NS 510: Exam 4

ns-510-exam-4

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Question 1 of 1

Time Left

526351

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The nurse demonstrates postoperative exercises for a patient. In which order will the nurse instruct the patient to perform the exercises?

Match the text (click and drag)

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Explanation

The sequence of exercises is leg exercises, turning, breathing, and coughing.

Match the Text
1
2
3
4

Click and drag
Coughing
Breathing
Turning
Leg exercises

526352

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The nurse is participating in a “time-out.” In which activities will the nurse be involved? (Select all that apply.)

Select the correct answer(s).

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Explanation

Evidence suggests that pre-warming for a minimum of 30 minutes may reduce the occurrence of hypothermia. Prevention of hypothermia (core temperature < 36° C) helps to reduce complications such as shivering, cardiac arrest, blood loss, SSI, pressure ulcers, and mortality.

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The nurse is caring for a postoperative patient with an incision. Which actions will the nurse take to decrease wound infections? (Select all that apply.)

Select the correct answer(s).

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Explanation

Performing hand hygiene before and after contact with the patient helps to decrease the number of microorganisms and break the chain of infection. Maintaining blood glucose levels at less than 150 mg/dL has resulted in decreased wound infection. Removing unwanted hair by clipping instead of shaving decreases the numbers of nicks and cuts caused by a razor and the potential for the introduction of microbes. The patient is postoperative; administration of an antibiotic 60 minutes before the surgical incision supports the defense against infection preoperatively. Providing a bath and linen change daily is positive but is not necessarily important for infection control. Many surgeons prefer to change surgical dressings the first time so they can inspect the incisional area, but this is done before 2 days postoperatively.

526354

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The nurse is preparing for a patient who will be going to surgery. The nurse screens for risk factors that can increase a person’s risks in surgery. What risk factors are included in the nurse’s screening? (Select all that apply.)

Select the correct answer(s).

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Explanation

Very young and old patients are at risk during surgery because of immature or declining physiological status. Normal tissue repair and resistance to infection depend on adequate nutrients. Obesity increases surgical risk by reducing respiratory and cardiac function. During pregnancy, the concern is for the mother and the developing fetus. Because all major systems of the mother are affected during pregnancy, risks for operative complications are increased. Race and ambulatory surgery are not risks associated with a surgical procedure.

526355

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The nurse is providing preoperative education and reviews with the patient what it will be like to be in the surgical environment. Which points should the nurse include in the teaching session? (Select all that apply.)

Select the correct answer(s).

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Explanation

The surgical staff is dressed in special clothing, hats, and masks—all for infection control. Families are not allowed in the operating suite for several reasons, which include infection control and sterility. The nurse is there as the coordinator and patient advocate during a surgical procedure. The rooms are very bright so everyone can see, and the operating table is very uncomfortable for the patient.

526356

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The operating room nurse is providing a hand-off report to the postanesthesia care unit (PACU) nurse. Which components will the operating room nurse include? (Select all that apply.)

Select the correct answer(s).

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Explanation

The surgical teams report will include topics such as the type of anesthesia provided, vital sign trends, intraoperative medications, IV fluids, estimated blood and urine loss, and pertinent information about the surgical wound (e.g., dressings, tubes, drains). When the patient enters the PACU, the nurse and members of the surgical team discuss his or her status. A standardized approach or tool for hand-off communications assists in providing accurate information about a patient’s care, treatment and services, current condition, and any recent or anticipated changes. The hand-off is interactive, multidisciplinary, and done at the patient’s bedside, allowing for a communication exchange that gives caregivers the chance to dialogue and ask questions. Insurance data and family location are unnecessary.

526357

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The nurse is caring for a group of postoperative patients on the surgical unit. Which patient assessments indicate the nurse needs to follow up? (Select all that apply.)

Select the correct answer(s).

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Explanation

Thready pulse, low blood pressure, and urine output of 20 mL/hr need to have follow-up by the nurse. Hemorrhage results in a fall in blood pressure; elevated heart and respiratory rates; thready pulse; cool, clammy, pale skin; and restlessness. Notify the surgeon if these changes occur. If the patient has a urinary catheter, there should be a continuous flow of urine of approximately 30 to 50 mL/hr in adults; this patient requires follow-up since the output is 20 mL/hr. All the rest are normal findings. A patent airway, a strong distal pulse, and approximated incision are all normal findings. Surgery involving portions of the urinary tract normally causes bloody urine for at least 12 to 24 hours, depending on the type of surgery.

