ATI Perioperative – Flashcards
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Post open transverse coly 5 days ago, nurse recognizes the wound has eviscerated. After covering with sterile, saline-soaked dressing, which of following actions should nurse take first? Go to Nurses station to seek assistance, reinsert organs into abdominal cavity, place client in reverse trendelenburg, obtain V/S to assess for shock.
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Obtain V/S to assess for shock
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When caring for postop patient with JP drain, which intervention should nurse use to ensure proper functioning of drain? Secure to clients bed sheet, clamp when ambulating, empty and compress drain as needed, keep drain higher than surgical incision
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empty and compress as needed
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When completing initial PACU assessment of patient postop knew arthroplasty who received spinal anesthesia, which finding indicates need to notify provider? Client states bilateral numbness to lower extremities, spinal anesthesia is at T10 level, client rouses to tactile stimuli, patient reports chest pain
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patient report chest pain
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Surgical nurse enters surgical suite to ensure surgical asepsis is maintained. Which observation requires an intervention. Scrub tech wearing a watch under his scrubs, circulating nurse opens dressing packages before applying sterile gloves, surgeon has hands folded 2 in (5cm) above waist, holding area nurse is performing patient education
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scrub tech wearing a watch under his scrubs
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When caring for a postoperative patient, what should the nurse do to prevent formation of thrombi in the postoperative period? Change patient's position q4h, have patient perform dorsal and plantar flexion of feet q1h, place patient in bed with pillow under knees, assess pedal and posterior tibial pulses q2h
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have patient perform dorsal and plantar flexion every hour
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when caring for a patient 2 days postop following cholecystectomy, the patient has been vomiting for past 24hrs & reports pain level of 8 on scale 0-10. Nurse notes hard, distended abdomen and absent bowel sounds. After conferring with provider, which of following actions should nurse take first? Draw blood for electrolytes, insert NG tube, administer pain medication, initiate intake & output
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Insert NG tube
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When caring for patient 2hrs postop following appendectomy, which finding should nurse report to provider? Urine output 20mL/h, Temp 36.4 (97.7), 2cmx2cm area bloody drainage on dressing, JP drainage 30ml?h
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Urine output 20mL/hr
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When completing prep assessment for a client who is a Jehovahs witness, which of following should nurse recognize as situation that could pose special care needs for this client? Having preop blood drawn, giving information about sexual history, providing informed consent to receive blood products, receiving care from nurse of opposite gender.
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providing informed consent to receive blood products
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When receiving afternoon report on 4 patient who have returned from PACU this morning, which patient first? Posted thoracotomy w/chest tube w/150mL bright-red blood in collection chamber from first hour, postop small bowel resection w/temp colostomy and absent bowel sounds x4 quadrants, postop tonsillectomy with 1 episode of coffee-ground emesis, postop following total knee arthroplasty and PCA reporting knee pain of 7
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postop thoracotomy w/chest tube w/150mL bright red blood in collection chamber from first hour
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When providing discharge instructions for a patient postop following abdominal surgery, which patient statement indicates need for further teaching? I will call doctor if increase in temp or wound draining, I will eat foods high in protein and Vit C during my recovery, I will complete entire course of antibiotics, I will remain on bed rest until follow-up with doctor.
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I will remain on bedrest until follow-up appt with doctor
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When preparing patient for surgery, patient appears apprehensive and asks multiple questions about risks of procedure. Which action should nurse take before witnessing patients signing of informed consent form? Explain risks and benefits of surgery, ask surgeon to speak to patient for clarification, reassure that procedure is necessary for recovery, document patients lack of preop teaching
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ask surgeon to speak to client for clarification
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When assessing patient who's 2 days postop following total prostatectomy, nurse notes patients right calf is red, edematous, warm to the touch. Which action should nurse take? Apply ice pack to right calf, elevate right extremity, administer testosterone, ,gently massage right calf
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elevate right extremity
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When providing preop teaching for patient scheduled for mastectomy, which patient statement indicates need for further treatment? I should wait 3-4 weeks after surgery to do water aerobics, I'll wait until a week after surgery to start hand strengthening exercises, I should avoid having blood drawn fro arm on side I had my mastectomy, I'll be able to shower after doctor removes drain
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I'll wait until a week after surgery to start hand strengthening exercises
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When providing teaching for patient scheduled to undergo moderate (conscious) sedation for bronchoscopy. Which statement verifies that the patient understands the procedure? I will need to complete a bowel prep the day before the procedure, I will drink plenty of fluids the morning of the procedure, I can eat as soon as the procedure is over, I can expect to feel sleepy for several hours after the procedure.
