Preop , I ntraop , Postop & Misc

1. Preop, Intraop, Postop & Misc

2. A nurse is preparing to administer digoxin (lanoxin) .25 mg by mouth to the patient. Before administering the medication, the nurse assesses the patient’s apical heart rate to be 55 beats per minute. Which critical thinking process can assist the nurse in deciding whether or not it is safe to administer the medication to the patient? Reflection Reasoning Clarifying Divergent thinking

3. A Nursing Instructor is explaining the nursing process to students in post conference. A nursing student demonstrates an understanding of the nursing process by stating: “The patient and the agency benefit from the nursing process.” “As nurses gain increasing autonomy in their practice, the use of the nursing process helps them identify their dependent practice domain.” “The nursing process can serve as a framework for patient satisfaction.” “The patient receives planned, individualized interventions; but cannot participate in all steps of the process.”

4. Which of the following steps are part of the nursing process? Select all that apply. assessment diagnosis critical thinking planning implementation evaluation

5. The patient is receiving coumadin (warfarin) by mouth each day for the prevention of clotting. The patient’s PT/INR today was 23.7 and 2.0 respectively. 10 mg of coumadin (warfarin) is ordered for today. In assessing the patient the nurse determines that: The patient may receive his daily coumadin as ordered this evening. The patient will receive half of the dosage ordered this evening. The patient’s medication will be held for today. The patient will have more blood work before he can receive this dose.

6. The home health nurse is caring for a patient with end stage heart failure. The nurse has been teaching the patient to maintain his daily weights, fluid restriction and sodium restriction. The nurse has also taught the patient to stop smoking and to avoid drinking alcoholic beverages. Despite the teaching, the home health nurse finds the smell of smoke in the house, a full ash tray and empty beer bottles on the kitchen counter. When the nurse approaches the patient and his family the response is the same, why bother to change when so little time is left. The patient should enjoy what life he has left. What are the implications here for the patient’s nurse? The nurse cannot have any feelings about the situation. It is out of the nurse’s control. The nurse can speak to the patient’s family and ask them to remove the beer and cigarettes from the house. The nurse can continue to repeat the teaching to the patient emphasizing the benefits of stopping the behavior. The nurse can verbalize her feelings to the patient and try to force the patient to quit his smoking and drinking.

7. A patient is admitted with end stage cancer and is no longer responsive. The nurses are struggling with the plan of care for this patient. What is the best way to determine the plan of care and level of treatment needed in this situation? Speak with the patient’s family in order to determine the patient’s wishes. Determine if the patient had a will made out prior to the hospitalization and illness. Speak with the patient to ascertain a DNR status. Determine if the patient had an advance directive prior to being incapacitated with a terminal disease.

8. The nurse on a neurological trauma unit cares for the same small group of patients during their entire hospital stay. The nurse is able to provide care; communicate with the patients, families, and other health care providers; and carry out discharge planning. Which model of care delivery does this describe? Primary Nursing Case Management Team Nursing Disease Management

9. Two (2) days after a colectomy, a patient’s breath sounds are diminished and the vital signs are: Temperature 100.2, respirations 24, pulse 104, and BP 136/84. Which nursing actions prevent post-operative complications? Mark all that apply. The application of TED hose Encouraging the use of the incentive spirometer Increasing intravenous and oral fluids Encouraging the patient to turn, cough, and deep breath Assisting the patient with all activities of daily living

10. A patient had a right, open reduction and internal fixation on the right hip two days ago to repair a hip fracture. The patient has been inactive secondary to episodes of right calf pain. Which post-operative complication does this patient exhibit? Paralytic Ileus Dehiscence Muscle atrophy Deep vein thrombosis

11. The following nursing diagnosis is a priority for a patient following an esophagogastroduodenoscopy (EGD). Choose the highest priority nursing diagnosis. Deficient Fluid Volume related to blood loss Infection, Risk for related to bacterial invasion Aspiration, Risk for related to the effects of sedatives Injury, Risk for related to the effects of sedatives

12. A patient has undergone a bronchoscopy, and is requesting lunch. The nurse should perform the following first: Assess the gag reflex and pain. Assess the patient’s bowel sounds. Offer finger foods for the initial meal. Asses the patient’s ability to ambulate.

13. A pre-operative nurse prepares a patient for surgery, which nursing interventions should be included in the plan of care? Mark all that apply. Maintain NPO status to prevent aspiration. Verify the patient’s signature on the consent prior to surgery. Remove dentures and contact lenses prior to surgery. Check the patient’s allergy and blood bands for accuracy. Verify the patient’s mobility in all extremities prior to surgery.

