Med Surg Success Q & A Exam 1

Questions and Answers

Which nursing intervention should the nurse include in the care plan?

Monitor respirations every 15 to 30 minutes. (correct)

Encourage the client to verbalize feelings.

Measure the client's intake and output hourly.

Administer sleep medications at night.

Which nursing task would be most appropriate to delegate to the unlicensed assistive personnel (UAP) on a postoperative unit?

Auscultate the bowel sounds in all four quadrants.

Teach the client how to perform incentive spirometry.

Empty and record the amount of drainage in the JP drain. (correct)

Change the dressing over the surgical site.

Which client assessment data are priority for the post-anesthesia care nurse?

IV fluid rate.

Surgical site.

Bowel sounds.

Vital signs. (correct)

The male client in the day surgery unit complains of difficulty urinating postoperatively. Which intervention should the nurse implement?

Assist the client to stand to void. Signup and view all the answers

The postoperative client complains of hearing a 'popping sound' and feeling 'something opening' when ambulating in the room. Which intervention should the nurse implement first?

Assess the operative site and cover the site with a moistened dressing. Signup and view all the answers

Which client problem would the nurse include in the plan of care for an elderly postoperative client who became confused during the previous shift?

Risk for injury. Signup and view all the answers

The client one day postoperative develops an elevated temperature. Which intervention would have priority for the client?

Encourage the client to deep breathe and cough every hour. Signup and view all the answers

Which statement made by the client who is postoperative abdominal surgery indicates the discharge teaching has been effective?

I will take all of my antibiotics until they are gone. Signup and view all the answers

Which interventions should the nurse implement for a client who is two (2) hours postoperative with noted vital signs: T 102.6°F, P 132, R 26, BP 92/46?

Check the abdominal dressing. Signup and view all the answers

The client comes into the emergency room in severe pain and reports that a pot of boiling hot water accidentally spilled on his lower legs. Which depth of burn should the nurse document?

Deep partial thickness. Signup and view all the answers

The client with full-thickness burns to 40% of the body is being transferred to a burn center. Which measure should be instituted before the transfer?

Adequate peripheral circulation to both feet ensured. Signup and view all the answers

After establishing a patent airway in a client with full-thickness burns to 65% of the body, including the chest area, what is the priority collaborative intervention?

Replace fluids and electrolytes. Signup and view all the answers

While applying mafenide acetate (Sulfamylon) to a client's lower extremity burn, which assessment data would require immediate attention by the nurse?

The client's ABGs are pH 7.34, PaO2 98, PaCO2 38, and HCO3 20. Signup and view all the answers

What is a xenograft?

The graft will come from an animal, probably a pig. Signup and view all the answers

Which client problem has priority for a client with severe full-thickness and deep partial-thickness burns over half the body?

High risk for infection. Signup and view all the answers

Which intervention would be appropriate for the nursing diagnosis 'impaired skin related to open burn wounds'?

Clean the client's wounds, body, and hair daily. Signup and view all the answers

Which nursing intervention should be included for the client who has full-thickness and deep partial-thickness burns to 50% of the body?

Administer antibiotics as prescribed. Signup and view all the answers

Which assessment data would warrant notifying the health-care provider for a client with deep partial-thickness and full-thickness burns to the chest area?

The client's urinary output is 50 mL in two (2) hours. Signup and view all the answers

Which intervention should the nurse implement for a client with full-thickness and partial-thickness burns to more than 30% of the body concerning nutritional status?

Encourage the client's family to bring favorite foods. Signup and view all the answers

Which information should the nurse provide to a client who sustained a hot grease burn to the right hand?

Place the hand in cool water. Signup and view all the answers

Which strategies should the nurse identify to promote the client's mental health upon discharge after being in the burn unit for six weeks?

Tell the client to remember that changes in lifestyle take time. Signup and view all the answers

Which intervention should the nurse implement when discussing health promotion activities for a client with a German heritage who leads a sedentary lifestyle?

Help the client to identify a routine exercise program. Signup and view all the answers

The elderly female client of Mexican heritage is upset and tells the nurse the unlicensed assistive personnel (AP) complimented her grandchild's hair. Which intervention should the nurse implement?

Explain to the AP about the cultural belief regarding the 'evil eye.' Signup and view all the answers

Which intervention should the nurse implement for the home health care visit to an elderly African American female client who talks loudly?

Discuss a weight-loss program for the client. Signup and view all the answers

In visiting a 42-year-old male client with terminal cancer, which behavior would best promote a therapeutic nurse/client relationship?

