Perioperative
A nurse is preparing to assist a physician with a procedure that requires the patient's consent. Which of the following actions by the nurse demonstrates an understanding of the informed consent process?
A) Explaining the benefits and risks of a procedure to a 14-year-old, then asking him to sign the consent form with a black pen
B) Asking a 62-year-old patient who is disoriented only to place and time to sign the consent
C) Having an interpreter available for the provider visit to obtain consent from a Spanish-speaking patient
D) Administering IV pain medication to the patient first so that they are comfortable, then having them sign the consent 15 mins later
C) Having an interpreter available for the provider visit to obtain consent from a Spanish speaking patient
Informed consent must be obtained in a way that the patient can understand, so it’s essential that language barriers do not impede this process. If the patient speaks a different language, a qualified interpreter should be used to ensure that the patient understands the procedure, risks, and alternatives fully before providing consent.
A patient who has been prescribed Ibuprofen for pain management following surgery, reports experiencing stomach discomfort and mild nausea. Which of the following actions should the nurse take?
A) Instruct the patient to take the medication on an empty stomach to increase absorption.
B) Advise the patient to stop taking the medication and report the symptoms to the healthcare provider.
C) Encourage the patient to take the medication with food or milk to reduce gastrointestinal irritation.
D) Recommend that the patient switch to acetaminophen, as it is less likely to cause gastrointestinal issues.
C) Encourage the patient to take the medication with food or milk to reduce gastrointestinal irritation.
NSAIDs like ibuprofen can irritate the stomach lining and lead to gastrointestinal discomfort, ulcers, or bleeding. To minimize this risk, the patient should be encouraged to take the medication with food or milk, which can help buffer the stomach lining and reduce irritation. Monitoring for more serious gastrointestinal symptoms should also be part of ongoing care.
A nurse is assessing a patient with a stage 3 pressure ulcer. The ulcer is characterized by a thick, dry, black necrotic tissue covering the wound bed. What is the appropriate nursing action for managing this type of tissue?
A) Debride the eschar immediately to promote healing of the wound.
B) Apply a dry sterile dressing to the wound and leave it undisturbed until the eschar falls off.
C) Apply a moist dressing and wait for the eschar to separate from the wound bed naturally.
D) Notify the healthcare provider to order a surgical consult for immediate excision of the eschar.
C) Apply a moist dressing and wait for the eschar to separate from the wound bed naturally.
Eschar, which is the dead tissue that forms over a wound, needs to be managed carefully. A moist dressing can facilitate autolytic debridement, a natural process where the body breaks down the necrotic tissue. The eschar may eventually separate from the wound bed without the need for immediate surgical intervention or aggressive debridement.
A nurse is preparing to administer sodium polystyrene sulfonate (Kayexalate) to a patient. Which of the following patient teaching points is most important for the nurse to include?
A) "You may experience diarrhea, which is a common side effect of this medication."
B) "You should take this medication with a high-potassium meal to enhance its effect."
C) "This medication was ordered due to your hyperphosphatemia."
D) "It’s important to monitor your blood sugar levels while on this medication."
A) "You may experience diarrhea, which is a common side effect of this medication."
Sodium polystyrene sulfonate (Kayexalate) works by binding to potassium in the gastrointestinal tract and promoting its excretion through the stool. A common side effect of this medication is diarrhea, which may occur as a result of the increased potassium excretion. The nurse should teach the patient about this potential side effect and advise them to report severe diarrhea or any signs of dehydration.
A nursing student is caring for a patient and identifies signs of phlebitis, including redness, warmth, and tenderness at the IV site. The nursing instructor observes the student’s assessment and identifies the need for additional teaching when the student states which of the following?
A) "I will apply a warm compress to the site to reduce inflammation and improve circulation."
B) "I will discontinue the IV line and document the findings in the patient’s chart."
C) "The IV flushes without resistance. I will continue the IV infusion at the current site to prevent further complications."
D) "I will monitor the patient for signs of systemic infection or blood clots."
C) "The IV flushes without resistance. I will continue the IV infusion at the current site to prevent further complications."
Phlebitis is inflammation of the vein, often caused by mechanical, chemical, or bacterial irritation. It is important to discontinue the IV to prevent further irritation and complications, such as infection or blood clots. Continuing the IV infusion at the same site is contraindicated because it may worsen the phlebitis and increase the risk of complications.
