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2024 NUR-112 TEST 4 EXAM WITH CORRECT ANSWERS
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2024 NUR-112 TEST 4 EXAM WITH CORRECT ANSWERS
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2024 NUR-112 TEST 4 EXAM WITHCORRECT ANSWERS
An older client is hospitalized after an operation. When assessing the client
for postoperative infection, the nurse places priority on which assessment?
a. Change in behavior
b. Daily white blood cell count
c. Presence of fever and chills
d. Tolerance of increasing activity - CORRECT-ANSWERSANS:A
Older people have an age-related decrease in immune system functioning
and may not show classic signs of infection such as increased white blood
cell count, fever and chills, or obvious localized signs of infection. A change
in behavior often signals an infection or onset of other illness in the older
client.
The nurse is caring for a patient in the postanesthesia care unit. The patient
asks for a bedpan and states to the nurse, "I feel like I need to go to the
bathroom, but I can't." Which of the following nursi
The nurse is monitoring a patient in the postanesthesia care unit (PACU) for
postoperative fluid and electrolyte imbalance. Which of the following actions
would be most appropriate for this patient?
a.
Encourage copious amounts of water.
b.
Weigh the patient and compare with preoperative weight.
c.
Measure and record all intake and output.
d.
Start an additional intravenous (IV) line. - CORRECT-ANSWERSANS:C
Accurate recording of intake and output assesses renal and circulatory
function. Measure and record all sources of intake and output. Encouraging
copious amounts of water in a postoperative patient might encourage
nausea and vomiting. In the PACU, it is impractical to weigh the patient while
waking from surgery, but in the days afterward, it is a good assessment
parameter for fluid imbalance. Starting an additional IV is not necessary and
is not important at this juncture.
ng interventions would be most appropriate?
a.
Encourage the patient to wait a minute and try again.
b.
Call the physician and obtain an order for catheterization.
c.
Assess the patient's intake and the patient for bladder distention.
,d.
Inform the patient that everyone feels this way after surgery. - CORRECT-
ANSWERSANS:C
Depending on the surgery, some patients do not regain voluntary control
over urinary function for 6 to 8 hours after anesthesia. Assess the amount of
fluid that the patient obtained while in surgery, and palpate the lower
abdomen just above the symphysis pubis for bladder distention. If fluid
intake is not excessive and the bladder is nondistended, allowing some time
might be appropriate. Not everyone feels as if they need to go but can't after
surgery. If the bladder is distended and the patient is unable to void, a
catheter might be in order.
The postanesthesia care unit (PACU) nurse transports the inpatient surgical
patient to the medical-surgical floor. Before leaving the floor, the medical-
surgical nurse obtains a complete set of vital signs. What is the rationale for
this nursing action?
a.
The first action in a head-to-toe assessment is vital signs.
b.
This is done to compare and monitor for vital sign variation during transport.
c.
This is done to ensure that the medical-surgical nurse checks on the
postoperative patient.
d.
This is done to follow hospital policy and procedure for care of the surgical
patient. - CORRECT-ANSWERSANS:B
The PACU nurse reviews the patient's information with the medical-surgical
nurse, including the surgical and PACU course, physician orders, and the
patient's condition. Before leaving the medical-surgical unit, the PACU nurse
waits while the medical-surgical nurse obtains a complete set of vital signs to
compare with PACU findings. Minor vital sign variations normally occur after
the patient is transported. Vital signs may or may not be the first action in a
head-to-toe assessment. Following policy or ascertaining that the floor nurse
checks on the patient is not a reason to obtain vital signs.
The nurse is caring for a patient who will undergo a coronary artery bypass
graft procedure. What level of care will the patient require immediately post
procedure?
a.
Acute care—medical-surgical unit
b.
Acute care—intensive care unit
c.
Ambulatory surgery
d.
Ambulatory surgery—extended stay - CORRECT-ANSWERSANS:B
,Patients undergoing extensive surgery and requiring anesthesia of longer
duration recover more slowly. If a patient is undergoing major surgery such
as a procedure on the heart, a stay in the hospital and specifically in the
intensive care unit is required to monitor for potential risks to well-being.