Initially address conversation to the eldest family member. Signup and view all the answers

When interviewing the client of Hindu heritage, which information should the nurse obtain to plan culturally sensitive care?

Assess the extent of the client's use of ayurveda. Signup and view all the answers

Which rationale should the nurse give the AP for allowing the client to continue to wear the amulet?

The client brought the amulet because it gives the client emotional support. Signup and view all the answers

After evaluating the meal tray of a Jewish client, the nurse notices the client ate none of the meal. Which intervention should the nurse implement first?

Determine why the client is not eating any of the meal. Signup and view all the answers

Which complementary therapy should the nurse suggest to assist the client's weight-loss program?

Hypnotherapy. Signup and view all the answers

When incorporating complementary therapies in a long-term care facility, which information should the nurse consider when matching the clients with the therapy? (Select all that apply)

The client's preferences. Signup and view all the answers

Which form of complementary therapy should the nurse encourage as a relaxation technique for the anxious elderly client admitted for surgery?

Deep breathing. Signup and view all the answers

What should the nurse include in the client's pain management plan for a client with a history of drug abuse?

The client should receive complementary therapies in addition to medications. Signup and view all the answers

Which intervention should the circulating nurse implement for the preoperative elderly client who is anxious and diaphoretic?

Play soft, slow-beat music in the operating room. Signup and view all the answers

Which statement best supports the nurse allowing the male Navajo client to wear the pouch filled with objects around his neck?

This is a cultural practice shared by many Navajo clients, and the nurse should not remove it unless it interferes with the client's care. Signup and view all the answers

Which statement explains the role of the curandero in Mexican culture?

He is a person who receives his gift from God and treats traditional illnesses. Signup and view all the answers

The home health nurse is visiting a Jewish client who has a small container on the doorpost of the house. What term best describes this container?

A mezuzah. Signup and view all the answers

Which intervention should the nurse implement for a client who requests to keep his religious medal on during surgery?

Tape the medal to the client and allow the client to wear the medal. Signup and view all the answers

Which client would not be able to consent legally to surgery?

The 16-year-old client who has a fractured ankle. Signup and view all the answers

Which intervention should the nurse implement first when preparing a client for surgery?

Complete the preoperative checklist. Signup and view all the answers

The 68-year-old client scheduled for intestinal surgery does not have clear fecal contents after (3) tap water enemas. Which intervention should the nurse implement first?

Notify the surgeon of the client's status. Signup and view all the answers

Which interventions should the nurse include in the care plan for a male client undergoing abdominal surgery? (Select all that apply)

Discuss how to cough and deep breath effectively. Signup and view all the answers

Which behavior indicates the need for further preoperative teaching for a client scheduled for total hip replacement?

The client gets out of bed by lifting straight upright from the waist and then swings both legs along the side of the bed. Signup and view all the answers

Which intervention should the nurse implement first when a client states they are allergic to codeine?

Ask the client what happens when he takes the codeine. Signup and view all the answers

Which laboratory result would require immediate intervention by the nurse for the client scheduled for surgery?

Potassium 2.4 mEq/L. Signup and view all the answers

Which information should the nurse report to the anesthesiologist for a surgical client? (Select all that apply)

The client has loose, decayed teeth. Signup and view all the answers

Which activities are the circulating nurse's responsibilities in the operating room?

Monitor the position of the client, prepare the surgical suite, and ensure the client's safety. Signup and view all the answers

What should the nurse do when the surgical scrub technician removes a sponge from the edge of the sterile field with a clamp?

Do nothing because this is the correct procedure. Signup and view all the answers

When the circulating nurse and the scrub technician find a discrepancy in the sponge count, what should the circulating nurse take first?

Re-count all sponges. Signup and view all the answers

Which violation of surgical asepsis would require immediate intervention by the circulating nurse?

The scrub nurse setting up the sterile field is wearing artificial nails. Signup and view all the answers

Which nursing intervention should the nurse implement for the client who is identified as 'risk for injury related to positioning' in the operating room?

Carefully pad the client's elbows before covering the client with a blanket. Signup and view all the answers

Which client has the greatest potential for nerve damage during surgery?

The 68-year-old client in the Trendelenburg position having a cholecystectomy. Signup and view all the answers

Which situation demonstrates the circulating nurse acting as the client's advocate?

Keeps the operating room door closed at all times. Signup and view all the answers

Which statement is the expected outcome when planning care for an intraoperative client?

The client has no injuries from the OR equipment. Signup and view all the answers

Which nursing intervention has the highest priority when preparing the client for a surgical procedure?

Apply soft restraint straps to the extremities. Signup and view all the answers

Which case should the nursing manager assign to the inexperienced nurse?

