1- A nurse is reviewing the laboratory results of a client who has metabolic alkalosis. Which of the following laboratory values should the nurse
... [Show More] expect?
A. pH 7.31, HCO3- 22 mEq/L, PaCO2 50 mmHg
B. pH 7.48, HCO3- 23 mEq/L, PaCO2 25 mmHg
C. pH 7.32, HCO3- 18 mEq/L, PaCO2 40 mmHg
D. pH 7.49, HCO3- 32 mEq/L, PaCO2 40 mmHg
2- A nurse in the emergency department is assessing a client who has deep, rapid respirations. Arterial blood gas analysis includes the following values: pH 7.25, PaCO2 40, and HCO3- 18. Which of the following acid-base imbalances should the nurse identify and report to the provider?
A. Respiratory alkalosis
B. Metabolic alkalosis
C. Respiratory acidosis
D. Metabolic acidosis
3- A nurse is caring for a client who is extremely anxious and is hyperventilating. The client's ABG results are pH 7.50, PaCO2 27 mmHg, and HCO3- 25 mEq/L. The nurse should identify that the client has which of the following acid-base imbalances?
A. Respiratory acidosis
B. Metabolic acidosis
C. Respiratory alkalosis
D. Metabolic alkalosis
4- A nurse is caring for an older adult client who has chronic obstructive pulmonary disease (COPD) with pneumonia. The nurse should monitor the client for which of the following acid-base imbalances?
A. Respiratory alkalosis
B. Respiratory acidosis
C. Metabolic alkalosis
D. Metabolic acidosis
5- A nurse is reviewing a client’s laboratory report. The client’s ABG levels are pH 7.5, PaCO2 32 mmHg, and HCO3- 24 mEq/L. The nurse should determine that the client has which of the following acid-base imbalances?
A. Respiratory alkalosis
B. Metabolic acidosis
C. Respiratory acidosis
D. Metabolic alkalosis
6- A nurse is rewarming a client following coronary artery bypass graft (CABG) surgery. For which of the following complications of the rewarming process should the nurse monitor the client?
A. Acidosis
B. Infection
C. Hypertension
D. Cardiac tamponade
7- A nurse is reviewing laboratory findings of an adolescent who has acute renal failure. Which of the following findings should the nurse expect?
A. Hypokalemia
B. Hypercalcemia
C. Decreased plasma creatinine level
D. Metabolic acidosis
8- A nurse is caring for a client who has emphysema and chronic respiratory acidosis. The nurse should monitor the client for which of the following electrolyte imbalances?
A. Hyperkalemia
B. Hyponatremia
C. Hypercalcemia
D. Hypomagnesemia
9- A nurse is assessing a client who is 12 hr postoperative following an open cholecystectomy. Which of the following findings should the nurse report to the provider?
A. Hypoactive bowel sounds
B. Indwelling urinary catheter output of 25 mL/hr (The nurse should report a urinary output of <30 mL/hr to the provider, as this can indicate hypovolemia or renal complication)
C. Heart rate of 96/min
D. Serous drainage at the surgical incision site
10- A nurse is reviewing the laboratory report of a client who has chronic kidney disease (CKD). The nurse finds the following laboratory test results: potassium 6.8 mEq/L, calcium 7.4 mg/dL, hemoglobin
10.2 g/dL, and phosphate 4.8 mg/dL. Which finding is the priority for the nurse to report to the provider?
A. Hypocalcemia
B. Hyperkalemia
C. Anemia
D. Hypoalbuminemia
11- A nurse is providing dietary teaching a client who has late-stage chronic kidney disease (CKD). Which of the following nutrients should the nurse instruct the client to increase in her diet?
A. Calcium (CKD can develop hypocalcemia)
B. Phosphorous
C. Potassium
D. Sodium
12- A nurse is checking the laboratory values of a client who has chronic kidney disease. The nurse should expect elevations in which of the following values?
A. Potassium and magnesium (CKD pte have hyperkalemia, hyperphosphatemia, and hypermagnesemia)
B. Calcium and bicarbonate
C. Hemoglobin and hematocrit
D. Arterial pH and PaCO2
13- A nurse is caring for a client who has chronic glomerulonephritis with oliguria. For which of the following electrolyte imbalances should the nurse monitor?