14. Which pre-operative nursing actions prevent post-operative complications? Mark all that apply. Inserting an 18 gauge gel-co Applying pneumatic compression hose Teaching the patient to splint while coughing Teaching the patient to use the incentive spirometer Instructing the patient to perform ankle pumps

15. During assessment of the wound of a patient with a hernia repair, the nurse notices a protrusion between the 5th and 8th staples. What should the nurse do first? Apply a wet-to-dry dressing Call the patient’s surgeon Check the patient’s vital signs Elevate the HOB 30 degrees

16. A patient has an eviscerated surgical wound with moderate exudate. The vital signs are: Temperature 100.1, pulse 108, BP 108/58, respirations 26, and a white blood count of 13,200/mm3. Which nursing diagnosis is a priority for this patient? Decreased cardiac output R/T surgical procedure AEB: Pulse 108 and BP 108/58 Infection R/T open wound AEB: Temperature 100.1, WBC count of 13,200/mm3 Skin Integrity, Impaired R/T disruption of dermal tissue AEB: open wound and exudate Thermoregulation Ineffective R/T bacterial invasion AEB: Temperature of 100.1

17. A post-operative patient with an abdominal wound who is receiving intravenous fluids infusing at 125 mL/hr returned to the unit six (6) hours ago. Which nursing interventions should the nurse add to the plan of care? Mark all that apply. Assess pain to prevent post-operative complications. Monitor labs to assess the patient’s physiologic response to surgery. Maintain TED hose at all times to prevent blood clots. Monitor intake and output to prevent fluid imbalances. Encourage the use of the incentive spirometer to prevent pneumonia.

18. The nurse is caring for a patient following a hysterectomy. The following nursing action is most likely to circumvent wound dehiscence. Encouraging the patient to reposition from side-to-side Instructing the patient to bear down when having bowel movements Repositioning the patient with a draw sheet Teaching the patient to use a pillow to splint when coughing

19. The nurse in an outpatient facility is caring for a patient after a laparoscopic cholecystectomy at 8:00 this morning. It is now 11:00 a.m., and the patient’s significant other is ready for the patient to be discharged. Vital signs are stable, pain is 3/10, and the patient has voided 30 ml of urine. Which nursing action is most appropriate? Discharge the patient; these findings are normal. Delay discharge until the patient’s pain subsides. Inform the doctor; the patient’s urine output is inadequate. Inform the doctor; the patient still complains of pain.

20. A patient scheduled for an arthroscopic knee replacement has a serum potassium of 5.9 mEq/L. The physical assessment does not show any alterations in status. What is the nurse’s best action? Call the doctor; the lab is abnormal. Ask the lab to re-draw the potassium level. Call the operating room, and alert the charge nurse. Continue with the current plan of care.

21. The nurse notices the surgical consent form of a pre-operative patient who is scheduled for surgery this morning is unsigned. What is the nurse’s best action? Notify the health care provider; it is the physician’s responsibility to obtain the consent. Provide the patient with the risks, benefits, and purpose of the surgical procedure. Notify the patient’s caregiver, and obtain telephone consent from the caregiver. Notify the patient’s caregiver, and obtain consent from the patient.

22. A patient is transferred to the surgical floor post-operatively after a colon resection. What priority outcome should the nurse add to the plan of care for this patient? The patient’s temperature will range from 96.8-100.1 in the first three hours post surgery. The patient’s pain level will range from 0/10-4/10 in the first five hours post surgery. The patient’s BP will range from 120/50-140/84 in the first three hours post surgery. The patient’s dressing will remain dry and intact in the first six hours post surgery.

23. One (1) day after a hernia repair, an 80-year-old patient experiences abdominal pain and has a temperature of 100.2 along with diminished breath sounds in the left lower base. Because the patient has not cooperated with pre-operative instructions to use the incentive spirometer 10 times per hour as well as the signs/symptoms, the nurse assesses for the following post-operative complication: Heart failure, which is a post-operative complication in geriatric patients. Deep vein Thrombosis, due to the lack of physical mobility. Pneumonia, due to the patient’s diminished breath sounds and fever. Atelectasis, which is a very common post-operative complication.

24. The nurse is evaluating a patient’s environment at home. Which of the following observations in the home would require further demonstration and education with the patient? Medications in a daily planner box and a list of all of his home medications. A small night light in the hallway as well as an overhead light. A small throw rug in the living room to cover an exposed extension cord. A small pantry with a variety of non-perishable foods.

25. When the nurse is explaining to a patient the specifications for safety in the home, which of the following topics and illustrations should be discussed? Choose all that apply. Electrical hazards A lamp with a frayed cord Monthly income with the patient Support system of the patients Cooking habits that may precipitate a fire Appropriate as well as inappropriate clothing

26. A patient with diabetes mellitus notifies the home health nurse that his sharps container at home is full and needs to be replaced before he gives himself another injection of insulin. The nurse tells the patient that she will not be able to visit him today. What is the safest recommendation that the nurse can make to the patient regarding the sharps container? Instruct the patient to wrap each syringe in a paper towel and put the towel at the bottom of the trash can. Dispose of the syringes in a thick liquid detergent bottle after using the syringe and replace the lip on the bottle. Recap the needle after using the syringe and store it in a plastic bag until the next nurses visit. Wipe the needle off with an alcohol swab and re-use the syringe until the nurse returns on her next visit.