The client having a biopsy of the breast. Signup and view all the answers

The circulating nurse assesses tachycardia and hypotension in the client. Which interventions should the nurse implement?

Prepare ice packs and mix dantrolene sodium. Signup and view all the answers

Which intervention has the highest priority when planning the care of a surgical client having conscious sedation?

Assess the client's respiratory status. Signup and view all the answers

The PACU nurse is receiving the client from the OR. What should the nurse assess first?

Vital signs. Signup and view all the answers

Which intervention should the nurse implement first?

Assess the client's breath sounds Signup and view all the answers

Which assessment data indicate the postoperative client who had spinal anesthesia is suffering a complication of the anesthesia?

The client has a respiratory rate of eight (8) Signup and view all the answers

After transferring the client from the PACU to the surgical unit, which intervention should the nurse implement first?

Elevate the feet and lower the head Signup and view all the answers

Which client problem should the nurse add to the plan of care for a client who received Narcan?

Risk for depressed respiratory pattern Signup and view all the answers

Which interventions should the nurse implement for the 26-year-old male client in the PACU? Select all that apply.

Apply ice packs to axillary and groin areas Signup and view all the answers

Which data indicate the nursing care has been effective for the client who is one day postoperative surgery?

T 99.0F, P 98, R 20, and BP 100/60 Signup and view all the answers

Which task can the nurse delegate to the unlicensed nursing assistant?

Take vital signs every four hours Signup and view all the answers

Which postoperative client is the most appropriate assignment for the graduate nurse?

A 24-year-old client who had an uncomplicated appendectomy the previous day Signup and view all the answers

Which statement would be an expected outcome for the postoperative client who had general anesthesia?

The client will have a pulse oximetry reading of 97% on room air Signup and view all the answers

When transferring the postoperative client from the PACU to the surgical floor, which action should the nurse implement first?

Assess the client's vital signs Signup and view all the answers

What is the priority client problem for someone who is one day postoperative?

Potential for hemorrhaging Signup and view all the answers

What intervention would be most appropriate for a first-day postoperative client's vital signs of T 100.8F, P 80, R 24, and B/P 148/80?

Help the client turn, cough, and deep breathe every two hours Signup and view all the answers

Which intervention should the nurse implement first for a client complaining of left shoulder pain?

Assess the neurovascular status of the left hand Signup and view all the answers

Which intervention should the nurse implement for a client in acute pain as a result of surgery?

Administer pain medication as soon as the time frame allows Signup and view all the answers

Which situation exemplifies the nurse fulfilling the role of client advocate?

The nurse contacts the health-care provider when pain relief is not obtained Signup and view all the answers

Which statement would indicate an expected outcome for a client experiencing acute pain?

The client will participate in self-care activities Signup and view all the answers

Which intervention has the highest priority when administering pain medication to a client experiencing acute pain?

Discuss the pain with the client Signup and view all the answers

Which intervention can the nurse delegate to the unlicensed nursing assistant when caring for a client experiencing acute pain?

Apply an ice pack to the site of pain Signup and view all the answers

Which interventions should the nurse implement to provide for client safety when administering an opioid narcotic? Select all that apply.

Compare the hospital number on the MAR to the client's bracelet Signup and view all the answers

Which technique would be most appropriate for the nurse to implement when assessing a four-year-old client for acute pain?

Have the child point to the face that describes the pain Signup and view all the answers

Which nursing intervention would be a priority for the client experiencing acute pain?

Assess the client's verbal and nonverbal behavior Signup and view all the answers

While interviewing a 75-year-old client admitted with acute pain, which question would take priority when assisting with pain management?

"Have you ever had difficulty getting your pain controlled?" Signup and view all the answers

What should the nurse implement after discovering that the client has used only a small amount of medication during the shift with the PCA pump?

Determine why the client is not using the PCA pump Signup and view all the answers

Which problem would be most appropriate for the nurse to identify for a client experiencing acute pain?

Alteration in comfort Signup and view all the answers

Which client would the nurse identify as having the highest risk for developing postoperative complications?

The 67-year-old client who is obese, has diabetes, and takes insulin Signup and view all the answers

Which information should the nurse report to the surgeon during the preoperative checklist?

The client uses the oral supplements licorice and garlic Signup and view all the answers

What explains the nurse's responsibility when obtaining informed consent for the client undergoing surgery?

The nurse should ensure the client is voluntarily giving consent Signup and view all the answers

Which client outcome should the nurse identify for the preoperative client?

The client will demonstrate the use of a pillow to splint while deep breathing Signup and view all the answers

Which problem would be appropriate for the nurse to identify for a preoperative client having an open reduction and internal fixation of the right ankle?