A. Hypercalcemia
B. Hyperkalemia (glomerulonephritis causes potassium retentation)
C. Hypomagnesemia
D. Hypophosphatemia
14- A nurse is caring for a client who has emphysema and chronic respiratory acidosis. The nurse should monitor the client for which of the following electrolyte imbalances?
A. Hyperkalemia
B. Hyponatremia
C. Hypercalcemia
D. Hypomagnesemia
15- A nurse is reviewing the laboratory findings of a client who has chronic kidney disease. The client reports significant persistent nausea and muscle weakness. Which of the following findings should the nurse expect?
A. Hypernatremia
B. Hypomagnesemia
C. Hypercalcemia
D. Hyperkalemia
16- A nurse is monitoring the electrocardiogram of a client who has hypocalcemia. Which of the following findings should the nurse expect?
A. Flattened T waves
B. Prolonged QT intervals
C. Shortened QT intervals
D. Widened QRS complexes
17- A nurse is caring for a client who has a major burn injury and is experiencing third spacing. Which of the following fluid or electrolyte imbalances should the nurse expect?
A. Hypokalemia
B. Hypernatremia
C. Elevated Hct
D. Decreased Hgb
18- A nurse is examining the ECG of a client who has hyperkalemia. Which of the following ECG changes should the nurse expect?
A. Elevated ST segments
B. Absent P waves
C. Depressed ST segments
D. Varying PP intervals
19- A nurse is reviewing the laboratory values of a client who has a positive Chvostek’s sign. Which of the following laboratory findings should the nurse expect?
A. Decreased calcium
B. Decreased potassium
C. Increased potassium
D. Increased calcium
20- A nurse is reviewing the laboratory data of a client who has a fever and watery diarrhea. Which of the following results should the nurse report to the provider?
A. Calcium 9.5 mg/dL
B. Sodium 150 mEq/L
C. Potassium 4 mEq/L
D. Magnesium 1.5 mEq/L
21- A nurse is reviewing the laboratory report of a 2-year-old child who has diarrhea and has been vomiting for 24 hr. Which of the following findings should the nurse report to the provider?
A. Hct 40%
B. Potassium 2.5 mEq/L
C. Serum creatinine 0.4 mg/dL
D. BUN 6 mg/Dl
22- A nurse is assessing a client who is receiving continuous ambulatory peritoneal dialysis. Which of the following findings should the nurse report to the provider?
A. WBC 6,000/mm^3
B. Potassium 3.0 mEq/L
C. Clear, pale yellow drainage
D. Report of abdominal fullness
23- A nurse is monitoring a client's laboratory results. Which of the following results should the nurse report to the provider?
A. Sodium 140 mEq/L
B. Potassium 3.0 mEq/L
C. Chloride 100 mEq/L
D. Magnesium 2.0 mEq/L
24- A nurse is assessing a client who has heart failure and is taking daily furosemide. The client's apical pulse is weak and irregular. The nurse should identify these findings as manifestations of which of the following electrolyte imbalances?
A. Hypokalemia
B. Hypophosphatemia
C. Hypercalcemia
D. Hypermagnesemia
25- A nurse is assessing a client who has a total calcium level of 12.7 mg/dL. Which of the following findings should the nurse expect?
A. Muscle tremors
B. Positive Chvostek's sign
C. Depressed deep-tendon reflexes (nausea, vomiting, bone pain, weakness, lethargy)
D. Numbness around the mouth
26- A nurse is assessing for disseminated intravascular coagulation (DIC) in a client who has septic shock secondary to an untreated foot wound. Which of the following findings should the nurse expect? (Select all that apply.) Shock
A. Bradycardia
B. Bleeding at the venipuncture site
C. Petechiae on the chest and arms
D. Flushed, dry skin
E. Abdominal distension
27- A nurse in the emergency department is caring for a client who has abdominal trauma. Which of the following assessment findings should the nurse identify as an indication of hypovolemic shock? Shock
A. Warm, dry skin
B. Increased urinary output
C. Tachycardia
D. Bradypnea
28- A nurse is caring for a client with dehydration who has developed hypovolemic shock. Which of the following laboratory values should the nurse expect for this client?
