MS2 Chapter 9 Lewis Flashcards

An older client is hospitalized after an operation. When assessing the client for postoperative infection, the nurse places priority on which assessment?

A preoperative nurse is assessing a client prior to surgery. Which information would be most important for the nurse to relay to the surgical team?

A nurse works on the postoperative floor and has four clients who are being discharged tomorrow. Which one has the greatest need for the nurse to consult other members of the health care team for post-discharge care?

A clinic nurse is teaching a client prior to surgery. The client does not seem to comprehend the teaching, forgets a lot of what is said, and asks the same questions again and again. What action by the nurse is best?

A preoperative nurse is reviewing morning laboratory values on four clients waiting for surgery. Which result warrants immediate communication with the surgical team?

An inpatient nurse brings an informed consent form to a client for an operation scheduled for tomorrow. The client asks about possible complications from the operation. What response by the nurse is best?

A client has a great deal of pain when coughing and deep breathing after abdominal surgery despite having pain medication. What action by the nurse is best?

A nurse is giving a client instructions for showering with special antimicrobial soap the night before surgery. What instruction is most appropriate?

A postoperative client has an abdominal drain. What assessment by the nurse indicates that goals for the priority client problems related to the drain are being met?

A client waiting for surgery is very anxious. What intervention can the nurse delegate to the unlicensed assistive personnel (UAP)?

A client who collapsed during dinner in a restaurant arrives in the emergency department. The client is going to surgery to repair an abdominal aortic aneurysm. What medication does the nurse prepare to administer

A client in the preoperative holding room has received sedation and now needs to urinate. What action by the nurse is best?

A student is caring for clients in the preoperative area. The nurse contacts the surgeon about a client whose heart rate is 120 beats/min. After consulting with the surgeon, the nurse administers a beta blocker to the client. The student asks why this was needed. What response by the nurse is best?

The perioperative nurse manager and the postoperative unit manager are concerned about the increasing number of surgical infections in their hospital. What action by the managers is best?

A nurse assesses a client in the preoperative holding area and finds brittle nails and hair, dry skin turgor, and muscle wasting. What action by the nurse is best?

A nurse is concerned that a preoperative client has a great deal of anxiety about the upcoming procedure. What action by the nurse is best?

A client has been given hydroxyzine (Atarax) in the preoperative holding area. What action by the nurse is most important for this client?

A client is on the phone when the nurse brings a preoperative antibiotic before scheduled surgery. The circulating nurse has requested the antibiotic be started. The client wants the nurse to wait before starting it. What response by the nurse is most appropriate?

A nurse is giving a preoperative client a dose of ranitidine (Zantac). The client asks why the nurse is giving this drug when the client has no history of ulcers. What response by the nurse is best?

A new perioperative nurse is receiving orientation to the surgical area and learns about the Surgical Care Improvement Project (SCIP) goals. What major areas do these measures focus on preventing? (Select all that apply.)

A nursing instructor is teaching students about different surgical procedures and their classifications. Which examples does the instructor include? (Select all that apply.)

A nurse is caring for several clients prior to surgery. Which medications taken by the clients require the nurse to consult with the physician about their administration? (Select all that apply.)

A nurse recently hired to the preoperative area learns that certain clients are at higher risk for venous thromboembolism (VTE). Which clients are considered at high risk? (Select all that apply.)

A student nurse is caring for clients on the postoperative unit. The student asks the registered nurse why malnutrition can lead to poor surgical outcomes. What responses by the nurse are best? (Select all that apply.)

A student nurse asks why older adults are at higher risk for complications after surgery. What reasons does the registered nurse give? (Select all that apply.)

A client is clearly uncomfortable and anxious in the preoperative holding room waiting for emergent abdominal surgery. What actions can the nurse perform to increase comfort? (Select all that apply.)

A nurse working in the preoperative holding area performs which functions to ensure client safety? (Select all that apply.)

The circulating nurse is plugging in a piece of equipment and notes that the cord is frayed. What action by the nurse is best?

The circulating nurse and preoperative nurse are reviewing the chart of a client scheduled for minimally invasive surgery (MIS). What information on the chart needs to be reported to the surgeon as a priority?

A client is having robotic surgery. The circulating nurse observes the instruments being inserted, then the surgeon appears to break scrub when going to the console and sitting down. What action by the nurse is best?

The circulating nurse is in the operating room and sees the surgeon don gown and gloves using appropriate sterile procedure. The surgeon then folds the hands together and places them down below the hips. What action by the nurse is most appropriate?