Knowledge deficit of postoperative care Signup and view all the answers

Which task would be most appropriate to delegate to unlicensed assistive personnel?

Assist the client to take a povidone-iodine (Betadine) shower Signup and view all the answers

Which action indicates that preoperative teaching has been effective?

The client demonstrates how to use the incentive spirometer device Signup and view all the answers

Which intervention has priority for the nurse in the surgical holding area?

Verify the surgical checklist Signup and view all the answers

What should the nurse say when the client in the surgical holding area expresses fear about the surgery?

"Does having surgery make you afraid?" Signup and view all the answers

What should the nurse do if overhearing a UAP discussing a problem during one of the surgeries?

Instruct the UAP and scrub tech to stop the discussion Signup and view all the answers

Which laboratory value should the nurse report to the health care provider immediately during the preoperative checklist?

Glucose 60 mg/dL Signup and view all the answers

Which problem is appropriate for the nurse to identify for a client in the intraoperative phase of surgery?

Risk for injury Signup and view all the answers

What nursing intervention should be implemented to decrease a complication from the lithotomy position during surgery?

Lower one leg at a time Signup and view all the answers

What should the circulating nurse do upon observing the surgeon tossing a bloody gauze sponge onto the sterile field?

Tell the surgical technologist about the sponge Signup and view all the answers

What should the circulating nurse do upon noting a discrepancy in the needle count?

Inform the other members of the surgical team about the problem Signup and view all the answers

Which interventions should the nurse implement if the client identifies the left arm as the surgical site but the permit designates the right arm? Select all that apply.

Immediately call a 'time-out' Signup and view all the answers

Which assessment data would warrant immediate intervention for a client received from the post-anesthesia care unit?

The client's vital signs are T 97˚F, P 108, R 24, and BP 80/40 Signup and view all the answers

What should the nurse be aware of after a client received naloxone (Narcan), an opioid antagonist, in the post-anesthesia care unit?

Patient may experience withdrawal symptoms from opioids. Signup and view all the answers

Study Notes

Health Promotion and Cultural Sensitivity

Promote exercise routines for clients with sedentary lifestyles, considering their heritage.
Address cultural sensitivities, such as the "evil eye" belief in certain communities, when handling personal compliments.
Understand that loud talking may not indicate anger; cultural factors and communication styles vary among individuals.

Therapeutic Communication and Family Dynamics

Initial communication with clients should consider addressing the eldest family member first, especially in culturally diverse families.
Engaging with clients about their cultural practices and preferences (e.g., use of ayurveda) enhances culturally sensitive care.

Complementary and Alternative Therapies

Hypnotherapy can assist in weight-loss programs by offering alternative approaches.
Complementary therapies, such as deep breathing and music therapy, may be integrated for anxiety management pre-surgery.
Encourage discussions on pain management that includes both medications and complementary therapies for clients with drug abuse histories.

Pre- and Postoperative Care

Performing a preoperative checklist is essential to ensure all aspects of care are addressed before surgery.
Understanding patients' health status is critical; for instance, notify the surgeon if a client has abnormal lab values like low potassium levels.
During postoperative care, monitor for respiratory complications, especially following spinal anesthesia.

Legal competence for surgical consent varies; assess factors such as age and mental orientation.
Gather detailed allergy histories, focusing on specific reactions to medications like codeine, to ensure safe practices.

Safety Protocols in Surgery

The responsibilities of the circulating nurse include patient safety and maintaining sterile conditions.
Interventions for patients at risk of injury during surgery involve taking precautions like padding extremities.

Recognizing and Responding to Emergencies

Detect vital sign irregularities such as tachycardia and hypotension, which may indicate medical emergencies.
Quick actions, like elevating the head after transfer from PACU if abnormal signs are noted, are crucial for patient stability.

Cultural Objects and Practices

Respect and understand the significance of cultural items such as amulets and pouches worn by clients, ensuring they are not removed without understanding their importance.

Dietary Considerations

Assess dietary restrictions for clients, such as ensuring kosher meals for Jewish patients, to promote adequate nutritional intake.

Emotional and Psychological Support

Provide emotional support through familiar items, like religious medals, during surgical procedures to alleviate anxiety.
Be aware of postoperative symptoms indicating complications, including respiratory distress or changes in blood pressure.### Postoperative Nursing Care
Temperature Monitoring: A postoperative client with T 99.0°F, P 98, R 20, and BP 100/60 indicates effective recovery after surgery.
Vital Signs Assessment: First action upon transfer from PACU to surgical floor is to assess the client's vital signs.
Delegation: Unlicensed Nursing Assistants (UAPs) can take vital signs every four hours but cannot check surgical sites or administer medications.

