PV
The nurse is preparing to administer a scheduled dose of heparin sodium subcutaneously to a client. The nurse should do which of the following to administer this medication correctly?
A) Remove the air bubble in the prefilled syringe.
B) Aspirate before injection to prevent intravenous administration.
C) Rub the injection site after administration to enhance absorption.
D) Pinch the skin between the thumb and forefinger before inserting the needle
D) Pinch the skin between the thumb and forefinger before inserting the needle
The nurse should gather together or “bunch up” the skin between the thumb and the forefinger before inserting the needle into the subcutaneous tissue but release before removing the needle. The nurse should neither aspirate nor rub the site after injection.
The nurse is assessing a client’s peripheral intravenous site and notes that phlebitis has developed over the past several hours. Which of the following actions should the nurse implement first?
A) Remove the client’s IV catheter.
B) Apply an ice pack to the affected area.
C) Decrease the IV rate to 20–30 mL/hour.
D) Administer prophylactic anticoagulants.
A) Remove the client’s IV catheter.
The priority intervention for superficial phlebitis is removal of the offending IV catheter; decreasing the IV rate is insufficient. Anticoagulants are not normally required, and warm, moist heat is often therapeutic.
Five minutes after receiving a preoperative sedative medication by IV injection, a client asks to get up to go to the bathroom to urinate. Which of the following actions is the most appropriate for the nurse to implement?
A) Offer the client to use the urinal/bedpan after explaining the need to maintain safety.
B) Assist the client to the bathroom and stay next to the door to assist the client back to bed when done.
C) Allow the client to go to the bathroom since the onset of the medication will be more than five minutes.
D) Ask the client to hold the urine for a short period since a urinary catheter will be placed in the operating room.
A) Offer the client to use the urinal/bedpan after explaining the need to maintain safety.
The prime issue after administration of either sedative or opioid analgesic medications is safety. Because the medications affect the central nervous system, the client is at risk for falls and should not be allowed out of bed, even with assistance.
Which of the following best describes the primary purpose of deep breathing and coughing for postoperative clients?
A) Prevention of hypotension
B) Prevention of alveolar collapse
C) Prevention of delirium
D) Prevention of hyperventilation
B) Prevention of alveolar collapse
Deep-breathing and coughing techniques in the postoperative phase help clients prevent alveolar collapse and move respiratory secretions to larger airway passages for expectoration.
The nurse formulates a nursing diagnosis of impaired physical mobility related to decreased muscle strength for an older-adult client following a left total knee replacement. Which of the following actions would be an appropriate nursing intervention for this client?
A) Promote vitamin D and calcium intake in the diet.
B) Provide passive range of motion to all of the joints q4h.
C) Encourage isometric quadriceps-setting exercises at least qid.
D) Keep the left leg in extension and abduction to prevent contractures.
C) Encourage isometric quadriceps-setting exercises at least qid.
Great emphasis is placed on postoperative exercise of the affected leg, with isometric quadriceps setting beginning on the first day after surgery.
The nurse is admitting preoperative client with a suspected abdominal aortic aneurysm (AAA). The medication history reveals that the client has been taking warfarin on a daily basis. Based on this history and the client’s admission diagnosis, the nurse should prepare to administer which of the following medications?
A) Vitamin K
B) Vitamin B12
C) Heparin sodium
D) Protamine sulphate
A) Vitamin K
Warfarin is an anticoagulant that could cause excessive bleeding during surgery if clotting times are not corrected before surgery. For this reason, vitamin K is given as the antidote for warfarin.
When doing a PV assessment the nurse is unable to palpate a peripheral pulse, the next option would be
A) Some pulses are hard to find, continue with the assessment
B) Find a doppler and listen for a pulse
C) Call the physician and report your findings
D) Keep palpating until the pulse is found
B) Find a doppler and listen for a pulse
Which of the following statements is the primary reason for accurately recording the client’s current medications during a preoperative assessment?
A) Some medications may alter the client’s perceptions about surgery.
B) Many anaesthetics alter renal and hepatic function, causing toxicity of other drugs.
C) Some medications may interact with anaesthetics, altering the potency and effect of the drugs.
D) Routine medications are withheld the day of surgery, requiring dosage and schedule adjustments after surgery.
C) Some medications may interact with anaesthetics, altering the potency and effect of the drugs.
Drug interactions may occur between prescribed medications and anaesthetic agents used during surgery. For this reason, it is important to take a careful medication history and check that they have been communicated to the anaesthesia care provider.
The nurse is working on a surgical floor and is preparing to receive a postoperative client from the postanaesthesia unit. Which of the following should be the nurse’s initial action upon the client’s arrival?
A) Assess the client’s pain.
