Med Surg 1 (Exam 2)

One hour after admission to the post anesthesia care unit (PACU), the postoperative patient has become very restless. What is the nurse's first action? A. Assess the oxygen saturation level B. Administer pain medication as ordered C. Call the surgeon to assess the patient D. Assess for bladder distention

Patient asks nurse what does this "thing" do and why do i have to use it. Nurse explains that using this thing (incentive spirometer) A. "The spirometer will help prevent blood clots" B. "The spirometer will help your lungs expand." C. "The spirometer will improve blood flow in your lungs." D. "The spirometer will help you cough effectively."

After abdominal surgery, the patient complains of severe gas pains and states, "I have not had bowels in 3 days." What is the appropriate nursing intervention? A. Call the physician for an order for a laxative B. Reinsert a nasogastric tube C. Provide the ordered prn Morphine D. Have the patient ambulate frequently

A patient with emphysema reports social isolation. What should the nurse encourage patient to do? A. Participate in community activities B. Ask the patient's physician for an anti anxiety agent C. Verbalize his or her thoughts and feelings D. Join a support group for people with emphysema

The patient's abdominal incision is draining a small amount of pinkish color secretion. How nurse document this finding on the patient's record? A. Small amount of bloody drainage noted on dressings. B. Small amount of serosanguineous drainage noted on dressings. C. Small amount of serous drainage noted on dressings. D. Small amount of sanguineous drainage noted on dressings.

What interventions should the nurse carry out to reduce postoperative pain and promote comfort to surgical patient? (Select all that apply) A. Control or remove noxious stimuli in the environment. B. Instruct the patient in relaxation techniques. C. Use ice to reduce and prevent swelling as indicated D. Encourage activity and exercise to point of fatigue E. Use pillows to assist to a position of comfort

A post-operative patient is in the post-anesthesia care unit (PACU) and reports having pain of 8 on a scale of 10. What is the best nursing action? A. Consult with the anesthesia care provider to manage the pain while the patient is still in PACU B. Have the nurses on the surgical unit to assess the patient and administer pain medication as appropriate C. Look at the routine post-operative orders and administer the pain medicine that is ordered. D. Sep up the Patient Controlled Analgesia (PCA) machine and push the button for the patient as needed.

The nurse is changing the patient's dressing on the second postoperative day and notes a small amount of serosanguineous drainage. What is the nurse's best action? A. Cover the incision with a transparent dressing B. Culture the drainage and leave the incision open to air C. Cleanse the suture line and apply a sterile dressing D. Notify the surgeon to assess the patient

What is the priority nursing intervention for the patient in the Post Anesthesia Care Unit (PACU) who reports, "I think I am going to vomit" A. Continue to monitor the vital signs B. Place a cool cloth on the patient's forehead C. Give the antiemetic as ordered D. Turn the patient on their side

A patient with a history of asthma is admitted to the emergency department with dyspnea, respiratory rate of 35 breaths per minute, nasal flaring, use of accessory muscles, and greatly diminished breath sounds. What action should the nurse take first? A. Initiate oxygen therapy and reassess the patient in 10 minutes B. Encourage the patient to relax and breathe slowly C. Draw blood for arterial blood gas analysis and send the patient for a chest X-ray D. Administer bronchodilators as ordered

The patient is 7 hours post-op and has not voided. What should the nurse do first? A. Call the surgeon stat and report the lack of voiding B. Insert an indwelling urinary catheter C. Determine when the last pain medication was given D. Palpate for presence of the bladder above the symphysis pubis

One hour after the administration of ondansetron hydrochloride (Zofran) (antiemetic), the nurse determines that the medication has been effective and documents this in the patient's record. What phase of the nursing process is illustrated? A. Diagnosis B. Evaluation C. Planning D. Assessment

The nurse is caring for several patients on the postoperative unit. Which patient does the nurse determine has the highest risk of respiratory complications after general anesthesia? A. Young adult with a body mass index of 40 B. Middle-aged woman taking a daily cholesterol lowering medication C. Middle-aged man with a deviated nasal septum D. Older woman taking a medication for hypertension

The nurse is caring for a patient who had abdominal surgery 3 days ago. The patient tells the nurse, "I felt something 'come apart' when I coughed." What is the nurse's best response? A. "That is a normal feeling in the incision whenever you are moving" B. "Be sure to splint the incision with a pillow or your hands when you cough" C. "Lie down flat on the bed with your knees u and let me examine your incision" D. "It is good you are coughing and deep-breathing to prevent pneumonia"

What is the best assessment the nurse should use to validate a patient's pain? A. Physiologic indicators, such as elevated vital signs B. A pain rating by someone who knows the patient well C. Facial grimacing and crying D. The patient's self-report of pain