Postoperative Complications

Potential Hemorrhaging: Recognized as priority complication for clients one day postoperative.
Monitoring for Infection: Vital signs and drainage from surgical sites must be regularly monitored to prevent infection.

Pain Management

Acute Pain Interventions: Administer pain medication as soon as the schedule allows; always assess patient's verbal and nonverbal cues for pain.
Client Education: Clients should understand to report pain adequately and use prescribed pain management techniques (e.g., PCA).
Nurse Advocacy: Nurses should contact health care providers when pain relief is not achieved.

Preoperative Considerations

Informed Consent: Nurses must ensure clients voluntarily consent to surgery without coercion or misunderstanding.
Assessment of Risks: Report any significant findings (e.g. herbal supplement use) to the surgeon before surgery.

Surgical Preparedness

Preoperative Checklist: Must confirm details such as site marking and surgical permits before procedures.
Patient Teaching: Effective teaching includes demonstrating the use of an incentive spirometer and discussing postoperative care.

Post-Anesthesia Care Unit (PACU) Focus

Vital Signs Priority: Continuous monitoring of vital signs is essential for identifying complications after surgery.
Respiratory Monitoring: After administering naloxone for opioid reversal, monitor respiratory rate frequently (every 15 to 30 minutes).

Emergency Situations

Postoperative Complications: Immediate intervention is required for clients with abnormal vital signs, such as vomiting, altered consciousness, or severe pain.

Discharge Readiness

Effective Discharge Education: Clients should verbalize understanding of medication regimes, particularly the importance of completing antibiotics.

Special Considerations in Surgical Patients

Elderly Clients: Increased vigilance for confusion and fall risks in older adults postoperatively; consider "risk for injury" in care plans.
Pain Assessment Techniques: Use age-appropriate methods for pain evaluation, such as the pain scale for children or non-verbal cues for elderly clients.

Acknowledging Non-Compliance

Medication Adherence: Emphasize the necessity of completing prescribed medications to prevent complications; clients should not assume they will have no further pain control needs post-surgery.

Potential Complications of Positioning

Lithotomy Positioning: Lowering one leg at a time can help decrease complications associated with prolonged surgical positioning, such as circulatory issues.

Nursing Responsibilities During Surgery

Surgical Counts: Ensure all instruments and supplies' counts are accurate and report any discrepancies immediately to maintain patient safety.### Burn Classification and Assessment
Blistered, mottled red skin with edema suggests deep partial thickness burn.
Full-thickness burns covering significant areas (e.g., 40% body including legs) necessitate interventions before transfer to a burn center, ensuring adequate peripheral circulation.
In cases of full-thickness burns (e.g., 65% body), immediate emphasis on replacing fluids and electrolytes is prioritized after airway stabilization.

Medication Administration and Patient Monitoring

Mafenide acetate (Sulfamylon) may cause pain upon application; however, abnormal ABG results (e.g., pH 7.34, low HCO3) require immediate nursing intervention.
Knowledge of xenografts is essential; they involve grafts sourced from animals, often pigs.

Nursing Priorities and Care Plans

High risk for infection is the primary concern in burn patients with extensive injuries (e.g., full-thickness and deep partial-thickness over 50% body).
Daily wound cleansing is vital in managing open burn wounds and preventing infection.

Infection Control Measures

Strict hygiene practices are crucial; thorough hand hygiene, sterile gloves for wound care, and wearing gowns/masks during procedures are essential.
Administer prescribed antibiotics to combat infection risk in severe burn cases.

Patient Assessment and Health Provider Notification

Urinary output of 50 mL in 2 hours raises concern and should prompt healthcare provider notification.
Signs of severe pain and vital sign changes (e.g., fever) also warrant close monitoring.

Nutritional Support

Family involvement in nutritional care is beneficial; encouraging familiarity and preference in food can aid recovery.
Weight monitoring should be consistent for accurate assessment of nutritional status.

First Aid and Initial Treatment

For hot grease burns, immediate action involves placing the affected area in cool water rather than applying ice packs, which can cause further damage.

Mental Health Strategies Post-Discharge

Encouraging realistic expectations regarding lifestyle changes is important for mental well-being post-discharge.
Promoting social interaction and community engagement is preferable to isolation.

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Description

Test your knowledge on health promotion interventions for clients with diverse backgrounds in this Med Surg Success Q & A quiz. This quiz focuses on implementing effective strategies for clients, especially those from a German heritage living a sedentary lifestyle.