Hallmark final exam BSN BSN 206 Nightingale College Question and answers already passed NUR 206 Final
The nurse in the PACU performs postsurgical assessments on the newly admitted patient every _________ minutes. - correct answer every 15 minutes
A patient is on postoperative day 2 after a...
NUR 206 Final
The nurse in the PACU performs postsurgical assessments on the newly
admitted patient every _________ minutes. - correct answer ✔every 15
minutes
A patient is on postoperative day 2 after a nephrectomy. What is the most
effective way to increase her peristalsis? - correct answer ✔Ambulation
A patient is transferred from the operating room to the recovery room after
undergoing an open reduction and internal fixation (ORIF) of his left ankle.
Which is the first assessment to make? - correct answer ✔Check airway for
patency.
A postoperative patient who had a left inguinal hernia repair is ready for his
discharge instructions. Which information should the nurse provide? (Select
all that apply.) - correct answer ✔- Care of the wound site and any dressings
- When he may operate a motor vehicle
- Signs and symptoms to report to the physician
- Actions and side effects of any medications
Anti-embolic stockings are in place on the obese post surgical patient. Which
statement accurately describes the standard of care in regards to anti-embolic
stockings? - correct answer ✔should be removed approximately 20 minutes
every shift.
Frequent assessment of a postoperative patient is essential. What is one of
the first signs and symptoms of hemorrhage? - correct answer
✔Restlessness
,The nurse educates the postsurgical patient about which potential effect of
smoking on postsurgical recovery? - correct answer ✔Delayed healing
The nurse is caring for a 90-year-old postoperative patient whose oxygen
saturation is frequently dropping below 90%. Which age-related change is
most likely related to this finding? - correct answer ✔weakened respiratory
muscles
The nurse is caring for a patient during the first postoperative day. Which goal
works to prevent atelectasis and is most appropriate for the nursing care
plan? - correct answer ✔Patient will "huff-cough" every 2 hours
The nurse is caring for a patient following abdominal surgery. The patient asks
the nurse when he will be able to eat a normal diet. Which response is best? -
correct answer ✔"Once you have bowel sounds and are passing gas, you
may have clear liquids, and your diet will be advanced based upon your
tolerance."
The nurse is caring for a patient who had spinal anesthesia. Which drink is the
best choice for the nurse to offer the patient? - correct answer ✔Tea
The nurse is caring for a surgical patient who complains of excessive gas.
Which action should the nurse take? - correct answer ✔Ambulate the patient
in the hall.
The nurse is educating the patient about vitamins and wound healing. The
nurse explains that which vitamin will enhance wound healing the most? -
correct answer ✔Vitamin C
The nurse is performing a neurological assessment on a patient who was just
transferred from the PACU following abdominal surgery. Which action(s)
,correctly demonstrate(s) knowledge of a neurological assessment? (Select all
that apply.) - correct answer ✔- Asking the patient to identify where he is.
- Noting if the patient can identify the sensation of touch.
- Asking the patient to move his arms and legs.
- Assessing the patient's pupils for response to light.
The nurse is performing the Aldrete scoring system. Which factor(s) must be
assessed? (Select all that apply.) - correct answer ✔- Activity
- Circulation
- Level of consciousness
- O2 saturation
- Respiration
The PACU nurse is caring for a semiconscious patient immediately following
abdominal surgery. The nurse correctly places the patient in which position? -
correct answer ✔Lateral
The PACU nurse is caring for an unconscious patient. Assessment reveals
diminished breath sounds bilaterally. Which action should the nurse take? -
correct answer ✔Document "diminished breath sounds in both lower lobes."
The patient is brought into PACU still unconscious. What should the nurse do
when the nurse assesses an oral temperature of 94° F? - correct answer
✔Cover with a warm blanket
The postoperative nursing intervention that would be contraindicated for a 45-
year-old patient who has had a repair of a cerebral aneurysm and is
presenting signs of increased intracranial pressure (ICP) would be: - correct
answer ✔coughing every 2 hours
, When the postoperative patient complains of sudden chest pain combined
with dyspnea, cyanosis, and tachycardia, the nurse recognizes the signs of: -
correct answer ✔pulmonary embolus
Which action is most important for the nurse to take prior to ambulating the
postsurgical patient for the first time? - correct answer ✔Raise the head of
the bed
Which of the following early postoperative observations should be reported
immediately? - correct answer ✔"Coffee ground" emesis
While turning a patient who had a bowel resection yesterday, the wound
eviscerated. What is the initial nursing intervention? - correct answer ✔Apply
a warm, moist normal saline sterile dressing.
During the course of surgery, the patient exhibits tachycardia, diaphoresis,
and rising body temperature. The priority intervention by the circulating nurse
is to: - correct answer ✔Alert the anesthesiologist and surgeon immediately.
In which situation might surgery be delayed? - correct answer ✔The patient
is still taking anticoagulants
The nurse clarifies the difference between regional anesthesia and procedural
sedation anesthesia. Which statement about procedural sedation anesthesia
is true? - correct answer ✔Procedural sedation anesthesia uses both
intravenous (IV) sedation and regional anesthesia
The nurse is caring for a patient who has just been given medication to
reverse neuromuscular blocking agents. The nurse is aware that the patient is
in which general anesthetic stage? - correct answer ✔Emergence
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