526358

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The nurse is caring for a postoperative patient who has had a minimally invasive carpel tunnel repair. The patient has a temperature of 97° F and is shivering. Which reason will the nurse most likely consider as the primary cause when planning care?

Select the correct answer(s).

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Explanation

The operating suite and recovery room environments are extremely cool. The patient’s anesthetically depressed level of body function results in lowering of metabolism and a fall in body temperature. Although the patient is dressed in a gown and there are air currents in the operating room, these are not the primary reasons for the low temperature. Also, the patient in this type of case does not have a large open body cavity to contribute to heat loss.

526359

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The nurse is caring for a group of patients. Which patient will the nurse see first?

Select the correct answer(s).

(0/0)

Explanation

For patients who have had eye, intracranial, or spinal surgery, coughing may be contraindicated because of the potential increase in intraocular or intracranial pressure. The nurse will need to see this patient first to control the cough and intraocular pressure. All the rest are normal postoperative patients. Leg exercise should not be performed on the operative leg with vascular surgery. A patient after knee surgery should receive heparin and be wearing intermittent pneumatic compression devices; while the nurse will check on the patient, it does not have to be first. Monitoring vital signs after surgery is required and this is the standard schedule.

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The nurse explains the pain relief measures available after surgery during preoperative teaching for a surgical patient. Which comment from the patient indicates the need for additional education on this topic?

Select the correct answer(s).

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Explanation

Anesthesia will be provided during the procedure itself, and the patient should not experience pain during the procedure; however, this will not minimize the pain after surgery. Pain management is utilized after the postoperative phase. Inform the patient of interventions available for pain relief, including medication, relaxation, and distraction. The patient needs to know and understand how to take the medications that the health care provider will prescribe postoperatively. During the stay in the facility, the level of pain is frequently assessed by the nurses. Coordinating pain medication with postoperative exercises helps to minimize discomfort and allows the exercises to be more effective.

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The nurse is caring for a patient who will undergo a removal of a lung lobe. Which level of care will the patient require immediately post procedure?

Select the correct answer(s).

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Explanation

Patients undergoing extensive surgery and requiring anesthesia of long duration recover slowly. If a patient is undergoing major surgery such as a procedure on the lung, a stay in the hospital and specifically in the intensive care unit is required to monitor for potential risks to well-being. This patient would require more care than can be provided on a medical-surgical unit. It is not appropriate for this type of patient to go home after the procedure or to stay in an extended stay area of an ambulatory surgery area because of the complexity and associated risks.

526362

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The nurse has administered a preoperative medication to the patient going to surgery. Which action will the nurse take next?

Select the correct answer(s).

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Explanation

Once a preoperative medication has been administered, instruct the patient to call for help when getting out of bed to prevent falls. For patient safety, explain the purpose of a preoperative medication and its effects. Notifying the operating suite that the medication has been given may be part of a facilities procedure but is not the best next step. It is important to have the patient sign consents before the patient has received medication that may make him/her drowsy. Wasting unused medication according to policy is important but is not the best next step.

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The nurse is caring for a patient in the operating suite. Which outcome will be most appropriate for this patient at the end of the intraoperative phase?

Select the correct answer(s).

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Explanation

A primary focus of intraoperative care is to prevent injury and complications related to anesthesia, surgery, positioning, and equipment use, including use of the electrical cautery grounding pad for the prevention of burns. The perioperative nurse is an advocate for the patient during surgery and protects the patient’s dignity and rights at all times. Signs and symptoms of infection do not have the time to present during the intraoperative phase. During the intraoperative phase, the patient is anesthetized and unconscious and typically has an endotracheal tube that prevents conversation. Nausea, vomiting, and pain typically begin in the postoperative phase of the experience.

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The nurse is caring for a patient in the postanesthesia care unit. The patient asks for a bedpan and states to the nurse, “I feel like I need to go to the bathroom, but I can’t.” Which nursing intervention will be most appropriate initially?

Select the correct answer(s).