Before beginning a surgical procedure, the surgical team performs a "time-out". Which of the following actions should be included in this protocol?
A) Confirming the patient's identity, surgical site, and procedure to ensure correct patient safety
B) Asking the patient to sign a consent form again before the procedure starts
C) Asking the patient to confirm the time of the procedure for accuracy.
D) Ensuring the patient is properly positioned and covered for warmth
A) Confirming the patient's identity, surgical site, and procedure to ensure correct patient safety.
The "time-out" protocol is a critical safety step before any procedure to confirm the patient’s identity, the correct surgical site, and the planned procedure. This process helps prevent errors such as wrong-site surgery and ensures that everyone in the surgical team is on the same page regarding the procedure.
A nurse is caring for a postoperative patient in the recovery room who reports pain at a level of 7 out of 10. The nurse also observes an increased heart rate and blood pressure. Which of the following actions should the nurse take next?
A) Administer pain medication as ordered and reassess vital signs in 30 minutes.
B) Encourage the patient to deep breathe and relax, as pain is not the primary concern.
C) Request that the physician place an order for an IV blous and antihypertensive medication.
D) Notify the physician immediately due to the abnormal vital signs.
A) Administer pain medication as ordered and recheck the vital signs in 30 minutes.
Pain can cause an increase in heart rate and blood pressure due to the body’s stress response. The priority is to manage the patient's pain by administering pain medication as ordered and then reassessing vital signs in 30 minutes to see if the pain relief results in a decrease in the HR and BP. If the vital signs remain abnormal despite pain management, further evaluation may be required.
A nurse is caring for a patient with a chronic wound that has recently begun to heal. The nurse observes that the wound bed is now filled with pinkish, moist tissue with small blood vessels visible on the surface. What is the nurse's interpretation of this finding?
A) The wound is infected, and the nurse should notify the healthcare provider for immediate intervention.
B) Granulation tissue is forming, indicating the wound is in the proliferative phase of healing.
C) The wound has developed eschar, and the nurse should begin debridement immediately.
D) The wound is in the inflammatory phase of healing, and no further action is necessary at this time.
B) Granulation tissue is forming, indicating the wound is in the proliferative phase of healing.
Granulation tissue is an important part of the wound healing process, particularly in the proliferative phase. It is characterized by its pink, moist appearance, with visible blood vessels. This tissue is essential for filling the wound bed and helping to close the wound.
A nurse is caring for a patient with fluid volume deficit. Which of the following clinical findings would the nurse expect to assess in this patient?
A) Increased blood pressure, bounding pulses, and peripheral edema.
B) Decreased urine output, dry mucous membranes, and increased thirst.
C) Weight loss, crackles in the lungs, and jugular vein distention.
D) Warm, pink skin and bradycardia.
B) Decreased urine output, dry mucous membranes, and increased thirst.
In fluid volume deficit, the patient will typically exhibit signs such as decreased urine output, dry mucous membranes, and increased thirst due to the body's attempt to conserve water. Increased blood pressure and bounding pulses are more indicative of fluid volume excess, while crackles in the lungs and jugular vein distention are also signs of fluid overload. Warm skin and bradycardia would not typically be seen in dehydration.
A nurse is caring for a patient with a central venous catheter (CVC). Which of the following actions is MOST effective in preventing a CLABSI?
A) Changing the central line dressing every 72 hours, regardless of its condition
B) Using strict sterile technique during dressing changes
C) Administering prophylactic antibiotics prior to central line insertion
D) Encouraging the patient to ambulate frequently to reduce the risk of infection
B) Using strict sterile technique during dressing changes.
The most effective prevention strategy for CLABSI is the use of strict sterile technique during both catheter insertion and maintenance. This minimizes the risk of introducing pathogens during the procedure and while handling the catheter afterward. This includes aseptic dressing changes, sterile preparation of the insertion site, and careful handling of the catheter.
A patient has just been transferred to the PACU after surgery. Which of the following assessments should the nurse prioritize during the immediate postoperative period?