A. BUN 18 mg/dL
B. Capillary refill 1.5 sec
C. Hct 55%
D. Urine specific gravity 1.001
29- A nurse is caring for a client who is in hypovolemic shock. While waiting for a unit of blood, the nurse should administer which of the following IV solutions? Shock
A. 0.45% sodium chloride
B. Dextrose 5% in 0.9% sodium chloride
C. Dextrose 10% in water
D. 0.9% sodium chloride
30- A nurse is planning care for a client who is postoperative following a hip arthroplasty. In the client’s medical record, the nurse notes a history of chronic obstructive pulmonary disease (COPD). Which of the following oxygen-delivery methods should the nurse plan to use for this client?
A. Simple face mask
B. Nonrebreather mask
C. Bag-valve-mask device
D. Nasal cannula
31- A nurse is preparing a client who is scheduled to have an arthroscopy the following day. Which of the following statements indicates that the client understands the preprocedure teaching?
A. "I have to keep my leg straight throughout the whole procedure."
B. "The doctor will be able to see if I have signs of rheumatoid arthritis."
C. "I should expect to stay overnight until I can walk around."
D. "I'll have a scar that will be about an inch long
32- A nurse is providing postoperative discharge teaching to a client following a panhysterectomy for uterine cancer. Which of the following pieces of information should the nurse include in the teaching?
A. "You will need to continue to use some form of birth control for 6 months."
B. "You might experience manifestations of menopause."
C. "Do not lift anything heavier than 15 lb."
D. "Pain or burning with urination is an expected outcome of this surgery."
33- A nurse is providing discharge teaching for a client who had a left total hip arthroplasty. Which of the following client statements indicates the teaching was effective?
A. "I should expect swelling of the affected leg for several weeks."
B. "I should not cross my legs at the ankles or knees."
C. "I will inspect my hip incision every other day for redness."
D. "I can bend over at the hip to pick up objects."
34- A nurse is caring for a client who is postoperative following a parathyroidectomy to treat hyperparathyroidism. Which of the following laboratory values should the nurse expect to decrease as a therapeutic effect of the procedure?
A. Calcium
B. Sodium
C. Potassium
D. Phosphorous
35- A nurse is preparing a client who is postoperative following total hip arthroplasty for discharge. Which of the following statements indicates that the client understands the instructions?
A. "I'll use alcohol pads to clean my incision each day."
B. "When I'm doing my exercises, I'll include bent-leg raises."
C. "I'll use a reacher to help me pick up anything I drop on the floor."
D. "When I can walk without my walker, I can stop attending physical therapy."
36- A nurse is caring for a client who is postoperative following a total knee arthroplasty and has been prescribed a continuous passive motion (CPM) machine and PCA. The client tells the nurse, "I am in so much pain." Which of the following actions should the nurse take first?
A. Remind the client to push the button for the PCA device
B. Discuss activities the client may use to distract from the pain
C. Ask the client to describe the characteristics of the pain
D. Pause the CPM machine briefly to apply a cold pack to the client’s knee
37- A nurse is caring for a client who is 3 days postoperative following abdominal surgery. The client states, "Something just popped when I coughed." Which of the following actions should the nurse take first?
A. Cover the client's wound with a sterile, moist dressing
B. Flex the client's knees
C. Reassure the client
D. Instruct the client to avoid coughing
38- A nurse is caring for a client who is postoperative following shoulder surgery. The client has a prescription to keep the affected arm adducted. Which of the following instructions should the nurse share with the client?
A. "Keep your arm bent at the elbow."
B. "Use a pillow to prop your shoulder up close to your ear."
C. "Hold your arm against the side of your body."
D. "Position your arm with the shoulder at a 90° angle."
39- A nurse is caring for a client who had a gastric resection to treat adenocarcinoma of the stomach. The client tells the nurse in the PACU that he does not remember why the surgeon said he had to have a tube in his nose. The nurse should explain that the NG tube serves which of the following purposes?
A. Prevents excessive pressure on suture lines
B. Allows gastric lavage after surgery
C. Allows early postoperative feeding
D. Facilitates obtaining gastric specimens for testing
40- A nurse is preparing a client for discharge who is postoperative following a conventional lumbar disk excision. Which of the following statements indicates that the client understands the nurse’s instructions?
