A preoperative nurse is assessing a client prior to surgery which information would be important for the nurse to relay to the surgical team
Use of multiple herbs
A nurse works on the postoperative floor and has four clients who are being discharged tomorrow which one has the greatest need for the nurse to consult other members of the healthcare team for post-discharge care
Older adult who lives alone at home despite some memory loss
A clinic nurse is teaching a client prior to surgery the client does not seem to comprehend the teaching forgets a lot of what is said and asks the same questions again and again what action by the nurse is best?
Assess the client for anxiety
A preoperative nurse is reviewing morning laboratory values on four clients waiting for surgery which result warrants immediate communication with the surgical team
Potassium 2.9 mEq/L
An inpatient nurse brings an informed consent form to a client for an operation scheduled for tomorrow the client asks about the possible complications from the operation what response by the nurse is best
Do not have the client sign the consent and call the primary healthcare provider
A client has a great deal of pain when coughing and deep breathing after abdominal surgery despite having pain medication what action by the nurse is best?
Demonstrate how to splint the incision
A nurse is giving a client instructions for showering the night before surgery what instruction is most appropriate?
Use the prescribed solution and wash the area where you will have surgery very thoroughly
A postoperative client has an abdominal drain what assessment by the nurse indicates that goals for the priority client problems related to the drain are being met?
There is no redness warmth or drainage at the insertion site
The perioperative nurse manager are concerned about the increasing number of surgical infections in their hospital what action by the manager is best
Audit charts to see if the surgical care improvement project (SCIP) outcomes were met
A nurse assesses a client in the preoperative holding area and finds brittle nails and hair, dry skin turgor and muscle wasting what action by the nurse is best?
Consult the primary healthcare provider about a dietitian referral
A client has arrived in the inpatient postoperative unit what action by the inpatient nurse takes priority?
Participating in hand off report
The postanesthesia care unit(PACU) charge nurse notes vital signs on four postoperative clients which client would the nurse assess first?
Client with a respiratory rate of 6 breaths/min
A client had a surgical procedure with spinal anesthesia the clients blood pressure was 122/78 mmHg 30 minutes ago and is now 138/60 and the client reports nausea what action by the nurse is best
Notify the primary health care provider
A postoperative client vomited after cleaning and comforting the client which action by the nurse is most important?
Auscultate lung sounds
A postoperative client has just been admitted to the postanesthesia care unit (PACU) what assessment by the PACU nurse takes priority?
Airway
A postoperative client has respiratory depression after recieiving morphine for pain which medication and dose does the nurse prepare to administer
Naloxone 0.4-2mg
A nurse on the postsurgical inpatient unit is observing a client perform leg exercises what action by the client indicates a need for further instruction
Bend both knees pushes against the bed until calf and thigh muscles contract
A registered nurse(RN) is watching a new nurse change a dressing and perform care around a Penrose drain what action by the new nurse warrants intervention
Securing the drains safety pin to the sheets
A postoperative nurse is caring for a client who recievied a neuromuscular blocking agent during surgery on assessment the nurse notes the client has weak hand grasps what assessment does the nurse conduct next
Signs of oxygenation
The postanesthesia care unit(PACU) nurse is caring for an older client following a lengthy surgery the clients pulse is 48 beats/min which is 20 beats/min lower than the preoperative baseline what assessment does the nurse make next
Temperature
The postoperative nurse is caring for a client who reports feeling something popped after vomiting what action by the nurse is best
Gather sterile nonadherent dressings
A new perioperative nurse is receiving orientation to the surgical area and learns about the surgical care improvement project (SCIP) goals. what major areas do these measures focus on (SATA)
Infection Prevention
Thromboembolism prevention
correct hair removal
A nurse is learning about different surgical procedures and their classifications which examples below does this include(SATA)
Liver biopsy: diagnostic
Arthroscopy: preventative Ilesostomy palliative total shoulder replacement
Body contouring cosmetic
A nurse is caring for several clients in the morning prior to surgery which medications taken by the client require the nurse to consult with the primary health care provider about their administration(SATA)
Insulin
Phenytoin
Metoprolol
Warfarin
Prednisone
A nurse recently hired to the preoperative area learns that certain clients are at higher risk for venous thromboembolism(VTE) which clients are considered to be at high risk(SATA)
Morbidly obese clients
client who smokes
client with severe heart failure
Wheelchair-bound client
A client received several doses of midazolam the nurse assesses the client to be difficult to arouse with respirations of 6 breaths/min what actions by the nurse are most important(SATA)
Administer oxygen per protocol
Ensure suction is working
transfer the client to intensive care
A nurse learns older adults are at high risk for complications after surgery what reasons for this does the nurse understand (SATA)
Decreased cardiac output
Decreased oxygenation
Frequent Nocturia
Mobility alterations
Slower reaction times
A nurse working in the preoperative holding area performs which functions to ensure client safety (SATA)
Check that consent is on the chart
Ensure that the client has an armband on
Have the client help mark the surgical site
Allow the client to use the toilet before giving sedation
Assesses the client for fall risks
A nurse orienting to the postoperative area learns which principles about the postoperative period(SATA)
Phase 1 requires intensive care unit monitoring
Phase 2 ends when the client is stable and awake
Vital signs may be taken only once a day in phase 3
A postanesthesia care unit(PACU) nurse is assessing a postoperative client with a nasogastric (NG) tube what laboratory values would warrant intervention by the nurse (SATA)
Hemoglobin 7.8 mg?dl
PH 7.68
Potassium 2.9
A nurse on the postoperative unit provides care to reduce the incidence of surgical wound infection what actions are best to achieve this goal (SATA)
Disposing of dressings properly
Performing proper hand hygiene
Removing and replacing wet dressing