Med Surg Exam 1

A - correct answer The nurse includes which nursing diagnosis in the plan of care for the patient admitted with pneumonia? A. Anxiety related to hypoxia B. Deficient knowledge related to cause of disorder C. Fear related to the threat of pain D. Ineffective breathing pattern related to decreased surfactant C - correct answer The nurse is reviewing orders on the patient who is to receive supplemental oxygen. It is a priority for the nurse to follow up with the provider about which order? A. Nasal cannula at 2 L/min B. Venturi mask at 24% concentration C. Nasal cannula at 8 L/min D. Venturi mask at 50% concentration A, B, C, E - correct answer What is the most important information for the nurse to include in the teaching plan about management of home oxygen therapy? (Select all that apply.) A. Do not change the settings of the oxygen without the health-care provider's permission. B. Place "No smoking" signs within the home. C. Oxygen is a fire hazard. D. Others may smoke around you as long as you do not smoke. E. Keep a fire extinguisher near the oxygen source A, D - correct answer The nurse is caring for a patient who is receiving oxygen therapy via the Venturi mask. Which complications are associated with oxygen therapy? (Select all that apply.) A. Oxygen toxicity B. Cachexia C. Bradycardia D. Absorption atelectasis E. Increased dead space A - correct answer The nurse is caring for a patient who has just been orally intubated. Which action should the nurse take first? A. Assess for symmetrical chest rise and fall with ventilation B. Provide mouth care to assure a clean oral cavity C. Assess the need for nutritional support by an oral nasogastric tube D. Provide a communication board for the patient and family D - correct answer When the nurse is performing postural drainage for the patient, which factor promotes the movement of secretions to the upper airways? A. Dilation of alveoli B. Action of the cilia C. Muscle contraction D. Force of gravity B - correct answer The nurse is screening patients for their risk of developing VAP. The nurse considers which patient at greatest risk? A. A patient who was extubated within 24 hours of being intubated B. A patient intubated and placed on mechanical ventilation less than 72 hours ago C. A patient with the head of the bed elevated 45 degrees D. A patient who was placed on a nasal cannula after being extubated B - correct answer A nursing preceptor is observing a newly hired nurse prioritizing patient rounds. Correct prioritization of assigned patients is indicated if the new nurse assesses which patient first? A. A patient with cellulitis of the right lower leg B. A patient who was extubated 2 hours ago C. A patient who was ordered nebulizer treatments prn D. A patient with an IV of D51 /2 NS at 125 mL/hr D - correct answer You are preparing a patient for surgery and have asked her to verify her information on her patient identification band. She tells you that the birth date is incorrect on her identification band. The most appropriate action by the nurse at this time is which of the following? A. Cross out the birth date and put the correct one in its place with the nurse's initials. B. Ask the family members to validate the patient's birth date. C. Call the surgeon's office to validate the birth date. D. Ask the admissions office to please send a corrected identification band. A, C, D - correct answer The nurse should report the following findings from a patient's history as an increased risk for DVTs postoperatively. (Select all that apply.) A. History of smoking B. Age C. History of DVTs with previous pregnancy D. Borderline hypertension E. Allergies C - correct answer Which of the following patients presents the greatest risk for a negative response to anesthesia? A. A 40-year-old male with high blood pressure B. A 20-year-old female with no prior surgical history C. A 29-year-old female with a history of stage II acute renal failure D. An 85-year-old male who drinks one glass of scotch every night A - correct answer During the initial assessment and admission questions, the nurse asks Maria for the time of her last oral intake. The patient replies, "I had dinner last night at 8 p.m., but I took a few sips of water this morning with my vitamins. The nurse's best response is which of the following? A. Explain to the patient that just a sip of water should not be a problem for anesthesia but that the vitamins may be a problem. We will pass that information on to the anesthesiologist. B. Tell the patient that the sip of water is not an issue because it was only a sip. C. Inform the patient that her surgery will not be performed today because the risk is too high for a negative outcome. D. Inform the patient that taking her vitamins before surgery was a good plan. B - correct answer Maria's surgeon has asked that thromboembolic stockings (TEDs) be placed on the patient before surgery as well as sequential compression devices on both legs to the knees. Maria asks the nurse what they will do for her. Which response by the nurse is most appropriate? A. "They work together to make sure that you do not have a decrease in arterial blood flow in your legs during the surgery." B. "They complement each other to prevent blood from backing up in your legs and causing a deep vein thrombosis due to you not moving during the surgery." C. "They prevent deep tissue clotting during the surgery." D. "The two devices do the same thing, but one is better during the surgery and the other is better postoperatively." A, B, C, D - correct answer When planning discharge education for a 65-year-old male who is having a hip replacement, it is appropriate for the nurse to consider which of the following? (Select all that apply.) A. The patient's resources at home for completing activities of daily living B. The number of stairs in the patient's home C. Transportation to follow-up appointments D. Preexisting medical conditions E. The number of bathrooms in the home D - correct answer Which of the following is the identified leader of the surgical team? A. The circulator B. The anesthesia care provider (the anesthesiologist/anesthetist) C. The PA D. The surgeon A, B, C, D, E, F - correct answer The OR nurse is completing a perioperative assessment for a patient who is scheduled for exploratory surgery. Which of the following interventions must be completed prior to this patient going into the OR? (Select all that apply.) A. Verify operative consent has been signed B. Assure allergy and ID bands are in place C. Removal of patient's personal clothing D. Determine evidence of advance directive E. Validate completed patient history and physical examination F. Determine NPO status (last food/fluid consumed) B - correct answer Which of the following is an example of a local anesthetic? A. Diazepam B. Lidocaine C. Pavulon D. Morphine C, D - correct answer Which of the following is an airway used to support airway management? (Select all that apply.) A. MAC B. MH C. LMA D. ETT E. PCP D - correct answer The nurse caring for a patient in the supine position on the OR table incorporates which nursing diagnosis into the plan of care? A. Risk for fluid volume deficit B. Risk for knowledge deficit C. Risk for aspiration D. Risk for potential alteration in skin integrity A, B, C - correct answer The nurse understands which actions are essential when providing support to the intraoperative patient and family during the OR experience? (Select all that apply.) A. Introduce the patient and family to the surgical team members. B. Give family members updates every 2 hours as possible during the procedure. C. Explain what to expect from the operative experience. D. Alert the family to mealtimes. E. Explain that once the procedure is complete, the surgeon will discuss surgery outcomes. C - correct answer The nurse understands PACUs are designed for which of the following? A. Managing the transition from anesthesia to long-term care B. Managing th