A. "I should have no problem climbing stairs when I get home."
B. "I'll wait about 3 weeks before I return to my usual activities."
C. "I'll use my heating pad if I feel any muscle spasms in my back."
D. "I can go back to driving in about 2 weeks or so."
41- A nurse is providing discharge instructions for a client who is postoperative following inner maxillary fixation with wiring. Which of the following pieces of information should the nurse include?
A. Cut the wiring if emesis occurs
B. Consume 3 meals daily as part of a low-protein diet
C. Swab the mouth with hydrogen peroxide if wiring produces oral irritation
D. Resume a soft diet in 3 to 5 days
42. A nurse is assessing a client who is 48 hr postoperative following open reduction and internal fixation of a fractured tibia. Which the following findings should the nurse report to the provider?
A. Toes that are cold to the touch
B. Serous drainage from the pin sites
C. Blanching of the toenail beds with pressure
D. Pink tissue around the fixator insertion sites
43. A nurse is caring for a client who is postoperative following vein ligation and stripping for varicose veins. Which of the following actions should the nurse take?
A. Position the client supine with his legs elevated when in bed
B. Encourage the client to ambulate for 15 min every hour while awake for the first 24 hr
C. Tell the client to sit with his legs dependent after ambulating
D. Instruct the client to wear knee-length socks for 2 weeks after surgery
44. A nurse is caring for a client who is postoperative following a frontal craniotomy. The nurse should place the client in which of the following positions? Perioperative
A. Trendelenburg
B. Prone
C. Semi-Fowler's
D. Sims'
45- A nurse is assessing a client who is 4 hr postoperative following a transurethral resection of the prostate and has an indwelling urinary catheter in place. Which of the following findings should the nurse expect?
A. Blood-tinged urine in the drainage bag
B. Catheter tubing coiled at the client's side
C. Client report of severe bladder spams
D. Urinary output of 20 mL/hr
46- A nurse is planning care for a client who is postoperative following a radical mastectomy. Which of the following interventions should the nurse include in the plan? Perioperative
A. Rest the arm on the affected side on the bed when the client is sleeping
B. Instruct the client to keep the affected arm flexed when ambulating
C. Begin exercises with the client 1 day after the procedure
D. Maintain the client on bed rest for 2 days after the procedure
47. A nurse is teaching a client who is preoperative for a cystoscopy. Which of the following statements should the nurse make?
A. "You will need to keep the sutures clean after this procedure."
B. "You will be placed on your left side for this procedure."
C. "Expect to be on bed rest for 24 hr after this procedure."
D. "Expect to have pink-tinged urine after this procedure."
48- A nurse is providing teaching to a client who is preoperative prior to a transurethral resection of the prostate (TURP). Which of the following client statements indicates an understanding of the information?
A. "I will not need to have a urinary catheter following this procedure.”
B. "I will expect my urine to be cloudy after having this procedure."
C. "At least I won’t have leakage of urine after having this procedure."
D. "I will feel the urge to urinate following this procedure."
49- A nurse is providing preoperative teaching for a client who is scheduled for total knee arthroplasty. Which of the following statements by the client indicates an understanding of the teaching?
A. "I will wear a continuous movement machine on my knee for 24 hr a day."
B. "I should avoid taking NSAID medications for pain after surgery."
C. "I should wear elastic stockings on both of my legs."
D. "I will begin exercising my legs the day after surgery."
50- A nurse is assessing a client who is postoperative following a transurethral resection of the prostate (TURP) and has continuous bladder irrigation. The nurse notes no drainage in the client's urinary drainage bag over 1 hr. Which of the following actions should the nurse take?
A. Instruct the client to attempt to void around the indwelling urinary catheter
B. Increase the rate of irrigation fluid instillation
C. Irrigate the indwelling urinary catheter with a syringe
D. Prepare to administer a diuretic
51- A nurse is assessing a client who is postoperative following a craniotomy and has a urine output of 600 mL/hr. The nurse suspects the client has manifestations of diabetes insipidus (DI). Which of the following laboratory values should the nurse plan to obtain to assess for DI?
A. Blood urea nitrogen (BUN)
B. Blood glucose
C. Urine ketones
D. Specific gravity
52- A nurse is providing discharge teaching to a client who is postoperative following cataract surgery and has an intraocular lens implant. Which of the following statements by the client indicates an understanding of the instructions?
