Pregunta 1
Pregunta
An inpatient is scheduled to have surgery tomorrow. The nurse takes an incentive spirometer to the patient's room to provide education on its use in the postoperative period. Which of the following are instructions the nurse should include?
Respuesta
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Standing position; deep breath; lips around mouthpiece; blow hard to make the ball rise
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Prone position; lips around mouthpiece; exhale; slowly inhale to raise the marker and float the ball; hold breath for 3 seconds if possible
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Upright position; lips around mouthpiece; exhale; slowly inhale to raise the marker and float the ball, hold breath for 3 seconds if possible
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Upright position; lips on mouthpiece; deep breath; blow hard to move the marker and float the ball
Pregunta 2
Pregunta
A presurgical patient has signed the informed consent form, after which, the nurse signs the consent form. What is the purpose of the nurse's signature?
Respuesta
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agreement that the patient understands the procedure
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witness to the physician explaining the procedure to the patient
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witness to the patient's signature
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the patient is ready to be taken to the operating room
Pregunta 3
Pregunta
A patient is scheduled for surgery in one hour and has had NPO after midnight orders. Blood was drawn for labwork 30 minutes ago. Under which of the following circumstances should the nurse contact the surgeon to inform them prior to the patient going to surgery? Select all that apply.
Respuesta
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the patient states they have not been told about the procedure and informed consent has not been signed
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the patient experienced nausea and the nurse administered an IV antiemetic per prn orders
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prothrombin time (PT) 22 seconds (range 10-13 seconds) and international normalized ratio (INR) 4 (range 2-3 for valvular heart disease prophlaxis)
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blood glucose 102 mg/dL
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the patient's temperature is 99.8 degrees
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the surgical site was prepped with electric clippers 8 hours ago
Pregunta 4
Pregunta
The patient is scheduled for an upper endoscopy and a colonoscopy at 1200 today. At 1000 the patient returned from hemodialysis during which heparin was administered. What is the primary risk for this patient?
Respuesta
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aspiration
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sedation
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bleeding
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infection
Pregunta 5
Pregunta
Which of the following may be allowed by the surgeon for a patient who is to have nothing by mouth (NPO) for a procedure involving sedation?
Pregunta 6
Pregunta
Which of the following are considered to be advance directives? Select all that apply.
Pregunta 7
Pregunta
Prior to surgery and prior to the patient receiving any [blank_start]sedative medication[blank_end], the patient [blank_start]marks[blank_end] the surgical site and the surgeon confirms it with [blank_start]marking[blank_end] as well. This is to ensure that the correct site is [blank_start]operated on[blank_end].
Respuesta
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sedative medication
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lunch
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marks
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points to
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marking
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pointing
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operated on
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marked
Pregunta 8
Pregunta
The nurse knows that infection is a primary risk to a surgical patient. Which of the following interventions is most important to protect a surgical patient from infection?
Respuesta
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adequate IV hydration
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careful surgical site preparation
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assessing WBCs prior to surgery
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sterilization of the surgical incision after the procedure
Pregunta 9
Pregunta
Which of the following should the preoperative nurse replace prior to allowing the patient to be transported to surgery? Select all that apply.
Respuesta
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an IV that has gone subcutaneous
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the patient's earrings so they don't get lost
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an identification band/bracelet that came off
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1 mL : 1 mL IV fluid to replace urine output over the 8 hours prior to surgery
Pregunta 10
Pregunta
Which of the following is included in the group of three signs that, together, can be an early indication of malignant hyperthermia? Select all that apply.
Respuesta
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decreased oxygen saturation (SpO2)
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increased respiratory rate
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restlessness
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elevated end-tidal CO2 level
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tachycardia
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bradycardia
Pregunta 11
Pregunta
The surgical nurse is discussing the monitoring of end-tidal carbon dioxide (etCO2) during surgery with a student. Which of the following should the nurse include in the education?
Respuesta
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etCO2 is also called capnography monitoring and can more accurately and more quickly measure a patient's oxygenation than SpO2 monitoring
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etCO2 is measured by a sensor on the patient's finger
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etCO2 monitoring is used only under special circumstances
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etCO2 is first measured in the preoperative area
Pregunta 12
Pregunta
Malignant hyperthermia is an emergency situation that any person undergoing surgery can experience.
Pregunta 13
Pregunta
The nurse is discussing patient controlled analgesia with a patient and his family members prior to surgery. When the nurse stresses the requirement that only the patient push the button for a dose of pain medication, which concept is being discussed?
Respuesta
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the use of a pain scale
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trust vs. mistrust
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PCA by proxy
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informed consent
Pregunta 14
Pregunta
The longer the surgical procedure, the higher the risk for:
(select all that apply)
Pregunta 15
Pregunta
The nurse is receiving hand-off report from another nurse about a patient who had abdominal surgery 12 hours ago, is stable, and is ambulating several times a day without difficulty. Which of the following should the receiving nurse question and ask for clarification about?
Respuesta
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the patient has an order for anti-embolism stockings AND sequential compression boots
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the patient should not be ambulating since surgery was only 12 hours ago
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the patient is wearing sequential compression boots when in bed
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the patient is doing coughing and deep breathing exercises q 2 hours
Pregunta 16
Pregunta
Which of the following would NOT be expected for a patient who had open abdominal surgery 24 hours ago?
Respuesta
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serous drainage on the dressing
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serosanguinous drainage on the dressing
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dehiscence of the wound
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the surgeon performs the first dressing change
Pregunta 17
Pregunta
Which of the following increase the risk of delayed surgical wound healing? Select all that apply.
Pregunta 18
Pregunta
Which of the following are acceptable actions to delegate to unlicensed personnel such as a patient care assistant or medical assistant who has received the proper training?
Respuesta
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measurement of vital signs
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interpretation of vital signs
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assessment of skin integrity
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documentation of skin assessment
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education of client on wound care
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empty and record volume of surgical drains and foley catheter bags
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check blood glucose using monitor
Pregunta 19
Pregunta
It important for a nurse to recall the anatomical [blank_start]numbering[blank_end] of fingers and [blank_start]toes[blank_end] for confirmation of [blank_start]surgical site[blank_end] when one of these digits will be operated on.
Respuesta
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numbering
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toes
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surgical site
Pregunta 20
Pregunta
Which of the following are true regarding malignant hyperthermia? Select all that apply.
Respuesta
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it is an inherited disorder
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diaphragmatic and intercostal muscle paralysis negatively affect respiratory status
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the treatment includes IV dantrolene, a skeletal muscle relaxant
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ongoing muscle contraction contributes to hypermetabolism
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metabolic alkalosis occurs
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hypotension, hypoxemia, hyperkalemia, renal injury or cardiac arrest can result