NURS 395 Ex 2- Ch 14,15,16,36,37 Questions
With Complete Solutions
A 78-year-old client is undergoing surgery to repair a right hip
fracture. What nursing action is appropriate during the
intraoperative phase? Correct Answers Appropriately position
the client using adequate padding and support.
Adequate padding and support should be used to prevent
positioning injuries. Older adults have lower bone mass, which
increases the risk of intraoperative positioning injuries. Pain
medication can still be used, just in smaller doses, due to
decreased liver and kidney function. For the same reason, lower
doses of anesthetic agents are used with older adults. The
operating room is usually maintained from 20°C to 24°C; 18°C
is lower than the recommended temperature and
can promote hypothermia in an older adult who already has
impaired thermoregulation and is prone to hypothermia.
A client asks about the purpose of withholding food and fluid
before surgery. Which response by the nurse is appropriate?
Correct Answers It prevents aspiration and respiratory
complications.
The major purpose of withholding food and fluid before surgery
is to prevent aspiration, which can lead to respiratory
complications. Preventing overhydration, decreasing urine
output, and decreasing blood sugar levels are not major purposes
of withholding food and fluid before surgery.
,A client continuously repeats, "I know all will go well." What
cognitive coping strategy should the nurse document? Correct
Answers Optimistic self-recitation
Rationale:
When the client verbalizes this statement repeatedly, it is an
optimistic coping strategy. Imagery occurs when the client
concentrates on a pleasant experience or restful scene.
Distraction occurs when the client thinks of an enjoyable story
or recites a favorite poem or song. Music therapy uses soothing
music to help the client cope.
A client has been administered ketamine for moderate sedation.
What is the priority nursing intervention? Correct Answers
Frequently monitoring vital signs
Vital signs must be monitored frequently to assess for
respiratory depression and to enable quick intervention. Oxygen
may need to be administered if respiratory
depression occurs; therefore, monitoring vital signs is a higher
priority nursing intervention. Providing a dark quiet room is
appropriate after the procedure is completed and the client is
recovering. Hallucinations may occur as a side effect of the
medication.
A client has been transported to the operating room for emergent
surgery. Which statement by the nurse best supports the need for
emergent surgery?
a) "The client was unresponsive, had a distended abdomen, and
had unstable vital signs after a motor vehicle accident."
b) A client with left abdominal pain
c) Epigastric pain with vomiting for 1 day
d) Lacerations to the face require sutures
, e)thyroidectomy to treat hyperthyroidism Correct Answers
"The client was unresponsive, had a distended abdomen, and
had unstable vital signs after a motor vehicle accident."
Rationale:
Emergency surgery means that the client requires immediate
attention and the disorder may be life threatening. A client with
unstable vital signs and a distended abdomen after a motor
vehicle accident requires immediate attention. A client with left
abdominal pain may not need surgery. Epigastric pain with
vomiting for 1 day is usually not an indication for emergent
surgery. Lacerations to the face require sutures, not emergent
surgery. A thyroidectomy to treat hyperthyroidism is a required
surgery, not an emergent one.
A client is brought to the operating room for an elective surgery.
What is the priority action by the circulating nurse? Correct
Answers Verify consent.
Surgery cannot be performed without consent. Documentation
of the start of surgery can only happen once the surgery has
started. Blood products must be
administered within an allotted time frame and therefore should
not be acquired unless needed. The sponge and syringe count is
a safety issue that should be
completed before surgery and while the wound is being sutured,
but if the client has not consented, the surgery should not take
place.
A client is receiving general anesthesia. The nurse anesthetist
starts to administer the anesthesia. The client begins giggling
and kicking her legs. What stage of anesthesia would the nurse
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