A. "I will sleep on the affected side."
B. "I will avoid bending over."
C. "I will restrict caffeine in my diet."
D. "I will take aspirin to relieve my pain."
53- A nurse is assessing a client who is 1 week postoperative following a living donor kidney transplant. Which of the following findings indicates the client is experiencing acute kidney rejection?
A. Blood pressure 160/90 mmHg
B. Creatinine 0.8 mg/dL
C. Sodium 137 mg/dL
D. Urinary output 100 mL/hr
54- A nurse is evaluating the laboratory values of a client who is in the resuscitation phase following a major burn. Which of the following laboratory findings should the nurse expect?
A. Hemoglobin 10 g/dL
B. Sodium 132 mEq/L (This laboratory finding is below the expected reference range. The nurse should anticipate a low sodium level because sodium is trapped in interstitial space.)
C. Albumin 3.6 g/dL
D. Potassium 4.0 mEq/dL
55- A nurse is caring for a client who is 48 hr postoperative following a small bowel resection. The client reports gas pains in the periumbilical area. The nurse should plan care based on which of the following factors contributing to this postoperative complication?
A. Blood loss
B. NPO status after surgery
C. Nasogastric tube suctioning
D. Impaired peristalsis of the intestines
56- A nurse is assessing a client who is postoperative. Which of the following findings should the nurse identify as an indication that the client is experiencing pain?
A. Diarrhea
B. Pupillary constriction
C. Flushing
D. Grimacing
58- A nurse is preparing a client for a bone-marrow biopsy. Which of the following pieces of information should the nurse include in preoperative teaching?
A. "You'll receive heavy sedation, so you might even sleep during the procedure."
B. "You'll have to lie on your back throughout the procedure."
C. "You'll feel a painful, pulling sensation when the doctor withdraws the marrow."
D. "Expect the procedure to take about an hour."
58. A nurse is providing preoperative teaching to a client who will undergo a total laryngectomy. Which of the following statements indicates that the client understands the impact of the surgery?
A. "I'm not going to be able to cough for a while after the surgery."
B. "After I recover from the anesthesia, I'll be able to eat regular food again."
C. "After the surgery, my voice will gradually return but might be weak."
D. "I understand that I will have a permanent tracheostomy after the surgery."
59. A nurse is teaching a group of unit nurses about the experiences of clients who are having surgery. In which phase of care is the client transferred to the surgical suite table before being transferred to the PACU?
A. Preoperative
B. Postoperative
C. Intraoperative
D. Admission
60- A nurse is receiving a client from the PACU who is postoperative following abdominal surgery. Which of the following actions should the nurse perform to transfer the client from the stretcher to the bed?
A. Lock the wheels on the bed and stretcher.
B. Instruct the client to raise his arms above his head.
C. Elevate the stretcher 2.5 cm (1 in) above the height of the bed.
D. Log-roll the client.
61- A nurse is accepting a transfer from the postanesthesia care unit (PACU) of a client who has had a subtotal thyroidectomy. Which of the following pieces of equipment should the nurse have available at the bedside for this client?
A. Cardiac monitor
B. Defibrillator
C. Thoracotomy tray
D. Tracheostomy tray
62- A nurse in the PACU is assessing a newly admitted client and observes intercostal retractions and a high-pitched inspiratory sound. The nurse should identify these findings as manifestations of which of the following complications?
A. Pulmonary edema
B. Tension pneumothorax
C. Flail chest
D. Respiratory obstruction
63- A nurse is caring for a client who was transferred to the surgical unit by stretcher from the PACU. Which of the following actions should the nurse perform immediately following the transfer?
A. Administer pain medication
B. Check the client's vital signs
C. Instruct the client to use the incentive spirometer every 1 hr
D. Provide ice chips as per provider prescription
65- A nurse is performing a preoperative assessment of a client about to undergo a cholecystectomy. The nurse should identify a risk for a latex allergy when the client reports an allergy to which of the following foods?
A. Cabbage
B. Oatmeal
C. Milk
D. Bananas
66- A nurse is preparing an IM injection for a client who is preoperative when another client suddenly calls for assistance. The nurse asks another nurse to give the injection since an assistive personnel is waiting to take the client to surgery. Which of the following actions should the second nurse take?
