(Ramsay Score) RSS 5 Correct Answers Patient exhibits a
sluggish response to stimulus.
(Ramsay Score) RSS 6 Correct Answers Patient exhibits no
response to stimulus. The RSS must be reapplied at intervals
until full consciousness is achieved.
A 47 year old patient is having surgery to remove kidney stones.
What is the correct classification for this surgery? Correct
Answers Urgent surgery
A 49 year old patient is in the PACU following a frontal
craniotomy for repair of a ruptured cerebral aneurysm.
The nurse assesses that the patient's eyes open on verbal
stimulation. Pupils are equal, reactive to light, and diameter is 3
mm.
The patient's hand grasps are equal and strong.
The patient's hand grasps are equal and strong.
When the nurse asks the patient to state name, the patient states
names correctly.
The patient has had one episode of nausea and vomiting.
,Incision edges are dry and approximated with sutures. Lung
sounds are slightly diminished per auscultation and the nurse
observes the patient is using abdominal accessory muscles to
breathe.
Which body systems has the nurse assessed? Correct Answers
Gastrointestinal. Neurologic. Integumentary. Respiratory.
A 75 year old patient is having an exploratory laparotomy
tomorrow. The wife tells the nurse that at night the patient gets
up and walks around his room. What priority action does the
nurse take after hearing this information? Correct Answers
Develops a plan to keep the patient safe.
A 76 year old patient is having a bilateral cataract removal.
What is the correct classification for this surgery? Correct
Answers Elective surgery
A 79 year old patient with type 2 diabetes is scheduled for
surgery to remove his left great toe. Which risk factors for
complications of surgery does the nurse assess for this patient?
Correct Answers Presence of chronic illness.
Problems with hearing.
Dehydration, electrolyte imbalances.
A CBC, urinalysis, and x-ray examination of the chest are
ordered for a client before surgery. The client asks why these
tests are done. Which is the BEST reply by the nurse? Correct
Answers "They are done to identify other health risks."
A client experiences abdominal distention following surgery.
A client had extensive, prolonged surgery. Which electrolyte
level should the nurse monitor most closely? Correct Answers
Potassium labs.
A client is admitted for surgery. Although not physically
distressed, the client appears apprehensive and withdrawn. What
is the nurse's BEST action? Correct Answers Orient the client
to the unit environment.
A client is being prepared for gastrointestinal surgery and
undergoes a bowel preparation. Why is this preoperative
procedure done? Correct Answers Reduce the number of
intestinal bacteria
A client is extubated in the post anesthesia care unit after
surgery.
For which common response should the nurse be alert when
monitoring the client for acute respiratory distress? Correct
Answers Restlessness.
A client reports severe pain 2 days after surgery.
Which INITIAL action should the nurse take after assessing the
character of the pain? Correct Answers Obtain the vital signs.
, A female patient is having a biopsy of a nodule found in the
right breast. Which classification identifies this surgery?
Correct Answers Diagnostic
A male patient has a scar on his forehead from a third-degree
burn. What is the correct classification for this surgery? Correct
Answers Cosmetic Surgery
A nurse in the ambulatory preoperative unit identifies that a
client is more anxious than most clients. What is the nurse's
BEST intervention? Correct Answers Attempt to identify the
client's concerns.
A nurse in the postanesthesia care unit observes that after an
abdominal cholecystectomy a client has serosanguineous
drainage on the abdominal dressing.
What is the next best nursing action? Correct Answers
Reinforce the dressing.
A nurse in the surgical intensive care unit is caring for a client
with a large surgical incision.
What medication does the nurse anticipate will be prescribed for
this client? Correct Answers Ascorbic acid (Ascorbicap)
A nurse is applying a dressing to a client's surgical wound using
sterile technique. While engaging in this activity, the nurse
accidentally places a moist sterile gauze pad on the cloth sterile
field.
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