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Explanation

Depending on the surgery, some patients do not regain voluntary control over urinary function for 6 to 8 hours after anesthesia. Palpate the lower abdomen just above the symphysis pubis for bladder distention. Another option is to use a bladder scan or ultrasound to assess bladder volume. The nurse must assess before deciding if the patient can try again. Not everyone feels as if they need to go but can’t after surgery. Calling the health care provider is not the initial best action. The nurse needs to have data before calling the provider.

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The postanesthesia care unit (PACU) nurse transports the inpatient surgical patient to the medical-surgical floor. Before leaving the floor, the medical-surgical nurse obtains a complete set of vital signs. What is the rationale for this nursing action?

Select the correct answer(s).

(0/0)

Explanation

Before the PACU nurse leaves the acute care area, the staff nurse assuming care for the patient takes a complete set of vital signs to compare with PACU findings. Minor vital sign variations normally occur after transporting the patient. The PACU nurse reviews the patient’s information with the medical-surgical nurse, including the surgical and PACU course, physician orders, and the patient’s condition. While vital signs may or may not be the first action in a head-to-toe assessment, this is not the rationale for this situation. While following policy or ascertaining that the floor nurse checks on the patient are good reasons for safe care, they are not the best rationale for obtaining vital signs.

NS 510: Exam 4

Question 1 of 1

Time Left

The nurse demonstrates postoperative exercises for a patient. In which order will the nurse instruct the patient to perform the exercises?

Match the text (click and drag)

(0/0)

Explanation

1

2

3

4

Coughing

Breathing

Turning

Leg exercises

The nurse is participating in a “time-out.” In which activities will the nurse be involved? (Select all that apply.)

Select the correct answer(s).

(0/0)

Explanation

The nurse is caring for a postoperative patient with an incision. Which actions will the nurse take to decrease wound infections? (Select all that apply.)

Select the correct answer(s).

(0/0)

Explanation

The nurse is preparing for a patient who will be going to surgery. The nurse screens for risk factors that can increase a person’s risks in surgery. What risk factors are included in the nurse’s screening? (Select all that apply.)

Select the correct answer(s).

(0/0)

Explanation

The nurse is providing preoperative education and reviews with the patient what it will be like to be in the surgical environment. Which points should the nurse include in the teaching session? (Select all that apply.)

Select the correct answer(s).

(0/0)

Explanation

The operating room nurse is providing a hand-off report to the postanesthesia care unit (PACU) nurse. Which components will the operating room nurse include? (Select all that apply.)

Select the correct answer(s).

(0/0)

Explanation

The nurse is caring for a group of postoperative patients on the surgical unit. Which patient assessments indicate the nurse needs to follow up? (Select all that apply.)

Select the correct answer(s).

(0/0)

Explanation

The nurse is caring for a postoperative patient who has had a minimally invasive carpel tunnel repair. The patient has a temperature of 97° F and is shivering. Which reason will the nurse most likely consider as the primary cause when planning care?

Select the correct answer(s).

(0/0)

Explanation

The nurse is caring for a group of patients. Which patient will the nurse see first?

Select the correct answer(s).

(0/0)

Explanation

The nurse explains the pain relief measures available after surgery during preoperative teaching for a surgical patient. Which comment from the patient indicates the need for additional education on this topic?

Select the correct answer(s).

(0/0)

Explanation

The nurse is caring for a patient who will undergo a removal of a lung lobe. Which level of care will the patient require immediately post procedure?

Select the correct answer(s).

(0/0)

Explanation

The nurse has administered a preoperative medication to the patient going to surgery. Which action will the nurse take next?

Select the correct answer(s).

(0/0)

Explanation

The nurse is caring for a patient in the operating suite. Which outcome will be most appropriate for this patient at the end of the intraoperative phase?

Select the correct answer(s).

(0/0)

Explanation

The nurse is caring for a patient in the postanesthesia care unit. The patient asks for a bedpan and states to the nurse, “I feel like I need to go to the bathroom, but I can’t.” Which nursing intervention will be most appropriate initially?

Select the correct answer(s).

(0/0)

Explanation

The postanesthesia care unit (PACU) nurse transports the inpatient surgical patient to the medical-surgical floor. Before leaving the floor, the medical-surgical nurse obtains a complete set of vital signs. What is the rationale for this nursing action?

Select the correct answer(s).

(0/0)

Explanation

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