B) Assess the client’s vital signs.
C) Check the rate of the IV infusion.
D) Check the physician’s postoperative orders.
B) Assess the client’s vital signs.
The highest priority action by the nurse is to assess the physiological stability of the client. This is in part accomplished by taking the client’s vital signs. The other actions can then take place in rapid sequence.
During a public health screening day, which of the following assessment findings would alert the nurse to the presence of osteoporosis in an older-adult client?
A) The presence of bowed legs
B) A measurable loss of height
C) Poor appetite and aversion to dairy products
D) The development of unstable, wide-gait ambulation
B) A measurable loss of height
A gradual but measurable loss of height and the development of kyphosis, or “dowager’s hump,” are indicative of the presence of osteoporosis, in which the rate of bone resorption is greater than that of bone deposition.
The nurse is reviewing the laboratory test results for a client whose warfarin therapy was terminated during the preoperative period. The nurse concludes that the client is in the most stable condition for surgery after noting which of the following international normalized ratio (INR) results?
A) 2.7
B) 1.0
C) 3.4
D) 1.8
B) 1.0
The therapeutic range for international normalized ratio (INR) results is 2.0–3.0 for many clinical diagnoses and 0.75–1.25 is the normal value with no clinical diagnoses. The larger the number, the greater the amount of anticoagulation. For this reason, the safest value before surgery is 1.0, meaning that the anticoagulation has been reversed.
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Acute arterial ischemia is a sudden decrease of arterial blood supply to tissues, organs, or an extremity. What are the causes of this disease?
A) Embolism
B) Thrombus
C) Trauma
D) Aneurysm
E) Polycythemia
A) Embolism
B) Thrombus
C) Trauma
D) Aneurysm
The nurse is preparing a client for surgery and the client refuses to remove a wedding ring. Which of the following actions is the most appropriate for the nurse to implement?
A) Insist the client remove the ring for safety purposes.
B) Explain that the hospital will not be responsible for the ring.
C) Tape the ring securely to the finger and document this on the preoperative checklist.
D) Note the presence of the ring in the nurse’s notes of the chart and on the preoperative checklist.
C) Tape the ring securely to the finger and document this on the preoperative checklist.
It is customary policy to tape a client’s wedding band to the finger and make a notation on the preoperative checklist that the ring is taped in place.
In planning postoperative interventions to promote ambulation, coughing, deep breathing, and turning, the nurse recognizes that which of the following actions will best enable the client to achieve the desired outcomes?
A) Administer adequate analgesics to promote relief or control of pain.
B) Ask the client to demonstrate the postoperative exercises every hour.
C) Give the client positive feedback when the activities are performed correctly.
D) Warn the client about possible complications if the activities are not performed.
A) Administer adequate analgesics to promote relief or control of pain.
Even when a client understands the importance of postoperative activities and demonstrates them correctly, it is unlikely that the best outcome will occur unless the client has sufficient pain relief to cooperate with the activities.
The nurse determines that dietary teaching for an older-adult client who has osteoporosis has been most successful when the client selects which one of the following highest calcium meals?
A) Chicken stir-fry with 237 g each of onions and snap peas, and 237 g of steamed rice
B) Ham and Swiss cheese sandwich on whole wheat bread, steamed broccoli, and an apple
C) A sardine (85 g) sandwich on whole wheat bread, 237 mL of fruit yogourt, and 237 mL of skim milk
D) A two-egg omelette with 57 g of cheese, one slice of whole wheat toast, and a half grapefruit
C) A sardine (85 g) sandwich on whole wheat bread, 237 mL of fruit yogourt, and 237 mL of skim milk
The highest calcium content is present in this lunch, containing milk and milk products and small fish with bones (sardines).
The nurse is caring for a preoperative client who has a prescription for vitamin K by subcutaneous injection. The nurse should verify that which of the following laboratory studies is abnormal before administering the dose?
A) Hematocrit (Hct)
B) Hemoglobin (Hb)
C) Prothrombin time (PT)
D) Partial thromboplastin time (PTT)
C) Prothrombin time (PT)
Vitamin K counteracts hypoprothrombinemia and/or reverses the effects of warfarin and thus decreases the risk of bleeding. High values for either the prothrombin time (PT) or the international normalized ratio (INR) demonstrate the need for this medication.
What are the 6 P's in a PV limb assessment?
1. Pain
2. Pallor
3. Pulselessness
4. Paresthesia
5. Polar/ Poikilothermia
6. Paralysis
The nurse is admitting a client to the same-day-surgery unit. The client tells the nurse that he was so nervous he had to take kava (herbal remedy) last evening to help him sleep. Which of the following nursing actions would be most appropriate?
