NUR 110 Final
- The nurse is caring for a client postoperatively. The vital signs are blood pressure 88/50
mm Hg, heart rate 110 beats/min, respiratory rate 24 breaths/min. The client stated the pain in the abdomen will not stop. The abdominal dressing is saturated with fresh blood. Along with notifying the surgeon, what is the nurse's priority in this situation? A female client age 54 years has been scheduled for a bunionectomy (removal of bone tissue from the base of the great toe) which will be conducted on an ambulatory basis. Which characteristic applies to this type of surgery?
Answer The client will be admitted the day of surgery and return home the same day.
- Which client most likely requires special preoperative assessment and treatment as a result
of the existing medication regimen?
Answer a woman who takes daily anticoagulants to treat atrial fibrillation
- Which surgical clients will return to activities in their everyday lives more quickly?
Answer Laparoscopic cholecystectomy
- A nurse preparing an older adult client for hip replacement surgery is aware of the surgical
risks related to the client's age. Which of the following accurately describes these risks? Select all that apply.
Answer decreased peripheral circulation
increased vascular rigidity decreased thermoregulation ability
- The healthy adult client is given a narcotic prior to a surgical procedure. The nurse is
completing the chart and notices the consent form was not signed by the client. Which of the following should the nurse do first?
Answer Notify the physician of the oversight. 1 / 2
- The recovery nurse is caring for a surgical client in the PACU. The client's blood pressure is
dropping and the heart rate is increasing. The nurse suspects the client is
Answer developing shock.
- A nurse is employed in an operative setting. Which of these roles is within the registered
nurse (RN) scope of practice? Select all that apply.
Answer counting sponges before and after surgery
monitoring the client's vital signs positioning the client on the operating table
- A client has arrived to the postanesthesia care unit (PACU) and is drowsy with a respiratory
rate of 12 breaths per minute. What would be an accurate interpretation by the nurse?
Answer This is an expected finding in the immediate postoperative period.
- he nurse is preparing a client for surgery and asks if the client has an advance directive. The
client asks "What is an advance directive?" What is the nurse's best response to this?
Answer "An advance directive will communicate your wishes for health care postoperatively in case you are unable to do so."
- Which nursing action should the PACU nurse take to prevent postoperative complications in
clients?
Answer Assist the client to do leg exercises to increase venous return.
- A nurse caring for clients in a PACU assesses a client who is displaying signs and
symptoms of shock. What is the priority nursing intervention for this client?
Answer Place the client in a flat position with legs elevated 45 degrees.
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