This patient would require more care than can be provided on a medical-
surgical unit. It is not appropriate for this type of patient to go home after the
procedure or to stay in an extended stay area of an ambulatory surgery area
because of the complexity and associated risks.
The ambulatory surgical nurse calls to check on the patient at home the
morning after surgery. The patient is reporting continued nausea and
vomiting. Which of the following discharge education points should be
reviewed with the patient?
a.
Instruct the patient to take deep breaths.
b.
Instruct the patient to drink ginger ale and eat crackers.
c.
Instruct and attempt to connect the patient with the physician.
d.
Instruct the patient to go to the emergency department. - CORRECT-
ANSWERSANS:C
Postoperative nausea and vomiting sometimes occur once the patient is at
home even if symptoms were not present in the surgery center. Options for
therapy include medications. Instructing the patient to call the physician and
connecting the patient with the physician can help the patient to obtain
relief. Taking deep breaths, drinking ginger ale, and eating crackers are
interventions that may be helpful, but this patient needs additional help.
Instructing the patient to go to the emergency department is an option with
continued nausea and vomiting.
A preoperative nurse is assessing a client prior to surgery. Which information
would be most important for the nurse to relay to the surgical team?
a. Allergy to bee and wasp stings
b. History of lactose intolerance
c. No previous experience with surgery
d. Use of multiple herbs and supplements - CORRECT-ANSWERSANS:D
Some herbs and supplements can interact with medications, so this
information needs to be reported as the priority. An allergy to bee and wasp
stings should not affect the client during surgery. Lactose intolerance should
also not affect the client during surgery but will need to be noted before a
postoperative diet is ordered. Lack of experience with surgery may increase
anxiety and may require higher teaching needs, but is not the priority over
client safety.
, A nurse works on the postoperative floor and has four clients who are being
discharged tomorrow. Which one has the greatest need for the nurse to
consult other members of the health care team for post-discharge care?
a. Married young adult who is the primary caregiver for children
b. Middle-aged client who is post knee replacement, needs physical therapy
c. Older adult who lives at home despite some memory loss
d. Young client who lives alone, has family and friends nearby - CORRECT-
ANSWERSANS:C
The older adult has the most potentially complex discharge needs. With
memory loss, the client may not be able to follow the prescribed home
regimen. The client's physical abilities may be limited by chronic illness. This
client has several safety needs that should be assessed. The other clients all
have evidence of a support system and no known potential for serious safety
issues.
A clinic nurse is teaching a client prior to surgery. The client does not seem
to comprehend the teaching, forgets a lot of what is said, and asks the same
questions again and again. What action by the nurse is best?
a. Assess the client for anxiety.
b. Break the information into smaller bits.
c. Give the client written information.
d. Review the information again. - CORRECT-ANSWERSANS:A
Anxiety can interfere with learning and cooperation. The nurse should assess
the client for anxiety. The other actions are appropriate too, and can be
included in the teaching plan, but effective teaching cannot occur if the
client is highly anxious.
A preoperative nurse is reviewing morning laboratory values on four clients
waiting for surgery. Which result warrants immediate communication with
the surgical team?
a. Creatinine: 1.2 mg/dL
b. Hemoglobin: 14.8 mg/dL
c. Potassium: 2.9 mEq/L
d. Sodium: 134 mEq/L - CORRECT-ANSWERSANS:C
A potassium of 2.9 mEq/L is critically low and can affect cardiac and
respiratory status. The nurse should communicate this laboratory value
immediately. The creatinine is at the high end of normal, the hemoglobin is
normal, and the sodium is only slightly low (normal low being 136 mEq/L), so
these values do not need to be reported immediately.
An inpatient nurse brings an informed consent form to a client for an
operation scheduled for tomorrow. The client asks about possible
complications from the operation. What response by the nurse is best?
a. Answer the questions and document that teaching was done.
b. Do not have the client sign the consent and call the surgeon.
c. Have the client sign the consent, then call the surgeon.
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