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Nursing 309 Quiz 3 Iggy 16 Questions With Complete Solutions

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Nursing 309 Quiz 3 Iggy 16 Questions With Complete
Solutions

A 49 year old patient is in the PACU following a frontal
craniotomy for repair of a ruptured cerebral aneurysm.

The nurse assesses that the patient's eyes open on verbal
stimulation. Pupils are equal, reactive to light, and diameter is 3
mm.
The patient's hand grasps are equal and strong.
The patient's hand grasps are equal and strong.
When the nurse asks the patient to state name, the patient states
names correctly.
The patient has had one episode of nausea and vomiting.
Incision edges are dry and approximated with sutures. Lung
sounds are slightly diminished per auscultation and the nurse
observes the patient is using abdominal accessory muscles to
breathe.

Which body systems has the nurse assessed? Correct Answers
Gastrointestinal. Neurologic. Integumentary. Respiratory.

A client experiences abdominal distention following surgery.

Which nursing actions are appropriate? Correct Answers
Encouraging ambulation.
Auscultating bowel sounds.

A client is extubated in the post anesthesia care unit after
surgery.

,For which common response should the nurse be alert when
monitoring the client for acute respiratory distress? Correct
Answers Restlessness.

A client reports severe pain 2 days after surgery.
Which INITIAL action should the nurse take after assessing the
character of the pain? Correct Answers Obtain the vital signs.

A nurse in the postanesthesia care unit observes that after an
abdominal cholecystectomy a client has serosanguineous
drainage on the abdominal dressing.

What is the next best nursing action? Correct Answers
Reinforce the dressing.

A nurse in the surgical intensive care unit is caring for a client
with a large surgical incision.
What medication does the nurse anticipate will be prescribed for
this client? Correct Answers Ascorbic acid (Ascorbicap)

A nurse is applying a dressing to a client's surgical wound using
sterile technique. While engaging in this activity, the nurse
accidentally places a moist sterile gauze pad on the cloth sterile
field.

What physical principle is applicable for causing the sterile field
to become contaminated? Correct Answers Capillary.

A nurse is caring for a postoperative client who had general
anesthesia during surgery.

, What independent nursing intervention may prevent an
accumulation of secretions? Correct Answers Frequent changes
of position.

A nurse is preparing to change a client's dressing. What is the
reason for using surgical asepsis during this procedure? Correct
Answers Keeps the area free of microorganisms.

A patient arrives at the PACU and the nurse notes a respiratory
rate of 10 with sternal retractions.
The report from anesthesia personnel indicates that the patient
had received fentanyl during surgery.

What is the nurse's best priority first action? Correct Answers
Maintain an open airway through positioning and suction if
needed.

A patient arrives in the PACU.
Which action the nurse performs first? Correct Answers Assess
for a patent airway and adequate gas exchange.

A patient cared for in the PACU has had a colostomy placed for
treatment of Crohn's disease.

The nurse assesses that an abdominal dressing is 25% saturated
with serosanguineous drainage and notes that the incision is
intact.
An IV is infusing with D5/lactated Ringer's at 100 mL/hr
through a 20-g peripheral IV access.
Auscultation of abdomen reveals hypoactive bowel sounds in all
four quadrants, abdomen soft, and no distention.

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