A) Tell the client that using kava to help sleep is often helpful.
B) Inform the anaesthesiologist of the client’s recent use of kava.
C) Tell the client that the kava should continue to help him relax before surgery.
D) Inform the client about the dangers of taking herbal medicines without consulting his health care provider.
B) Inform the anaesthesiologist of the client’s recent use of kava.
Kava may prolong the effects of certain anaesthetics. Thus the anaesthesiologist needs to be informed of recent ingestion of this herbal supplement.
Bronchial obstruction by retained secretions has contributed to a postoperative client’s recent pulse oximetry reading of 87%. Which of the following health problems is the client experiencing?
A) Atelectasis
B) Bronchospasm
C) Hypoventilation
D) Pulmonary embolism
A) Atelectasis
The most common cause of postoperative hypoxemia is atelectasis, which may be the result of bronchial obstruction caused by retained secretions or decreased respiratory excursion. Bronchospasm involves the closure of small airways by increased muscle tone, whereas hypoventilation is marked by an inadequate respiratory rate. Pulmonary emboli do not involve blockage by retained secretions.
The nurse is caring for an older-adult client who has osteoarthritis (OA). In assessing the client’s understanding of this disorder, the nurse concludes that teaching has been effective when the client describes the condition as which of the following statements?
A) Joint destruction caused by an autoimmune process
B) Degeneration of articular cartilage in synovial joints
C) Overproduction of synovial fluid resulting in joint destruction
D) Breakdown of tissue in non–weight-bearing joints by enzymes
B) Degeneration of articular cartilage in synovial joints
Osteoarthritis (OA) is a degeneration or breakdown of the articular cartilage in synovial joints. The condition has also been referred to as degenerative arthritis; it is now known to involve the formation of new joint tissue in response to cartilage destruction.
A client with varicose veins has been prescribed compression stockings. Which of the following statements is accurate when teaching the client?
A) “As much as possible, try to keep your stockings on 24 hours a day.”
B) “While you’re still lying in bed in the morning, put on your stockings.”
C) “Dangle your feet at your bedside for 5 minutes before putting on your stockings.”
D) “Your stockings will be most effective if you can remove them for a few minutes several times a day.”
B) “While you’re still lying in bed in the morning, put on your stockings.”
The client with varicose veins should apply stockings in bed, before rising in the morning. Stockings should not be worn continuously but they should not be removed several times daily. Dangling at the bedside prior to application is likely to decrease their effectiveness.
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Treatment of peripheral artery disease (PAD) includes:
A) Elevating the legs
B) Hanging the legs
C) Applying compression stockings
D) Surgery
B) Hang the legs
D) Surgery
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Before admitting a client to the operating room, the nurse recognizes that which of the following data must be in the chart of all clients?
A) Electrocardiogram
B) Signed consent form
C) Functional status evaluation
D) Renal and liver function tests
E) A physical examination report
B) Signed consent form
E) A physical examination report
It is essential to have a physical examination report and signed consent form in the chart of a client going for surgery. The physical examination document explains in detail the overall status of the client for the surgeon and other members of the surgical team.
Which of the following preoperative clients likely faces the greatest risk of bleeding as a result of medication?
A) A woman who takes metoprolol (beta blocker) for the treatment of hypertension
B) A man whose type 1 diabetes is controlled with insulin injections four times daily
C) A man who is taking clopidogrel (antiplatelet agent) after the placement of a coronary artery stent
D) A man who recently started taking finasteride (5-alpha reductase inhibitors ) for the treatment of benign prostatic hyperplasia
C) A man who is taking clopidogrel (antiplatelet agent) after the placement of a coronary artery stent
Any drug that inhibits platelet aggregation, such as clopidogrel (Plavix), represents a bleeding risk. Insulin, metoprolol, and finasteride are less likely to contribute to a risk for bleeding.
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The nurse is reinforcing general health teaching with a client with osteoarthritis (OA) of the hip. Which of the following points should the nurse include in this review of the disorder?
A) OA cannot be successfully treated with any current therapy options.
B) OA is an inflammatory disease of the joints that may present symptoms at any age.
C) Joint degeneration with pain and disability occurs in the majority of people by the age of 60.
D) OA is more common with aging, but usually it remains confined to a few joints and does not cause crippling.
E) OA can be prevented from progressing when well controlled with a regimen of exercise, diet, and medication.
D) OA is more common with aging, but usually it remains confined to a few joints and does not cause crippling.
E) OA can be prevented from progressing when well controlled with a regimen of exercise, diet, and medication.
Osteoarthritis (OA) occurs with greater frequency with increasing age, but it usually remains confined to a few joints and can be managed with a combination of exercise, diet, and medication. OA can lead to significant disability.