A. Prepare a new syringe for the client who is preoperative.
B. Give the prepared medication to the client who is preoperative.
C. Help the client requesting assistance so the first nurse can give the prepared injection.
D. Report this request to the charge nurse.
67- A nurse is providing preoperative teaching to a client who will undergo surgery to create a temporary colostomy. The client asks the nurse about the difference between colostomies and ileostomies. Which of the following responses should the nurse make?
A. "A colostomy drains stool, and an ileostomy drains urine."
B. "A colostomy is temporary, and an ileostomy is permanent."
C. "A colostomy is from the large intestine, and an ileostomy is from the small intestine."
D. "An ileostomy requires dietary restrictions, while a colostomy does not."
68- A nurse is preparing a school-age child for a tonsillectomy. Which of the following actions should the nurse take?
A. Schedule the child for a preoperative visit to the facility
B. Inform the child he will be put to sleep for the procedure
C. Read the child a story about a cartoon character having a similar operation
D. Tell the child the appointment is to have his throat checked
69- A nurse is planning preoperative teaching for a school-age child who is scheduled for cardiac surgery. Which of the following actions should the nurse plan to take when teaching the child?
A. Limit teaching sessions to 10 min
B. Use simple, concrete terms when giving explanations
C. Use photographs to help explain the procedure
D. Conduct the teaching session 2 days before the procedure
70- A nurse is providing preoperative teaching for a client who will undergo laser-assisted in situ keratomileusis (LASIK) surgery. Which of the following pieces of information should the nurse include?
A. "You might need glasses after the surgery."
B. "You may drive home after the procedure."
C. "Continue to wear your contact lenses until the day of the surgery."
D. "Expect complete healing and clear vision in about a week."
71- A nurse is providing preoperative teaching to a client who is scheduled for arthroplasty in the next month and may require a blood transfusion. The client expresses concern about the risk of acquiring an infection from the blood transfusion. Which of the following statements should the nurse share with the client?
A. "Ask your provider to prescribe epoetin before the surgery."
B. "You should ask your provider about taking iron supplements prior to the surgery."
C. "Ask a family member to donate blood for you."
D. "Donate autologous blood before the surgery."
72- A nurse is providing teaching to a client who is preoperative for a renal biopsy. Which of the following statements should the nurse make?
A. "You will be NPO for 8 hr following the procedure."
B. "An allergy to shellfish is a contraindication to this procedure."
C. "You will need to be on bed rest following the procedure."
D. "A creatinine clearance is needed prior to the procedure."
73- A nurse is providing preoperative education for an 8- year-old child prior to cardiac surgery. Which of the following actions should the nurse take?
A. Provide education for the child immediately before the surgery.
B. Plan a teaching session that will last no longer than 60 min.
C. Use a doll with tubes and an incision to explain the surgery.
D. Discuss methods to cover the scar once healing has occurred.
74- A nurse is caring for a 13-year-old female client who is admitted for an emergency appendectomy. While the nurse is providing the preoperative teaching, the client asks, "Will I have a large scar from the surgery?" Which of the following responses should the nurse make?
A. "It will be small enough that it won’t show when you're wearing a bathing suit."
B. "That isn’t our biggest concern right now. You will be fine."
C. "You should be happy. You won't be in pain for much longer."
D. "What is your favorite class in school?"
75- A nurse is providing preoperative teaching to a client who is to undergo a pneumonectomy. The client states, "I am afraid coughing will hurt after the surgery." Which of the following statements by the nurse is appropriate?
A. "After the surgeon removes the lung, you will not need to cough."
B. "I'll make sure you get a cough suppressant to keep you from straining the incision when you cough."
C. "Don’t worry. You will have a pump that delivers pain medication as needed, so you will have very little pain."
D. "I will show you how to splint your incision while coughing."
76- A nurse is providing preoperative teaching for a client with colorectal cancer who is scheduled to undergo colostomy placement with a perineal wound. Which of the following statements by the client indicates an understanding of the teaching?
A. "Not having any more rectal pain will be a relief."
B. "I will need to sit on a rubber donut when I am in the chair."
C. "I can have only liquids for 2 days before the surgery."
D. "The colostomy will start working about 7 days after the surgery."
77- A nurse is caring for a client who is postoperative following a lumbar disk excision. Which of the following interventions should the nurse include in the client's plan of care?
