nclex chapter 19 med surg – Flashcards

1.ID: 809532923 The nurse would be alerted to the occurrence of malignant hyperthermia when the patient demonstrates what manifestation? Hypocapnia Muscle rigidity Correct Decreased body temperature Confusion upon arousal from anesthesia

Before admitting a patient to the operating room, which forms or results must the nurse make sure are in the chart of all patients (select all that apply)? Electrocardiogram Signed consent form Correct Functional status evaluation Incorrect Renal and liver function tests Incorrect A history and physical report Correct

Which intraoperative nursing responsibilities should be performed by the scrub nurse (select all that apply)? Documenting intraoperative care Keeping track of irrigation solutions for monitoring of blood loss Correct Passing instruments and supplies to the surgeon by anticipating his or her needs Correct Coordinating the flow and activities of members of the surgical team in the surgical suite

What event in the surgical suite represents a violation of aseptic technique? A glove contacts the leg of the table that supports the sterile field. Correct The cuff of the scrub nurse's sterile gown contacts the sterile field. The sterile field was established at 0650, and the current time is 0900. Bacteria are present in the nares and upper respiratory passages of the nurse.

The perioperative nurse would recognize the need to monitor the patient for hallucinations and agitation when which anesthetic agent is administered? Nitrous oxide Incorrect Ketamine (Ketalar) Correct Thiopental (Pentothal) Halothane (Fluothane)

6.ID: 809532937 A 71-year-old male patient who is currently undergoing coronary artery bypass graft (CABG) surgery has just experienced intraoperative vomiting. The nurse should consequently anticipate the use of which drug? Midazolam (Versed) Fentanyl (Sublimaze) Meperidine (Demerol) Ondansetron (Zofran) Correct

7.ID: 809532947 A surgical patient's premedication regimen includes midazolam (Versed). What are the most likely desired effects of this medication? Monitored anesthesia care and amnesia Correct Potentiates volatile agents to speed induction Analgesia and prevention of intraoperative vomiting Relaxation of skeletal muscles and facilitation of endotracheal intubation Incorrect

The new nursing student is confused about where the patient's family (who are wearing street clothes) can be with the patient in the surgical suite. Which explanation should the perioperative nurse give to the student nurse? The family is not allowed to talk to the nurse at the nursing station. The family can be with the patient in the preoperative holding area. Correct The family cannot be with the patient until the postanesthesia care unit. Incorrect The family is only allowed in the conference room for preoperative teaching.

View video. The nurse is preparing a sterile field. What occurrences in this video cause contamination of this field (select all that apply)? Reaching over the sterile field Correct Turning her back on the sterile field Allowing the fluid to permeate the field Correct Leaving the room to obtain more supplies

Which National Patient Safety Goal (NPSG) requirement is enacted immediately before surgery with a surgical time-out? Prevention of infection Improved staff communication Identify patients at risk for suicide. Patient, surgical procedure, and site are checked. Correct

A patient having an open reduction internal fixation (ORIF) of a left lower leg fracture will receive regional anesthesia during the procedure. As the patient is prepared in the operating room, what should the nurse implement to maintain patient safety during surgery that is directly related to the type of anesthesia being used? Apply grounding pad to unaffected leg. Assess peripheral pulses and skin color. Incorrect Verify the last oral intake before surgery. Ensure a smooth surface under the patient. Correct

A 78-year-old patient is having surgery. What risk areas will the nurse need to be especially aware of for this patient during surgery? Sterility Paralysis Incorrect Urine output Skin integrity Correct

13.ID: 809532929 The patient is going to have a colonoscopy. Which type of anesthesia should the nurse expect to be used? Local anesthesia Moderate sedation General anesthesia Incorrect Monitored anesthesia care (MAC) Correct

14.ID: 809532925 In which surgical area will the patient's skin be prepped for surgery, and what clothing will the person doing the prepping be wearing? Surgical suite wearing a lab coat Preoperative holding area wearing street clothes Postanesthesia care unit (PACU) wearing scrubs Operating room wearing surgical attire and masks Correct

