Quiz Fall 8-Nursing - Medical Surgical Health Assessment Critical Care

1

You are responsible for the care of a postoperative patient with a thoracotomy. The patient has been given the nursing diagnosis of Activity Intolerance. Which action should you delegate to the UAP?

2

After undergoing a modified radical mastectomy, a client is transferred to the post anesthesia care unit (PACU). Which nursing action is best to delegate to an experienced LPN/LVN?

3

On which concern should the nurse focus when caring for a client after abdominal surgery?

4

After an abdominal cholecystectomy, a client has a T-tube attached to a collection device. On the day of surgery, at 10:30 PM, 300 mL of bile is emptied from the collection bag. At 6:30 AM the next day, the bag contains 60 mL of bile. What should the nurse consider in response to this information?

5

A postoperative client is diagnosed as having atelectasis. Which nursing assessment supports this diagnosis?

6

A client is extubated in the post anesthesia care unit after surgery. For which common response should the nurse be alert when monitoring the client for acute respiratory distress?

7

After abdominal surgery a client reports pain. What action should the nurse take first?

8

A nurse in the surgical intensive care unit is caring for a client with a large surgical incision. What medication does the nurse anticipate will be prescribed for this client?

9

While caring for a client with a portable wound drainage system, a nurse observes that the collection container is half full and empties it. What is the next nursing intervention?

10

When assessing an obese client, a nurse observes dehiscence of the abdominal surgical wound with evisceration. The nurse places the client in the low-Fowler position with the knees slightly bent and encourages the client to lie still. What is the next nursing action?

11

A nurse is preparing to change a client's dressing. What is the reason for using surgical asepsis during this procedure?

12

A nurse is applying a dressing to a client's surgical wound using sterile technique. While engaging in this activity, the nurse accidentally places a moist sterile gauze pad on the cloth sterile field. What physical principle is applicable for causing the sterile field to become contaminated?

13

Four days after abdominal surgery a client has not passed flatus and there are no bowel sounds. Paralytic ileus is suspected. What does the nurse conclude is the most likely cause of the ileus?

14

A nurse in the post anesthesia care unit (PACU) observes that after an abdominal cholecystectomy a client has serosanguineous drainage on the abdominal dressing. What is the next nursing action?

15

A nurse is caring for a postoperative client who had general anesthesia during surgery. What independent nursing intervention may prevent an accumulation of secretions?

16

What is the priority nursing intervention for a client during the immediate postoperative period?

17

Which patient is most at risk for postoperative nausea and vomiting (PONV)?

18

The medical-surgical nurse is caring for a postoperative patient whose lab values reveal an increase in band cells (immature neutrophils). What is the nurse's best interpretation of this value?

19

The nurse is assessing a postoperative patient's gastrointestinal system. What is the best indicator that peristaltic activity has returned?

20

The PACU nurse is caring for postoperative patient. The patient's oxygen saturation drops from 98% to 88%. What is the nurse's priority action?

21

The morning after a patient's lower leg surgery, the nurse notes that the dressing is wet from drainage. The surgeon has not yet been in to see the patient on rounds. What does the nurse do about the dressing?

22

The nurse is caring for a patient who has had abdominal surgery. After a hard sneeze, the patient reports pain in the surgical area, and the nurse immediately sees that the patient has a wound evisceration. What priority action must the nurse do first?

23

Which intervention for post surgical care of the patient is correct?

24

The nurse is teaching incisional care to a patient who has been discharged after abdominal surgery. Which priority instruction must the nurse include?

25

The health care team determines a patient's readiness for discharge from the PACU by noting a post anesthesia recovery score of at least 10. After determining that all criteria have been met, the patient is discharged to the hospital unit or home. Review the patient profiles after 1 hour in the PACU listed below. Which patient should the nurse expect to be discharged from the PACU first?

in Nursing

a. 10-year-old girl, tonsillectomy, general anesthesia. Duration of surgery 30 minutes. Immediate response to voice. Alert to place and person. Able to move all extremities. Respirations even, deep, rate of 20. Vital signs are within normal limits. IV solution is D5RL. Has voided on bedpan. Eating ice chips, Complaining of sore throat.
b. 55-year-old man, repair of fractured lower left leg. General anesthesia. Duration of surgery 1 hour, 30 minutes. Drowsy, but responds to voice. Nausea and vomiting twice in PACU. No urge to void at this time. IV infusing D5NS. Pedal pulses noted in both lower extremities. VS: Temperature 98.6 degrees F; pulse 130 beats/min; respiratory rate 24.min; blood pressure 124/76 mm Hg.
c. 24 year old man, reconstruction of facial scar. General anesthesia. Duration of surgery 2 hours. Sleeping, groans to voice command. VS are within normal limits. Respirations 10 breaths/min. No urge to void. IV of D5Rl infusing. Complains of pain in surgical area.
d. 42 year old woman, colonoscopy, IV conscious sedation. Awake and alert. Up to bathroom to void. IV discontinued. Resting quietly in chair. VS are within normal limits.

26

A patient arrives in the PACU. Which action does the nurse perform first?

27

A patient arrives at the PACU and the nurse notes a respiratory rate of 10 with sternal retractions. The report from anesthesia personnel indicates that the patient had received fentanyl during surgery. What is the nurses best priority first action?

28

A patient develops respiratory distress after having a left total hip replacement. The patient develops labored breathing and a pulse oximetry reading is 83% on 2L oxygen via nasal cannula. Which intervention is appropriate for the nurse to delegate to unlicensed assistive personnel (UAP)?

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Quiz Fall 8-Nursing - Medical Surgical Health Assessment Critical Care

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