A. Keep the client's legs flat with the knees extended
B. Encourage the client to sit up in a chair for as long as possible
C. Logroll the client in bed for care procedures
D. Expect urinary retention for the first postoperative day
78- A nurse is caring for an infant who is preoperative for the treatment of an intact myelomeningocele sac. In which of the following positions should the nurse place the infant?
A. Side-lying
B. Supine
C. Prone
D. Semi-Fowler's
79- A nurse is witnessing a client sign an informed consent form for surgery. What is the nurse affirming by this action?
A. The client fully understands the provider's explanation of the procedure.
B. The client has been informed about the risks and benefits of the procedure.
C. The nurse witnessed the provider's explanation of the procedure.
D. The signature on the preoperative consent form is the client's.
80- A nurse is planning preoperative teaching for a 5-yearold child. Which of the following interventions should the nurse include?
A. Explain the long-term benefits of the procedure.
B. Provide diagrams and pictures while explaining the procedure.
C. Use correct medical terminology during the teaching session.
D. Explain the procedure in terms of what the child will feel, see, hear, and taste.
81- A nurse is planning preoperative teaching for a preschooler who is scheduled for a tonsillectomy. Which of the following interventions should the nurse plan to include?
A. Encourage the preschooler to bring a favorite toy to the hospital
B. Spend 30 minutes teaching the preschooler about what to expect
C. Schedule the teaching session for the morning of the preschooler's procedure
D. Reassure the preschooler that medicine will prevent pain after the procedure
82- A nurse is preparing to provide self-care teaching to a client who is 4 days postoperative following the creation of a colostomy and refuses to look at the stoma. Which of the following actions should the nurse take?
A. Postpone any teaching with the client at this time
B. Reinforce the preoperative information with the client
C. Encourage the client to empty the colostomy bag first
D. Ask the client to begin assuming responsibility for self-care of the colostomy
83- A nurse is performing a preoperative assessment of a client who is about to undergo an aneurysm clipping. The nurse should identify a risk for increased bleeding when the client reports taking which of the following dietary supplements?
A. Soy
B. Garlic
C. Black cohosh
D. Green tea
84- A nurse on a surgical unit is receiving a client who had abdominal surgery from the post-anesthesia care unit. Which of the following assessments should the nurse make first?
A. Pain level
B. Hydration status
C. Airway
D. Urinary output
85- A nurse on a medical-surgical unit is washing her hands prior to assisting with a surgical procedure. Which of the following actions by the nurse demonstrates proper surgical handwashing technique?
A. The nurse washes each part of her hands with 5 strokes.
B. The nurse washes from the elbows down to the hands.
C. The nurse holds her hands higher than her elbows while washing.
D. The nurse uses minimal friction when washing her hands
86- A nurse is admitting a child who has acute lymphocytic leukemia. Which of the following laboratory values should the nurse expect?
A. Platelets 500,000 mm^3
B. RBCs 2.5 million/uL
C. WBCs 4,000/mm^3
D. Hct 60%
87- A nurse is reviewing the laboratory values of a client who has diabetic ketoacidosis. Which of the following laboratory values is consistent with diabetic ketoacidosis?
A. Blood glucose 30 mg/dL
B. Negative urine ketones
C. Blood pH 7.38
D. Bicarbonate level 12 mEq/L
88- A nurse is demonstrating postoperative deep breathing and coughing exercises to a client who is scheduled for emergency surgery for appendicitis. Which of the following statements indicates a lack of readiness to learn by the client?
A. The client asks the nurse to repeat the instructions before attempting the exercises.
B. The client reports severe pain.
C. The client asks the nurse how often deep breathing should be done after surgery.
D. The client tells the nurse that this exercise will probably be painful after surgery.
89- A nurse is caring for a client who has just returned from the surgical suite following a right nephrectomy. Which of the following indicates that the client is meeting a successful short-term goal following this procedure?
A. The client requests pain medication upon arrival from surgery.
B. A chest X-ray shows consolidation in the right lower lobe.
C. Urinary output is 35 to 50 mL/hr consistently.
D. The client has slight abdominal distention
90- A nurse on a medical-surgical unit is caring for a client who is postoperative following a hip replacement surgery. The client reports feeling apprehensive and restless. Which of the following findings should the nurse recognize as an indication of pulmonary embolism?
