv vv vv vv vv vv vv vv vv vv
assessment? (Select all that apply.) - ANSWER-✔✔- Asking the patient to identify where he is.
vv vv vv vv vv vv vv vv vv vv vv vv vv vv vv
, - Noting if the patient can identify the sensation of touch.
vv vv vv vv vv vv vv vv vv vv
- Asking the patient to move his arms and legs.
vv vv vv vv vv vv vv vv vv
- Assessing the patient's pupils for response to light.
vv vv vv vv vv vv vv vv
The nurse is performing the Aldrete scoring system. Which factor(s) must be assessed? (Select all that
vv vv vv vv vv vv vv vv vv vv vv vv vv vv vv
apply.) - ANSWER-✔✔- Activity
vv vv vv vv
- Circulation
vv
- Level of consciousness
vv vv vv
- O2 saturation
vv vv
- Respiration
vv
The PACU nurse is caring for a semiconscious patient immediately following abdominal surgery. The
vv vv vv vv vv vv vv vv vv vv vv vv vv
nurse correctly places the patient in which position? - ANSWER-✔✔Lateral
vv vv vv vv vv vv vv vv vv vv
The PACU nurse is caring for an unconscious patient. Assessment reveals diminished breath sounds
vv vv vv vv vv vv vv vv vv vv vv vv vv
bilaterally. Which action should the nurse take? - ANSWER-✔✔Document "diminished breath sounds in
vv vv vv vv vv vv vv vv vv vv vv vv vv
both lower lobes."
vv vv vv
The patient is brought into PACU still unconscious. What should the nurse do when the nurse assesses an
vv vv vv vv vv vv vv vv vv vv vv vv vv vv vv vv vv
oral temperature of 94° F? - ANSWER-✔✔Cover with a warm blanket
vv vv vv vv vv vv vv vv vv vv vv
The postoperative nursing intervention that would be contraindicated for a 45-year-old patient who has
vv vv vv vv vv vv vv vv vv vv vv vv vv
had a repair of a cerebral aneurysm and is presenting signs of increased intracranial pressure (ICP) would
vv vv vv vv vv vv vv vv vv vv vv vv vv vv vv vv vv
be: - ANSWER-✔✔coughing every 2 hours
vv vv vv vv vv vv
When the postoperative patient complains of sudden chest pain combined with dyspnea, cyanosis, and
vv vv vv vv vv vv vv vv vv vv vv vv vv
tachycardia, the nurse recognizes the signs of: - ANSWER-✔✔pulmonary embolus
vv vv vv vv vv vv vv vv vv vv