A) Monitoring the patient's blood glucose levels to prevent hypoglycemia
B) Assessing the patient's airway, breathing, and circulation to ensure stabilization
C) Checking the surgical site for signs of infection or delayed wound healing
D) Measuring the patient's pain level and administering pain medications as needed
B) Assessing the patient's airway, breathing, and circulation to ensure stabilization.
The priority in the immediate postoperative period in the PACU is to assess the patient's airway, breathing, and circulation to ensure they are stable and to prevent complications such as respiratory distress, hypoxia, or shock. While monitoring blood glucose, surgical site assessment, and pain management are important, ensuring the ABCs is the first and most crucial step in recovery from anesthesia.
A patient is brought into the emergency department with suspected opioid overdose. The nurse prepares to administer naloxone. Which of the following is the most important consideration when administering naloxone?
A) Naloxone should be administered slowly over a period of 30 minutes to avoid side effects.
B) The nurse should be prepared for the patient to experience withdrawal symptoms after administration.
C) Naloxone should be administered only if the patient’s respiratory rate drops below 10 breaths per minute.
D) The nurse should wait for the patient to regain consciousness before administering naloxone.
B) The nurse should be prepared for the patient to experience withdrawal symptoms after administration.
Naloxone is an opioid antagonist used to reverse the effects of opioid overdose, including respiratory depression. While naloxone can quickly reverse these effects, it may also precipitate withdrawal symptoms in patients who are dependent on opioids. The nurse should be prepared for signs of withdrawal, such as agitation, sweating, and nausea, after administration. It is important to administer naloxone as soon as respiratory depression is noted.
Which of the following best defines evisceration?
A) The partial opening of a surgical wound with underlying tissue visible.
B) The protrusion of internal organs, such as the intestines, through a surgical wound or injury.
C) An infection at the site of a surgical wound.
D) The formation of a blood clot in a surgical wound.
B) The protrusion of internal organs, such as the intestines, through a surgical wound or injury.
Evisceration refers to the protrusion of internal organs, especially the intestines, through an open surgical wound or injury. This is a serious medical emergency and requires immediate intervention to prevent further complications, such as infection or organ damage.
A nurse is assessing a patient who has recently been diagnosed with heart failure and has been receiving IV fluids. The patient’s vital signs include tachycardia, elevated BP, and crackles in the lungs. The nurse notes 2 kg of weight gain over the past 24 hours. Which of the following actions should the nurse prioritize to monitor the patient's fluid status?
A) Monitor the patient’s daily weight and urinary output.
B) Assess the patient’s skin turgor every 4 hours.
C) Encourage the patient to drink only 2 liters of water daily.
D) Perform a thorough cardiovascular assessment every 8 hours.
A) Monitor the patient’s daily weight and urinary output.
In patients with heart failure and fluid volume excess, daily weight and urinary output are the most reliable indicators of fluid retention. A weight gain of 2 kg in 24 hours is significant and suggests fluid overload. Monitoring urinary output is essential to assess kidney function and fluid elimination.
A nursing student is preparing to administer an IM injection of an irritating medication to a patient using the Z-track method. The instructor observes the student and identifies the need for additional teaching when the student states:
A) "I will displace the skin and tissue to the side before inserting the needle, and then release the skin after the injection to prevent medication leakage."
B) "I will insert the needle at a 90-degree angle to the skin."
C) "I will massage the site after the injection to promote absorption of the medication."
D) "I will use the Z-track technique to minimize tissue irritation and staining caused by the medication."
C) "I will massage the site after the injection to promote absorption of the medication."
The Z-track method is used for IM injections of irritating or staining medications to prevent medication leakage into the subcutaneous tissue and reduce the risk of skin irritation. Massaging the injection site after administering an IM injection is generally discouraged, especially when using the Z-track method, because it can cause irritation, discomfort, or medication leakage from the muscle.
A patient is scheduled for surgery, and their prothrombin time (PT) is found to be elevated. Which of the following actions should the nurse take before the patient undergoes the procedure?
A) Proceed with surgery as planned, since PT elevation is common and does not typically affect surgical outcomes.
B) Notify the surgeon and anesthesiologist about the elevated PT, as it may indicate a bleeding risk that requires further evaluation.
C) Ask the patient to take an extra dose of their anticoagulant medication to correct the PT before surgery.
D) Check the patient's medical chart and trend their PT over the past few months.
