GNRS 555 Med Surg Care Adult Study Questions and Correct Answers
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Course
GNRS 555
Institution
GNRS 555
Pressure injuries form primary as a result of: Tissue Ischemia
The nurse notes a client's skin is reddened with a small abrasion and serous fluid present. The nurse should classify this stage of pressure injury formation as: Stage II
A 43-year-old client is scheduled to have a gastrectomy. Which ...
GNRS 555 Med Surg Care Adult Study
Questions and Correct Answers
Pressure injuries form primary as a result of: ✅Tissue Ischemia
The nurse notes a client's skin is reddened with a small abrasion and serous fluid
present. The nurse should classify this stage of pressure injury formation as: ✅Stage II
A 43-year-old client is scheduled to have a gastrectomy. Which of the following is a
major preoperative concern?
a. The client's brother had a tonsillectomy at age 11.
b. The client smokes a pack of cigarettes a day.
c. The client has an intravenous (IV) infusion.
d. The client has a history of employment as a computer programmer. ✅b. The client
smokes a pack of cigarettes a day
As obese client is admitted for abdominal surgery. The nurse recognizes that this client
is more susceptible to the postoperative complication of: ✅Dehiscence
Define dehiscence ✅When surgical wound reopens partially or completely. Wounds
can reopen either internally or externally.
Nurse is working in a postoperative care unit in an ambulatory surgery center. Of the
following clients that have come to have surgery, the client at the greatest risk during
surgery is a:
a. 78 yr old taking an analgesic agent
b. 43 yr old taking an antihypertensive agent
c. 27 yr old taking an anticoagulant agent
d. 10 year old taking an antibiotic agent ✅c. 27 yr old taking an anticoagulant agent
(why? anticoagulants alter normal clotting factors and thus increase the risk for
hemorrhaging during surgery)
The nurse is evaluating the outcome "Client describes surgical procedures and
postoperative treatment" and determines that the client has not achieved this outcome.
The nurse should:
a. obtain the consent, b/c this is expected with preoperative anxiety
b. teach the client all about the procedure
c. ask the unit manager to assist with a teaching plan
,d. inform the surgeon so that information can be provided ✅d. inform the surgeon so
that information can be provided
The client will have an incision in the lower left abdomen. Which of the following
measures by the nurse will help decrease discomfort in the incisional area when the
client coughs postoperatively?
a. Applying a splint directly over the lower abdomen
b. Keeping the client flat with her feet flexed
c. Turning the client onto the right side
d. Applying pressure above and below the incision ✅a. Applying a splint directly over
the lower abdomen (why? splinting the incision with hands or a pillow provides firm
support and reduces incisional pulling)
The client is scheduled for abdominal surgery and has just received the preoperative
medications. The nurse should:
a. keep the client quiet
b. obtain the consent
c. prepare the skin at the surgical site
d. place the side rails up on the bed or stretcher ✅d. place the side rails up on the bed
or stretcher
The nurse is completing the preoperative checklist for an adult client who is scheduled
for an operative procedure later in the morning. Which of the following preoperative
assessment findings for this client indicates a need to contact the anesthesiologist?
a. temperature is 100 F
b. pulse is 90 bpm
c. respiratory rate is 20 breaths per min
d. BP is 130/74 mm Hg ✅a. temperature is 100 F
The client tells the nurse that "blowing into this tube thing (incentive spirometer) is a
ridiculous waste of time." The nurse explains that the specific purpose of the therapy is
to:
a. directly remove excess secretions from the lungs
b. increase pulmonary circulation
c. promote lung expansion
d. stimulate the cough reflex ✅c. promote lung expansion
The female client on the surgical unit is being prepared for abdominal surgery with
general anesthesia. In preparing this client for surgery, the nurse should:
a. leave all of her jewelry intact
b. provide her with sips of water for dry mouth
,c. remove her makeup and nail polish
d. remove her hearing aid before transport to the OR ✅c. remove her makeup and nail
polish (why? these should be removed to expose normal skin and nail color to
determine level of oxygen and circulation during and after surgery)
The client asks the nurse the purpose of having medications (Demerol and Vistaril)
given before surgery. The nurse should inform the client that these particular
medications:
a. reduce preoperative fear
b. promote emptying of the stomach
c. reduce body secretions
d. ease the induction of the anesthesia ✅d. ease the induction of the anesthesia
Following abdominal surgery, the nurse suspects that the client may be having internal
bleeding. Which of the following findings is indicative of this complication?
a. increased BP
b. incisional pain
c. abdominal distention
d. increased urinary output ✅c. abdominal distention
Define Abdominal distention ✅Bloating and swelling of abdominal area; may be
indicative of internal bleeding following abdominal surgery
The client had surgery in the morning that involved the right femoral artery. To assess
the client's circulation status to the right leg, the nurse will make sure to check the pulse
at the:
a. radial artery
b. ulnar artery
c. brachial artery
d. dorsalis pedis artery ✅d. dorsalis pedis artery
A client who is scheduled for surgery is found to have thrombocytopenia. A specific
postoperative concern for the nurse for this client is:
a. hemorrhage
b. wound infection
c. fluid imbalance
d. respiratory depression ✅a. hemorrhage
The perioperative nurse realizes that the most effective means of evaluating the client's
understanding of previous teaching is to:
a. provide written material on the subject to be reviewed after discharge
, b. reinforce the material with family as the procedure is being performed
c. discuss it with the client and family in the immediate preoperative period
d. offer to answer any questions that the client or family may have just before discharge
✅c. discuss it with the client and family in the immediate preoperative period
Which of the following preoperative assessment findings would most likely delay a
planned procedure requiring general anesthetic?
a. a cough and low-grade fever
b. the pulse oximetry reading of 97% on room air
c. a BP that is 5 systolic points higher than baseline
d. the client's report of "being so nervous about this procedure" ✅a. a cough and low-
grade fever
A 74-year-old is accompanied by his daughter to the ambulatory surgery department for
the surgical removal of a suspicious skin lesion. The client has experienced dysphasia
since a cerebral vascular accident 3 years ago. The most effective way for the nurse to
secure the necessary preoperative interview information is to:
a. question the client's daughter
b. review the client's past medical record
c. present the questions in a simple format
d. counting the respirations per minute ✅a. question the client's daughter
Define dysphasia ✅A language disorder that affects a person's ability to communicate
A client who has type 2 diabetes is scheduled for the removal of a skin lesion on his
right shoulder at an ambulatory surgery unit. The nursing diagnosis the client is at
greatest risk for postoperatively is:
a. risk for injury
b. risk for infection
c. impaired wound healing
d. imbalanced nutrition: less than body requirements ✅c. impaired wound healing
(why? the remaining options are not of primary concern bc steps can be taken to
minimize the risk. Impaired wound healing is not as easily managed).
A client scheduled for an ambulatory surgery procedure requiring anesthetics arrives
with a low-grade fever and a productive cough. The postponement of the procedure is
most likely a result of the:
a. client's increased risk for a respiratory tract infection
b. possibility of a respiratory complication during anesthesia
c. increased risk for the client's infecting staff and other clients
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