Nurse 4500 Test 1 with Complete Solutions
What needs to be taken into consideration when planning pain management? CorrectCultural and spiritual practices and beliefs
What needs to be taken into consideration when planning pain management? Correct-
Cultural and spiritual practices and beliefs
What special consideration must be taken for a pt who has had spinal anesthesia and is going
into shock? Correct-The legs should not be elevated any more then having a pillow under
them or else the diaphragm muscles may become impaired
What are post-op signs of a paralytic ileus? Correct-vomiting, abdominal distention, and
absence of bowl sounds
What should a nurse do if an abdominal wound eviscerates? Correct-1. call for help/have
surgeon notified
2. stay w the patient and place in low fowlers with knees bent
3. Cover wound with sterile NS dressing
4. take VS and keep pt calm
, Nurse 4500 Test 1 with Complete Solutions
The nurse has just reassessed the condition of a post-op client who was admitted 1 hr ago to
the surgical unit. The nurse plans to monitor for which parameter MOST carefully during the
next hour? Correct-Urinary output of 20mL/hr
Urinary output of less then 30mL/hr for more then 2 hours should be reported to the
physician
T/F- perioperative care procedures do not apply when a surgical procedure is done through
ambulatory care or 1-day surgical units. Correct-False
many surgeries are done this way and perioperative procedures still apply
T/F- hair on the head or face, such as eyebrows, should only be shaved as prescribed
Correct-True
What may stridor, wheezing, or crowing be indicative of? Correct-partial obstruction,
bronchospasm, or laryngospasm
What may crackles of ronchi be indicative of? Correct-atelectasis, pneumonia, or
pulmonary edema
, Nurse 4500 Test 1 with Complete Solutions
What position should a patient be placed in if vomiting and why? Correct-Side-lying to
prevent aspiration; suction equipment should be available and ready to use
The nurse is teaching a client about coughing and breathing techniques to prevent post-op
complications. Which statement is MOST appropriate for the nurse to make to the client at
this time as it relates to these techniques? Correct-The use of an incentive spirometer will
help prevent pneumonia
Use helps prevent atelectasis and pneumonia
The nurse is creating a plan of care for a client scheduled for surgery. The nurse should include
which activity in the nursing plan of care for the day of surgery Correct-Have the client
void immediately before going into surgery.
A client with a gastric ulcer is scheduled for surgery. the client cannot sign the operative
consent form because of sedation from opioid analgesics that have been administered. The
nurse should take which MOST appropriate action of care of this client? Correct-Every
effort is made to obtain consent from a responsible family member. A telephone consent
, Nurse 4500 Test 1 with Complete Solutions
must be witnessed by 2 persons who hear the family member's oral consent. The 2 witnesses
then sign the consent with the name of the family members and note that oral consent was
given.
A preoperative client expresses anxiety to the nurse about upcoming surgery. Which response
by the nurse will most likely stimulate further discussion between the client and the nurse?
Correct-"Can you share with me what you've been told about the surgery?
allows the nurse to base their explanation on what the patient already knows
The nurse is conducting preoperative teaching with a client about the use of an incentive
spirometer. The nurse should include which piece of information in the discussion with the
client? Correct-The best results are achieved when sitting up or HOB elevated to 45-90
degrees
Allows for optimal lung expansion
The nurse has conducted pre-op teaching for a client scheduled surgery in one week. The
client has a history of arthritis and has been taking acetylsalicylic acid. The nurse determines
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