Unless contraindicated by the surgical procedure, which position is preferred for the unconscious patient immediately postoperative? Supine Lateral Correct Semi-Fowler's High-Fowler's Unless contraindicated by the surgical procedure, the unconscious patient is positioned in a lateral "recovery" position. This recovery position keeps the airway open and reduces the risk of aspiration if the patient vomits. Once conscious, the patient is usually returned to a supine position with the head of the bed elevated. Awarded 1.0 points out of 1.0 possible points. 2.ID: 809562156 The nurse is working on a surgical floor and is preparing to receive a postoperative patient from the postanesthesia care unit (PACU). What should the nurse's initial action be upon the patient's arrival? Assess the patient's pain. Assess the patient's vital signs. Correct Check the rate of the IV infusion. Check the physician's postoperative orders. The highest priority action by the nurse is to assess the physiologic stability of the patient. This is accomplished in part by taking the patient's vital signs. The other actions can then take place in rapid sequence. Awarded 1.0 points out of 1.0 possible points. 3.ID: 809562158 When assessing a patient's surgical dressing on the first postoperative day, the nurse notes new, bright-red drainage about 5 cm in diameter. In response to this finding, what should the nurse do first? Recheck in 1 hour for increased drainage. Notify the surgeon of a potential hemorrhage. Incorrect Assess the patient's blood pressure and heart rate. Correct Remove the dressing and assess the surgical incision. The first action by the nurse is to gather additional assessment data to form a more complete clinical picture. The nurse can then report all of the findings. Continued reassessment will be done. Agency policy determines whether the nurse may change the dressing for the first time or simply reinforce it. Awarded 0.0 points out of 1.0 possible points. 4.ID: 809562154 In planning postoperative interventions to promote repositioning, ambulation, coughing, and deep breathing, which action should the nurse recognize will best enable the patient to achieve the desired outcomes? Administering adequate analgesics to promote relief or control of pain Correct Asking the patient to demonstrate the postoperative exercises every 1 hour Giving the patient positive feedback when the activities are performed correctly Warning the patient about possible complications if the activities are not performed Even when a patient understands the importance of postoperative activities and demonstrates them correctly, it is unlikely that the best outcome will occur unless the patient has sufficient pain relief to cooperate with the activities. Awarded 1.0 points out of 1.0 possible points. 5.ID: 809562152 Bronchial obstruction by retained secretions has contributed to a postoperative patient's recent pulse oximetry reading of 87%. Which health problem is the patient probably experiencing? Atelectasis Correct Bronchospasm Hypoventilation Pulmonary embolism The most common cause of postoperative hypoxemia is atelectasis, which may be the result of bronchial obstruction caused by retained secretions or decreased respiratory excursion. Bronchospasm involves the closure of small airways by increased muscle tone, whereas hypoventilation is marked by an inadequate respiratory rate or depth. Pulmonary emboli do not involve blockage by retained secretions. Awarded 1.0 points out of 1.0 possible points. 6.ID: 809562146 In caring for the postoperative patient on the clinical unit after transfer from the PACU, which care can be delegated to the unlicensed assistive personnel (UAP)? Monitor the patient's pain. Do the admission vital signs. Assist the patient to take deep breaths and cough. Correct Change the dressing when there is excess drainage. The UAP can encourage and assist the patient to do deep breathing and coughing exercises and report complaints of pain to the nurse caring for the patient. The RN should do the admission vital signs for the patient transferring to the clinical unit from the PACU. The LPN or RN will monitor and treat the patient's pain and change the dressings. Awarded 1.0 points out of 1.0 possible points. 7.ID: 809562140 The patient had abdominal surgery. The estimated blood loss was 400 mL. The patient received 300 mL of 0.9% saline during surgery. Postoperatively, the patient is hypotensive. What should the nurse anticipate for this patient? Blood administration Restoring circulating volume Correct An ECG to check circulatory status Return to surgery to check for internal bleeding The nurse should anticipate restoring circulating volume with IV infusion. Although blood could be used to restore circulating volume, there are no manifestations in this patient indicating a need for blood administration. An ECG may be done if there is no response to the fluid administration, or there is a past history of cardiac disease, or cardiac problems were noted during surgery. Returning to surgery to check for internal bleeding would only be done if patient's level of consciousness changes or the abdomen becomes firm and distended. Awarded 1.0 points out of 1.0 possible points. 8.ID: 809562150 The patient donated a kidney, and early ambulation is included in her plan of care. But the patient refuses to get up and walk. What rationale should the nurse explain to the patient for early ambulation? "Early walking keeps your legs limber and strong." "Early ambulation will help you be ready to go home." "Early ambulation will help you get rid of your syncope and pain." "Early walking is the best way to prevent postoperative complications." Correct The best rationale is that early ambulation will prevent postoperative complications that can then be discussed. Ambulating increases muscle tone, stimulates circulation that prevents venous stasis and VTE, speeds wound healing, and increases vital capacity and maintains normal respiratory function. These things help the patient be ready for discharge, but early ambulation does not eliminate syncope and pain. Pain management should always occur before walking. Awarded 1.0 points out of 1.0 possible points. 9.ID: 809562144 An older patient who had surgery is displaying manifestations of delirium. What should the nurse do first to provide the best care for this new patient? Check his chart for intraoperative complications. Check which medications were used for anesthesia. Check the effectiveness of the analgesics he has received. Check his preoperative assessment for previous delirium or dementia. Correct If the patient's ABCs are okay, it is important to first know if the patient was mentally alert without cognitive impairments before surgery. Then intraoperative complications, anesthesia medications, and pain will be assessed as these can all contribute to delirium. Awarded 1.0 points out of 1.0 possible points. 10.ID: 948093086 The patient had surgery at an ambulatory surgery center. Which criteria support that this patient is ready for discharge (select all that apply)? Vital signs baseline or stable Correct Minimal nausea and vomiting Correct Wants to go to the bathroom at home Responsible adult taking patient home Correct Comfortable after IV opioid 15 minutes ago Ambulatory surgery discharge criteria includes meeting Phase I PACU discharge criteria that includes vital signs baseline or stable and minimal nausea and vomiting. Phase II criteria includes a responsible adult driving patient, no IV opioid drugs for last 30 minutes, able to void, able to ambulate if not contraindicated, and received written discharge instruction with patient understanding confirmed. Awarded 3.0 points out of 3.0 possible points. 11.ID: 809562138 A patient is having elective cosmetic surgery performed on her face. The surgeon will keep her at the surgery center for 24 hours after surgery. What is the nurse's postoperative priority for this patient? Manage patient pain. Control the bleeding. Maintain fluid balance. Manage oxygenation status. Correct The nurse's priority is to manage the patient's oxygenation status by maintaining an airway and ventilation. With surgery on the face, there may be swelling that could compromise her ability to breathe. Pain, bleeding, and fluid imbalance from the surgery may increase her risk for upper airway edema causing airway obstruction and respiratory suppression, which also indicate managing oxygenation status as the priority. Awarded 1.0 points out of 1.0 possible points.