A patient reports pain 8 hours after surgery. The patient has already received an opioid within the past 2 hours. What should the nurse do? A. Give the ordered pain medication early B. Call the surgeon immediately C. Assess the pain further D. Document the finding in the chart

A post-operative patient has atelectasis in the left lung confirmed by chest x-ray. What priority intervention should the nurse plan to include in the patient's care? A. Monitoring oxygen saturation hourly B. Assessing the breath sounds every two hours C. Monitoring respiratory rate rhythm twice a shift D. Encouraging use of the incentive spirometer hourly E. Changing positions every three hours

A patient is prescribed albuterol (Proventil, Ventolin) via metered-dose inhaler (MDI), two puffs every 4 hours. What should the nurse teach the patient about potential adverse effects of this drug? A. Pedal edema B. Wheezing C. Irregular Heartbeat D. Constipation

Two days after surgery, a patient refuses a PRN dose of analgesic for fear of becoming "hooked". How should the nurse respond? A. "Occurrence of side effects warrants the discontinuing of medication" B. "Research has shown it is impossible to become hooked on PRN narcotics" C. "Short-term use of narcotics is not likely to cause a person to become dependent on them" D. "Patients who do not take PRN medications are more likely to become dependent on narcotics"

The patient was given 15 mg of morphine IM for post surgical pain. One hour later, the patient is sleeping and has a respiratory rate of 10 breaths/min. What is the nurse's first action? A. Administer naloxone (Narcan) IV push B. Administer oxygen by nasal cannula C. Arousing the patient by calling his or her name D. Documenting the findings and continuing to monitor

The nurse is working in the post anesthesia care unit (PACU) and receives a patient from the operating room (OR). What does the nurse assess first? A. Patient's nasogastric tube B. Hemovac drain at the incision site C. Patient's urinary catheter D. Patient's endotracheal tube

What should the nurse include in the plan of care for a patient with patient-controlled epidural anesthesia (PCEA)? A. Change the epidural dressing daily B. Assess but do not disturb the epidural dressing C. Use septic technique when handling the epidural catheter D. Apply an antibiotic ointment to the site BID

Which assessment finding is cause for concern in a patient who has taken 4 grams of acetaminophen (Tylenol) to relieve back pain? A. Increased liver function tests B. Gastrointestinal bleeding C. Difficulty with urination D. Decreased respiratory rate

Which instruction should the nurse give a patient who has a patient-controlled analgesia device (PCA) after abdominal surgery? A. "Push the button when you first feel pain instead of waiting until pain is severe" B. "Instruct you visitor to press the button for you when you are sleeping" C. "Try to go as long as you possibly can before you press the button" D. "Push the button every 15 minutes whether you feel pain that time or not"

The nurse assess a patient who has received morphine sulfate. The patient blood pressure is 90/50 mm Hg; pulse rate 58 beats per minute; respiratory rate 4 beats per minute. What drug should the nurse prepare to administer? A. Flumazenil (Romazicon) B. Meperidine (Demerol) C. Ondansetron hydrochloride (Zofran) D. Naloxone hydrochloride (Narcan)

The nurse empties the Jackson-Prat drainage bulb. What nursing intervention ensures correct functioning of the drain? A. Connection to to a drainage bag and clamping it off B. Irrigating it with normal saline C. Compressing it and then plugging it to establish suction D. Connection it to low intermitted suction

A nurse is assessing a surgical patient's vital signs 8 hours after surgery. Before surgery, the blood pressure (BP) was 120/80 mm Hg and on admission tot he medical-surgical unit the BP was 110/80 mmHg. The patient's BP is now 90/7- mm Hg. What should the nurse do first? A. Check the intake and output record B. Administer pain medication C.Notify the surgeon immediately D. Elevate the head of the bed

What is the priority nursing assessment upon the patient's admission to the Post Anesthesia Care Unit (PACU) A. Patient's level of consciousness and hanging IV fluid level B. Vital signs and ABCs, beginning with the respiratory system C. Patient identification using attached ID band with two identifiers D. The surgical interventional procedure performed and OR number

For the patient who is experiencing post operative pain on post-op day 2, what medicate should the nurse plan to administer A. Acetaminophen (Tylenol) B. Morphine Sulfate C. Acetylsalicylic Acid (Aspirin) D. Ibuprofen (Advil)

Following surgery, a patient has difficulty getting out of bed, walking and coughing and deep breathing. Although patient-controlled analgesia (PCA) is in place, it is rarely used. What statement is the best way for the nurse to address this concern with the patient? A. "I noticed you use very little pain medication. You must be very brave and strong. But without pain medication you will get weaker, bot stronger." B."I can understand why you are reluctant to use pain medication. Many people feel the same way. Yet, without pain relief, you can get atelectasis, pneumonia and blood clots" C. "I noticed you don't use much pain medication. If you don't push that button, I will. You need that medicine. Don't worry about getting addicted. It won't happen" D. "I noticed you haven't used your pain medication very often since your surgery. Im wondering if you are hesitant to use the PCA medication"