B) Notify the surgeon and anesthesiologist about the elevated PT, as it may indicate a bleeding risk that requires further evaluation.
An elevated prothrombin time indicates a potential risk for bleeding due to clotting abnormalities, which may complicate surgery. The nurse should immediately notify the surgeon and anesthesiologist to assess the patient's clotting status further and determine if any interventions, such as correcting the PT or delaying the procedure, are necessary.
A nurse is caring for a patient who has been prescribed oxycodone for pain management after surgery. Which of the following actions is most important to include in the nursing care plan for this patient?
A) Monitor the patient for signs of sedation, confusion, and respiratory depression.
B) Encourage the patient to take the medication on an empty stomach for maximum effect.
C) Advise the patient to stop taking the medication as soon as pain is reduced by 50%.
D) Instruct the patient to avoid drinking fluids to prevent nausea.
A) Monitor the patient for signs of sedation, confusion, and respiratory depression.
Oxycodone is an opioid analgesic that can cause side effects such as sedation, confusion, and respiratory depression, especially in high doses or in patients who are opioid-naive. It is crucial for the nurse to closely monitor these symptoms to prevent potentially life-threatening complications.
A nurse is preparing to obtain a wound culture from a patient with a suspected infection. Which of the following actions should the nurse take to ensure proper collection of the wound culture?
A) Use a sterile cotton swab to collect the sample from the wound's surface.
B) Clean the wound with an antiseptic solution before obtaining the sample.
C) Press the swab firmly into the wound to collect a deep tissue sample.
D) Collect the sample from the edges of the wound to avoid contamination.
A) Use a sterile cotton swab to collect the sample from the wound's surface.
It's important to avoid cleaning the wound with an antiseptic solution before taking the culture, as this could affect the accuracy of the test. The culture should be obtained from the wound's surface rather than deep tissue to identify any infection present at the wound site. Pressing the swab too firmly or collecting from the edges may introduce contaminants, which could interfere with the results.
A nurse is caring for a patient who is experiencing symptoms of hypocalcemia. The patient’s lab results show a calcium level of 7.2 mg/dL (normal range: 8.5-10.2 mg/dL). The nurse assesses the patient and elicits both a positive Chvostek’s sign and a positive Trousseau’s sign. Based on these findings, which of the following interventions should the nurse prioritize?
A) Administering IV calcium gluconate as prescribed.
B) Monitoring the patient’s cardiac rhythm and oxygen saturation.
C) Increase the patient’s oral calcium intake immediately and encourage the use of calcium-rich foods, but wait for the patient to stabilize before considering IV intervention.
D) Place the patient on continuous cardiac monitoring and prepare for possible mechanical ventilation to manage airway compromise from laryngospasm.
A) Administering intravenous calcium gluconate as prescribed.
Hypocalcemia can lead to neuromuscular irritability, as indicated by positive Chvostek’s and Trousseau’s signs. The most immediate concern in this situation is the risk of severe complications, such as seizures or cardiac arrhythmias, due to low calcium levels. Intravenous calcium gluconate is typically administered in acute cases of hypocalcemia to raise calcium levels quickly and stabilize the patient.
A nursing student is reviewing different types of vascular access devices in preparation for clinical practice. Which of the following statements made by the nursing student indicates a need for further teaching regarding the types of VADs?
A) "A midline catheter is typically used for short-term intravenous therapy, and it is inserted into a peripheral vein."
B) "A peripherally inserted central catheter (PICC) is ideal for long-term therapy and can be used for drawing blood, as it is inserted into a central vein."
C) "A portacath is used for short-term access and is best for patients who need frequent, long-term blood draws and medications."
D) "A central venous catheter (CVC) is inserted into a large central vein and is suitable for administering high-concentration medications like chemotherapy or TPN."
C) "A portacath is used for short-term access and is best for patients who need frequent, long-term blood draws and medications."
A portacath is a type of long-term vascular access device, typically used for patients who require frequent infusions or treatments such as chemotherapy. It is not used for short-term access. Portacaths are ideal for patients needing extended treatment and minimal maintenance.
A nurse is caring for a patient who is receiving Dantrolene after being diagnosed with malignant hyperthermia. Which of the following is the most important nursing action when administering Dantrolene?
A) Monitor the patient for signs of drowsiness or confusion.
B) Assess liver function before administering and during treatment.