A client is in stage 2 of general anesthesia. What action by the nurse is most important?

A client is having surgery. The circulating nurse notes the clients oxygen saturation is 90% and the heart rate is 110 beats/min. What action by the nurse is best?

A nurse is monitoring a client after moderate sedation. The nurse documents the clients Ramsay Sedation Scale (RSS) score at 3. What action by the nurse is best?

A client is scheduled for a below-the-knee amputation. The circulating nurse ensures the proper side is marked prior to the start of surgery. What action by the nurse is most appropriate?

A client has received intravenous anesthesia during an operation. What action by the postanesthesia care nurse is most important

A circulating nurse has transferred an older client to the operating room. What action by the nurse is most important for this client?

A circulating nurse wishes to provide emotional support to a client who was just transferred to the operating room. What action by the nurse would be best?

A client in the operating room has developed malignant hyperthermia. The clients potassium is 6.5 mEq/L. What action by the nurse takes priority?

A student nurse observing in the operating room notes that the functions of the Certified Registered Nurse First Assistant (CRNFA) include which activities? (Select all that apply.)

The nursing student observing in the perioperative area notes the unique functions of the circulating nurse, which include which roles? (Select all that apply.)

The circulating nurse reviews the days schedule and notes clients who are at higher risk of anesthetic overdose and other anesthesia-related complications. Which clients does this include? (Select all that apply.)

A client is having shoulder surgery with regional anesthesia. What actions by the nurse are most important to enhance client safety related to this anesthesia? (Select all that apply.)

What actions by the circulating nurse are important to promote client comfort? (Select all that apply.)

A client has arrived in the postoperative unit. What action by the circulating nurse takes priority?

The postanesthesia care unit (PACU) charge nurse notes vital signs on four postoperative clients. Which client should the nurse assess first?

A postoperative nurse is caring for a client whose oxygen saturation dropped from 98% to 95%. What action by the nurse is most appropriate?

Ten hours after surgery, a postoperative client reports that the anti-embolism stockings and sequential compression devices itch and are too hot. The client asks the nurse to remove them. What response by the nurse is best?

A client had a surgical procedure with spinal anesthesia. The nurse raises the head of the clients bed. The clients blood pressure changes from 122/78 mm Hg to 102/50 mm Hg. What action by the nurse is best?

A postoperative client vomited. After cleaning and comforting the client, which action by the nurse is most important?

A postoperative client has just been admitted to the postanesthesia care unit (PACU). What assessment by the PACU nurse takes priority?

A postoperative client has respiratory depression after receiving midazolam (Versed) for sedation. Which IV-push medication and dose does the nurse prepare to administer?

A nurse is caring for a postoperative client who reports discomfort, but denies serious pain and does not want medication. What action by the nurse is best to promote comfort?

A nurse is preparing a client for discharge after surgery. The client needs to change a large dressing and manage a drain at home. What instruction by the nurse is most important?

An older adult has been transferred to the postoperative inpatient unit after surgery. The family is concerned that the client is not waking up quickly and states She needs to get back to her old self! What response by the nurse is best?

A nurse answers a call light on the postoperative nursing unit. The client states there was a sudden gush of blood from the incision, and the nurse sees a blood spot on the sheet. What action should the nurse take first?

A client on the postoperative nursing unit has a blood pressure of 156/98 mm Hg, pulse 140 beats/min, and respirations of 24 breaths/min. The client denies pain, has normal hemoglobin, hematocrit, and oxygen saturation, and shows no signs of infection. What should the nurse assess next?

A registered nurse (RN) is watching a nursing student change a dressing and perform care around a Penrose drain. What action by the student warrants intervention by the RN?

A nurse orienting to the postoperative area learns which principles about the postoperative period? (Select all that apply.)

A postanesthesia care unit (PACU) nurse is assessing a postoperative client with a nasogagastric (NG) tube. What laboratory values would warrant intervention by the nurse? (Select all that apply.)

A nurse is admitting an older client for surgery to the inpatient surgical unit. The client relates a prior history of acute confusion after a previous operation. What interventions does the nurse include on the clients plan of care to minimize the potential for this occurring? (Select all that apply.)

A postoperative client is being discharged with a prescription for oxycodone hydrochloride with acetaminophen (Percocet). What instructions does the nurse give the client? (Select all that apply.)

A client is experiencing pain after leg surgery but cannot yet have more pain medication. What comfort interventions can the nurse provide? (Select all that apply.)

A nurse on the postoperative nursing unit provides care to reduce the incidence of surgical wound infection. What actions are best to achieve this goal? (Select all that apply.)