Exam (elaborations)
NURS 320 EXAM 1
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NURS 320 EXAM 1A patient is now in the recovery room after having vaginal surgery. Due to the positioning of the
procedure, you would want to assess for what while the patient is in recovery?
A. Bowel Sounds
B. Dysrhythmia
C. Homan's Sign
D. Hemoglobin Level - ANSWER C
After surgery your patient is semicomatose with vital signs within normal limits. As the nurse, what
position would be best for this patient?
A. Semi-Fowlers
B. Prone
C. Low-Fowlers
D. Side positioning preferably on the left side - ANSWER D
After surgery your patient starts to shiver uncontrollably. What nursing intervention would you do
FIRST?*
A. Apply warm blankets & continue oxygen as prescribed
B. Take the patient's rectal temperature
C. Page the doctor for further orders
D. Adjust the thermostat in the room - ANSWER A
The nurse is monitoring the patient who is 24 hours post-opt from surgery. Which finding requires
intervention?*
A. BP 100/80
B. 24-hour urine output of 300 ml
C. Pain rating of 4 on 1-10 scale
D. Temperature of 99.3' F - ANSWER B
A patient is 6 days post-opt from abdominal surgery. The patient is to be discharged later today. The
patient uses the call light and asks you to come to his room and look at his surgical site. On arrival,
you see that approximately 2 inches of internal org ANSWER are protruding through the incision.
What intervention would you NOT do?*
,A. Put the patient in prone position with knees extended to put pressure on the site
B. Cover the wound with sterile normal saline dressing
C. Monitor for signs of shock
D. Notify the MD and administer as prescribed antiemetic to prevent vomiting - ANSWER A
A patient reports he hasn't had a bowel movement or passed gas since surgery. On assessment, you
note the abdomen is distended and no bowel sounds are noted in the four quadrants. You notify the
MD. What non-invasive nursing interventions can you perform without a MD order?
A. Insert a nasogastric attached to intermittent suction
B. Administer IV fluids
C. Encourage ambulation, maintain NPO status, and monitor intake & output
D. Encourage at least 3000 ml of fluids per day - ANSWER C
What is a potential postoperative concern regarding a patient who has already resumed a solid diet?
*
A. Failure to pass stool within 12 hours of eating solid foods
B. Failure to pass stool within 48 hours of eating solid foods
C. Passage of excessive flatus
D. Patient reports a decreased appetite - ANSWER B
A nurse is developing a care plan for a patient who is at risk for developing pneumonia after surgery.
Which of the following is not an appropriate nursing intervention?*
A. Encourage patient intake of 3000 ml/day of fluids if not contraindicated
B. Encourage patient to use the incentive spirometer device 10 times every 1-2 hours while awake
C. Encourage early ambulation and patient to eat meals in beside chair
D. Repositioning every 3-4 hours - ANSWER D
When assessing your patient who is post-opt, you notice that the patient's right calf vein feels hard,
cord-like, and is tender to the touch. The patient reports it is aching and painful. What would NOT be
an appropriate nursing intervention for this patient?*
A. Allow the patient to dangle the legs to help increase circulation and alleviate pain
B. Instruct the patient to not sit in one position for a long period of time
C. Elevate the extremity 30 degrees without allowing any pressure on affected area
,D. Administer anticoagulants as ordered by MD - ANSWER A
A patient is recovering from surgery. The patient is very restless, heart rate is 120 bpm and blood
pressure is 70/53, skin is cool/clammy. As the nurse you would?*
A. Continue to monitor the patient
B. Notify the MD
C. Obtain an EKG
D. Check the patient's blood glucose - ANSWER B
A patient is taking Aspirin 325 mg PO by mouth daily. The patient is scheduled for surgery in a week.
What education do you provide the patient with before surgery?*
A. Educate the patient to take the scheduled dose of Aspirin the day of surgery to help prevent
blood clots
B. To hold his morning dose of Aspirin because the nurse will give it to him before surgery
C. None of the above are correct
D. The medication should be discontinued for 48 hours prior to the scheduled surgery date -
ANSWER D
You are observing your patient use the incentive spirometry. What demonstration by the patient lets
you know the patient understands how to use the device properly?*
A. The patient inhales slowly on the device and maintains the flow indicator between 600 to 900
level
B. The patient blows on the mouthpiece rapidly.
C. The patient uses the incentive spirometry once a day
D. The patient rapidly inhales on the devices and exhales - ANSWER A
As the nurse you are getting the patient ready for surgery. You are completing the preoperative
checklist. Which of the following is not part of the preoperative checklist?*
A. Assess for allergies
B. Conducting the Time Out
C. Informed consent is signed
D. Ensuring that the history and physical examination has been completed - ANSWER B
, You are completing the history on a patient who is scheduled to have surgery. What health history
increases the risk for surgery for the patient?*
A. Urinary Tract infections
B. History of Premature Ventricle Beats
C. Abuse of street drugs
D. Hyperthyroidism - ANSWER C
As a nurse, which statement is incorrect regarding an informed consent signed by a patient?*
A. The nurse is responsible for obtaining the consent for surgery
B. Patients under 18 years of age may need a parent or legal guardian to sign a consent form
C. The nurse can witness the client signing the consent form
D. It is the nurse's responsibility to ensure the patient has been educated by the physician about the
procedure before informed consent is obtained - ANSWER A
The nurse is preparing a client for surgery. What is the most effective method for obtaining an
accurate blood pressure reading from the client?
A.
Obtain a cuff that covers the upper one third of the client's arm
B.
Position the cuff approximately 4 inches above the antecubital arm
C.
Use a cuff that is wide enough to cover the upper two thirds of the client's arm
D.
Identify the Korotkoff sounds, and take a systolic reading at 10 mmHg after the first sound - ANSWER
C
Which of the following items on a client's presurgery laboratory results would indicate a need to
contact the surgeon?
A.
Platelet count of 250,000/cu.mm
B.
Total cholesterol of 325 mg/dl
C.
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