A. Sudden onset of dyspnea
B. Tracheal deviation
C. Bradycardia
D. Difficulty swallowing
91- A nurse is caring for a client who reports feeling a pop after coughing without properly splinting an abdominal incision. On assessment, the nurse notes that the client's wound has eviscerated. Which of the following actions should the nurse take? (Select all that apply.)
A. Carefully reinsert the intestine through the opening in the wound
B. Place the client in a supine position with the hips and knees flexed
C. Leave the room to call the surgeon
D. Cover the wound and intestine with a sterile, moistened dressing
E. Monitor the client for manifestations of shock
92- A nurse in the emergency department is caring for a client who has sustained a pelvic fracture in a motor vehicle collision. Which of the following would be a sign of hypovolemic shock in this client?
A. Distended neck veins
B. An apical pulse rate of 140 BPM
C. A blood pressure of 170/100 mm Hg
D. A urine output of 70 ml per hour
93- A nurse is monitoring a client who is receiving a blood transfusion. Which of the following will the nurse expect if this client develops a blood transfusion reaction?
A. Hypertension
B. Diaphoresis
C. Polyuria
D. Warm skin
94- Which of the following best describes the rapid onset of hypotension or severe respiratory distress after injection of a contrast agent or ingestion of a food?
A. Allergic rhinitis
B. Asthma
C. Anaphylaxis
D. Sepsis
95- A nurse is monitoring a postoperative client. The nurse should identify which of the following signs as an indication of potential complication?
A. Pulse rate 80 beats/min
B. Blood pressure 110/70 mmHg
C. Pain at surgical site
D. Increasing restlessness
96- A client is experiencing diarrhea for 3 days. Which of the following indicates hypovolemia?
A. Sudden weight gain
B. Light colored urine
C. Decreased blood pressure
D. Wet mucus membrane
97- A nurse is caring for a client who has manifestations of dehydration while in the PACU. Which of the following findings should the nurse report to the provider? (Select all that apply.)
A. Urine output less than 25 mL/hr
B. Hematocrit 55%
C. BUN 30 mg/dL
D. Tenting of skin over the sternum
E. Radial pulse rate 60/min
98- A nurse is caring for four clients. The nurse should identify that which of the following clients is at risk for developing a dysrhythmia? (Select all that apply.)
A. A client who has metabolic alkalosis
B. A client who has a total serum calcium level of 9.5 mg/dL
C. A client who has an SaO2 of 96%
D. A client who has COPD
E. A client who had a stent placement in a coronary artery
99- The physician orders hourly urine output measurement for a postoperative client. The nurse records the following amounts for 2 consecutive hours: 20mL and 25mL. What may be the next nursing action?
A. Notify the physician
B. Irrigate the catheter
C. Increase the rate of IV inflow
D. Continue to monitor and record urine output
100- A client has undergone total hip replacement and returns to the recovery room. What postoperative care should be given by the nurse?
A. Keep pillows between the legs
B. Allow to cross legs of the patient
C. Lower the head end of the bed
D. Make the patient to sit in a low level chair
101- A nurse is reviewing the laboratory results of a client who is preoperative. Which of the following results should the nurse report to the provider? (Select all that apply.)
A. Potassium 3.9 mEq/L
B. Sodium 136 mEq/L
C. Creatinine 2.6 mg/dL
D. Blood glucose 206 mg/dL
E. WBC 15,000/mm3
102- The preoperative teaching for prevention of postoperative complications includes leg exercises. The nurse teaches leg exercises preoperative to gallbladder surgery to help prevent:
A. Muscle spasms
B. Paralytic spasms
C. Stasis and clot formation
D. Vasogenic shock
103- Preoperatively, which information is important to teach the client before the subtotal thyroidectomy?
A. Techniques for changing positions
B. Reasons for performing leg exercises
C. The necessity for daily dressing changes
D. Postoperative use of the incentive spirometer
104- A nurse is giving preoperative teaching on deep breathing and coughing exercises to a preoperative client. Which of the following statements of the client indicate a need for further teaching?
A. I should do it in sitting position
B. It should be done every 1-2 hours
C. I have to inhale and exhale through the nose slowly
D. I have to hold the 3rd breath for 3 seconds and then cough deeply for 3 times 105- [Show Less]