What intervention should the nurse implement to prevent pulmonary emboli from forming in the post-operative patient? A. Massage the patient's lower legs every four hours B. Encourage the patient to cough and deep breath C. Have the patient perform leg exercises every hour whole awake D. Have the patient wear anti embolism stockings only when out of bed

The patient has a Salem Sump nasogastric tube (NGT) connected to low intermitted suction whose "pigtail" is draining stomach contents. What should the nurse do? A. Clamp the pigtail to prevent gastric leakage B. Insert 30 mL of air into the pigtail to spear the drainage C. Call the surgeon to check placement of the NGT D. Increase the suction to high continuous suction

The nurse is caring for a patient is the post anesthesia care unit (PACU) 2 hours after abdominal surgery. The nurse auscultates the patient's abdomen and notes that there are no bowel sounds. What action should the nurse take? A. Palpate the bladder and measure abdominal girth B. Document the finding and continue to monitor C. Insert a nasogastric tube to low intermittent suction D. Position the patient of the left side with the bed flat

The post-operative patient has been transferred from the Post Anesthesia Care Unit (PACU) to the medical-surgical unit. What should the nurse do first? A. Assess airway and oxygenation B. Check the dressing for any drainage C. Provide pain medication as ordered D. Perform a neurological check

The nurse's abdominal assessment of a post-operative patient reveals the patient's abdomen is flat, non distended, and no bowel sounds are audible. What is the best explanation of the finding? A. Exposure of the patient to the cold operating room causes bowel sounds to stop B. Permanent loss of bowel sounds occurs with certain types of abdominal surgery C. Due to the effects of general anesthesia, the patient has a paralytic ileus D. Bowel sounds are absent as a result of the narcotics given for pain control

A patient is prescribed fluticasone (Flovent) via metered-dose inhaler (MDI) BID. What actions indicate the patient is using the MDI correctly? (Select all that apply) A. The patient waits 5 minutes between puffs B. The mouth is rinsed with water after administration C. the inhaler is held upright D. The patient lies supine for 15 minutes following administration E. The patient breathes in quickly and shallowly

A post-operative patient who is on bed rest asks why intermittent compression devices are needed. How should the nurse respond? A. "These are more comfortable than compression stockings" B. "These remind you to keep still and avoid around too much" C. "These will improve the arterial circulation in your body" D. "These help prevent clot formation in your legs while you are inactive"

A patient with asthma reports "not being able to take deep breaths." The nurse auscultates decreased breath sounds in the bases and no wheezes. What is the nurse's best action? A. Have the patient cough forcefully B. Encourage the patient to stay calm and take deep breaths C. Assess the patient's oxygen saturation D. Document the findings and continue to monitor

The nurse is evaluating a patient's response to medication therapy to asthma. The patient has a peak flowmeter reading in the yellow zone. What does the nurse do next? A. Nothing: this is an acceptable range B. Assist the patient to use a reliever (rescue) inhaler C. Assess the patient's lungs D. Teach the patient to take deeper breaths

The nurse is teaching a patient with asthma about self-management. Which statement by the nurses the best? A. Keep a daily symptoms and intervention diary B. Establish your personal best peak expiratory flow during an attack C. Note your symptoms when you don't take your medications D. Exercise before and after taking inhalers and compare tolerance

A patient with emphysema has a respiratory rate of 24 breaths per minute, bilateral crackles, and is coughing but unable to expectorate sputum. Which nursing diagnosis is the priority for the patient? A. Impaired Gas Exchange r/t ventilation-perfusion mismatch B. Ineffective Airway Clearance r/t inability to expectorate sputum C. Risk for Decreased Cardiac Output secondary to for pulmonale D. Ineffective Breathing Pattern r/t increased work of breathing

What statement but the nurse indicated the understanding of the administration of oxygen to the patient with emphysema? A. High oxygen concentration will cause coughing and dyspnea B. Administration of oxygen is contraindicated in patients who use bronchodilators C. High oxygen concentration may inhibit the hypoxic stimulus to breathe D. Increased oxygen use will cause the patient to become dependent on the oxygen

What outcome is appropriate for the patient with emphysema who has been discharged to home? A. The patient states he will call the health care provider if dyspnea on exertion occurs B. The patient promises to do pursed-lip breathing at home if short of breath C. The patient states he will use oxygen via nasal cannula at 5 L/minute D. The patient verbalizes actions to reduce and manage pain

When instructing patient on how to decrease the risk of chronic obstructive pulmonary disease (COPD). What should the nurse emphasize? A. Avoid exposure to people with known respiratory infections B. Abstain from cigarette smoking C. Participate regularly in aerobic exercises D. Maintain a high protein diet