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NUR 206 Final Exam with correct answers
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NUR 206 Final Exam with correct answersThe 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
The nurse is caring for a patient who has received epoetin alfa (Epogen) 2 to 3 weeks prior to a scheduled surgery. The nurse
understands that this patient will likely: - correct answer -not require a blood transfusion during surgery
The nurse is caring for an 82-year-old pre-surgical patient. Which abnormal finding is most important for the nurse to report
immediately? - correct answer -Temperature of 99.8° F
The nurse is caring for an Asian patient who received atropine as a preoperative drug. For which problem should the nurse
should carefully monitor the patient? - correct answer -Tachycardia
The nurse is performing a preoperative assessment on a patient scheduled for surgery today. The patient reports drinking two
glasses of wine daily, smoking one pack of cigarettes daily for 20 years, completing a round of corticosteroids for asthma
control 2 days ago, and taking a dose of passion flower extract yesterday. Which action should the nurse take next? - correct
answer -Notify the physician immediately regarding the patient's recent use of corticosteroids.
The nurse is reviewing the pre-surgical patient's laboratory reports and notes an elevated aspartate aminotransferase (AST)
and bilirubin. The nurse understands that this patient is most at risk for which potential complication? - correct answer -
Excessive bleeding during or after surgery
The patient questions the nurse about robotics surgery. Which information should the nurse include? (Select all that apply.) -
correct answer -- "Robotics gives the surgeon greater magnification than the human eye."
- "Robotics allows the surgeon to be more precise than normal."
- "Robotics allows for a smaller incision."
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