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I can expect to feel sleepy for several hours after the procedure
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When caring for patient postop after abdominal surgery, which of the following nursing interventions should nurse perform to prevent respiratory complication? Instruct patient to exhale into incentive spirometer every 1-2 hrs, minimize amount of pain meds patient receives to prevent sedation, advise patient to splint surgical incision when coughing and deep breathing, reposition client q8h for first 48hrs
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Advise patient to splint surgical incision when coughing and deep breathing
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When monitoring a patient receiving succinylcholine during a surgical procedure, which of following actions should nurse take if patient develops malignant hyperthermia? Administer dantrolene, institute seizure precautions, measure blood glucose, give IV atropine
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administer dantrolene
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When caring for patient has NG tube set to continuous low suction following gastrectomy, which of following findings should nurse report to the provider? gastric distention, absent bowel sounds, incisional pain of 9 on scale 0-10, small amount of bloody drainage in NG tube.
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gastric distension
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Nurse providing teaching for patient who's in the immediate postop period and has PCA pump. Which of following statements should nurse include in teaching? You will receive a dose of medication every time you push the button, do not allow your family to push the PCA button if you're sleeping, you cannot receive too much medication by pushing the button, do not push the PCA button until your pain reaches a severe level
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Do not allow your family to push PCA if you're sleeping
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When caring for patient during surgery, what action should be taken to prevent neuromuscular complications during surgical procedure? administer IV bolus of normal saline, massage lower extremities during procedure, support bony prominences with foam padding, extend joints and maintain position w/padded straps
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support bony prominences with foam padding
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When assessing patients recovery from spinal anesthesia, which of following sensations should nurse expect to return to patient first? Pain, Cold, touch, warmth
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touch
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When taking preoperative medication history on client scheduled for surgery, which of the following medications should nurse recognize as placing patient at risk for complications due to interaction w/anesthetic agents? Captopril, Atorvastatin, Ranitidine, Ciproflaxin
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Captopril
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When providing preop teaching for patient, which of following prescribed medications should nurse instruct patient to d/c 48hrs prior to surgery? Furosemide, Digoxin, Prednisone, Warfarin
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Warfarin
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When working in surgical suite, check rooms are maintained at cool temperature with low humidity to decrease which of the following? Risk for malignant hyperthermia, amount of anesthetic agents clients need, risk of infection, amount of O2 patient needs
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risk of infection
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when caring for patient receiving moderate (conscious) sedation with midazolam and fentanyl, patient's respirations decrease from 16/min to 6/min and O2 sat decreases from 92% to 85%. Which of following actions should nurse take first? Gather suction equipment, obtain equipment necessary for CPR, administer reversal agents, start additional IV line.
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administer reversal agents
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When caring for patient postop following total hip arthroplasty, which assessment data indicates patient is at increased risk for infection? Use of herbal remedies, long term use of corticosteroids, excessive exposure to sunlight, diet high in cholesterol
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long term use of corticosteroids
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When reviewing medical record of patient who is to undergo general anesthesia for surgery, which of the following findings should nurse report to provider? Potassium 2.8, sodium 140, INR 1.5, BUN 12
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potassium 2.8
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When caring for patient with surgical wound and penrose drain in place, which interventions should nurse plan to perform? Cut slit in 4inch square gauze pad to place around drain, use sterile technique when performing dressing changes, establish clamping schedule prior to removal, apply negative pressure when emptying drain
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use sterile technique when performing dressing changes
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when assessing patient in PACU to determine if he's ready for discharge, which finding indicates he is ready? Preop BP was 140/90, postop BP 100/65, pain rating at 4 on 0-10 scale, able to move all four extremities on command, requires tactile stimulation to awaken
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able to move all four extremities on command
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Patient transferred from surgical suite to PACU following oral surgery, while monitoring clients vital signs, nurse finds that tongue has become swollen and is obstructing the airway. Which of the following actions should nurse take first? Contact anesthesiologist, assist with ET intubation, increase clients flow of O2, Use head-tilt, chin-lift method to open the airway
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use head-tilt, chin-lift method to open airway
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When providing preop teaching to patient scheduled for gastrectomy in 1 week, patient is anxious about upcoming surgery. Which of following is appropriate action for nurse to take? Sympathize with clients feelings, reassure, patient that surgery will go fine, change topic of discussion, provide concise factual information
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provide concise, factual information