C) Encourage the patient to drink plenty of fluids to prevent dehydration.
D) Administer the medication through an intravenous push over a period of 10 minutes.
B) Assess liver function before administering and during treatment.
Dantrolene can have serious side effects, particularly hepatotoxicity, so it is important to monitor liver function both before and during treatment. Elevated liver enzymes or signs of liver dysfunction should be closely observed.
A nurse is caring for a postoperative patient who is using a PCA pump. The patient is alert and oriented, but reports feeling mild discomfort. The nurse checks the PCA pump settings and finds that the dosage and lockout interval are set appropriately. Which of the following is the most appropriate action for the nurse to take?
A) Encourage the visitor to push the PCA pump button for the patient if the patient is unable to do so to help manage their pain.
B) Instruct the patient to limit PCA button usage to every 15 minutes to avoid overdose.
C) Assess the patient's pain level and check the last administered dose on the PCA pump.
D) Notify the healthcare provider to adjust the settings of the PCA pump, as it has already been 12 hours since the patient's procedure.
C) Assess the patient's pain level and check the last administered dose on the PCA pump
The nurse should always assess the patient's pain level and ensure that the PCA pump is delivering adequate pain relief. If the patient still reports pain despite using the PCA pump correctly, the nurse may need to adjust the settings (in consultation with the healthcare provider).
A nurse is caring for a postoperative patient with a surgical wound. The wound has been cleaned and dressed, and the nurse is preparing to manage the wound for the next 24 hours. Which of the following actions is most important to promote optimal healing and prevent infection?
A) Apply a dry dressing to the wound to keep it moisture-free.
B) Change the dressing routinely twice per shift, even if it does not appear soiled.
C) Use sterile technique when changing the dressing and assess the wound for signs of infection.
D) Massage the area around the wound to improve circulation, thus promoting healing.
C) Use sterile technique when changing the dressing and assess the wound for signs of infection.
To promote optimal healing and prevent infection, it is essential to use sterile technique when changing the dressing and to assess the wound for signs of infection. Dressing changes should be done according to the healthcare provider’s orders, which may vary depending on the type of wound and its healing progress. Frequent dressing changes are not necessary unless the dressing is soiled. Massaging the area around the wound is not recommended, as it could disrupt the healing process or cause additional injury.
A nurse is caring for a patient with hypercalcemia secondary to malignancy. The patient’s calcium level is 14.0 mg/dL (normal range: 8.5-10.2 mg/dL), and they are experiencing confusion, lethargy, and polyuria. The healthcare provider orders the following interventions: IV fluids, loop diuretics, bisphosphonates, and calcitonin. What is the nurse’s priority action in managing this patient’s hypercalcemia?
A) Administering IV NS to improve renal perfusion and facilitate calcium excretion.
B) Administering IV furosemide to increase calcium excretion through the kidneys.
C) Preparing for hemodialysis to rapidly remove excess calcium from the bloodstream.
D) Monitoring the patient for signs of hyperkalemia due to the administration of loop diuretics.
A) Administering IV normal saline to improve renal perfusion and facilitate calcium excretion.
In patients with hypercalcemia, especially when the cause is malignancy, IV hydration with NS is the priority intervention. This helps improve renal perfusion, which increases calcium excretion through the kidneys. Adequate hydration also prevents dehydration, which can worsen hypercalcemia.
A nurse is working in the ED and must prioritize care for four patients who have just arrived. Which patient should the nurse assess FIRST?
A) A 45-year-old male with a history of asthma who is experiencing shortness of breath and wheezing after exposure to an allergen.
B) A 68-year-old female with a history of hypertension, with an elevated blood pressure of 169/85 mmHg and blood glucose of 162.
C) A 59-year old female with a history of CHF and bilateral lower extremity edema.
D) A 51-year-old female who is complaining of abdominal pain and has a history of peptic ulcer disease.
A) A 45-year-old male with a history of asthma who is experiencing shortness of breath and wheezing after exposure to an allergen.
Airway and breathing are the priority here. Asthma exacerbations can lead to airway obstruction, which can be life-threatening if not treated promptly. Wheezing and shortness of breath indicate that the patient is struggling to breathe, so this patient should be seen first to administer the appropriate medications, secure the airway and prevent respiratory failure.