Comprehensive Review CD Questions

Comprehensive Review CD Questions {AQ question: 1624, 1631 (Note to developer: the student will need to use a drag and drop feature to answer Question 1631 and list the nursing actions in order of priority. The correct order of action is provided in the answer.); formula: 1624} 1601. A client returns from the recovery room following an abdominal surgical procedure. Following the arrival of the client to the nursing unit, the initial nursing action is to assess the: 1. Abdominal dressing 2. Urinary output in the Foley bag 3. Intravenous (IV) solution for accurate flow rate 4. Vital signs Answer: 4 Rationale: The initial nursing action is to assess the client’s vital signs. The vital signs will provide information regarding airway, breathing, and the circulatory status of the client. Additionally, this data provides a baseline for further assessments. The abdominal dressing, IV, and urine output are also components of the assessment, and these assessments would follow the assessment of the vital signs. Test-Taking Strategy: Use the principles of prioritization when answering this question. Use the ABCs—airway, breathing, and circulation. Vital signs provide data regarding airway, breathing, and circulation. Options 1, 2, and 3 are all nursing actions that should be performed after vital signs. Review care to the postoperative client if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Delegating/Prioritizing References: Christensen, B., & Kockrow, E. (2003). Adult health nursing (4th ed.). St. Louis: Mosby, p. 50. Perry, A., & Potter, P. (2004). Clinical nursing skills & techniques (5th ed.). St. Louis: Mosby, p. 1631. 1602. A nurse is changing the abdominal dressing on a client following a suprapubic prostatectomy. A Penrose drain is in place in the abdominal wound. Which nursing action would be appropriate during the dressing change? 1. Wearing clean gloves during the procedure 1 PN~CD~Questions~ - - 2. Advancing the drain by ¼ inch 3. Checking the wound site for drainage from the drain 4. Securing the drain by taping it firmly to body Answer: 3 Rationale: Usually the drainage from the wound is pale, red, and watery. Active bleeding will be bright red in color. Aseptic technique must be used when changing the dressing to prevent contamination of the wound, and sterile gloves are worn. The drain should be checked for patency to provide an exit for the fluid and blood to promote healing. The drainage needs to flow freely, and there should be no kinks in the drains. Curling, folding, or taping the drain prevents the flow of the drainage. The tube is not advanced. Test-Taking Strategy: Knowledge of the care of drains is necessary to answer this question. Read each option carefully and visualize each option. Note that option 3 is the only option that is a data collection action, the first step in the nursing process. Review nursing care to the client with a Penrose drain if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Fundamental Skills References: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed.). Philadelphia: W. B. Saunders, p. 350. Potter, P., & Perry, A. (2005). Fundamentals of nursing (6th ed.). St. Louis: Mosby, p. 1507. 1603. A nurse is assisting in caring for a client immediately following an abdominal surgical procedure who lost a significant amount of blood during surgery. Which finding would indicate a sign of a potential complication? 1. Absent bowel signs 2. A pulse rate of 90 beats/min 3. A blood pressure of 120/70 mm Hg 4. Increasing restlessness Answer: 4 Rationale: Increasing restlessness noted in a client is a sign that requires continuous and close monitoring because it could be indicative of a potential indication of a complication, such as shock. Absent bowel sounds are a normal occurrence in the immediate postoperative period following abdominal surgery. A blood pressure of 120/70 mm Hg with a pulse of 90 beats/min is a relatively normal sign. Test-Taking Strategy: Note the key words immediately, abdominal, and lost a significant amount of blood. Eliminate options 1, 2, and 3 because these are normal expected findings. If you had difficulty with this question, review the normal expected postoperative findings and the signs and symptoms of postoperative complications. Level of Cognitive Ability: Analysis Client Needs: Physiological Integrity Integrated Process: Nursing Process/Data Collection Content Area: Fundamental Skills References: Harkreader, H., & Hogan, M.A. (2004). Fundamentals of nursing: Caring 2 PN~CD~Questions~ - - and clinical judgment (2nd ed.). Philadelphia: W.B. Saunders, p. 906. Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed.). Philadelphia: W.B. Saunders, p. 346. Perry, A., & Potter, P. (2004). Clinical nursing skills & techniques (5th ed.). St. Louis: Mosby, p. 982. Potter, P., & Perry, A. (2005). Fundamentals of nursing (6th ed.). St. Louis: Mosby, p. 1642. 1604. A nurse is changing the abdominal dressing on a postoperative client following abdominal surgery. The nurse notes that the incision line is separated and notes the appearance of underlying tissue. Wound dehiscence is suspected. Which of the following is the appropriate initial nursing action? 1. Ask the client to cough to verify the presence of dehiscence 2. Apply a sterile dressing soaked with sterile normal saline to the wound 3. Leave the incision open to the air 4. Apply a dry sterile dressing to the wound Answer: 2 Rationale: Wound dehiscence is the separation of wound edges at the suture line. Signs and symptoms include increased drainage and the appearance of underlying tissue. It usually occurs 6 to 8 days after surgery. The client should be instructed to remain quiet and to avoid coughing or straining. The client should be positioned to prevent further stress on the wound. Sterile dressings soaked with sterile normal saline should be used to cover the wound. The physician needs to be notified. Test-Taking Strategy: Use the process of elimination. Eliminate option 1 because coughing will disrupt the exposed underlying tissue and organs. Eliminate option 3 because this action would expose the open wound and underlying tissue to infection. Eliminate option 4 next. A dry dressing will irritate the exposed body tissue. Review emergency care when dehiscence or evisceration occurs, if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Fundamental Skills References: Harkreader, H., & Hogan, M.A. (2004). Fundamentals of nursing: Caring and clinical judgment (2nd ed.). Philadelphia: W.B. Saunders, pp. 621-622. Potter, P., & Perry, A. (2005). Fundamentals of nursing (6th ed.). St. Louis: Mosby, pp. . 1605. A nurse is preparing a client for surgery. Which of the following would be a component of the plan of care? 1. Review the results of the preoperative laboratory studies 2. Report any increases in blood pressure on the day of surgery 3. Verify that the client has remained NPO for 24 hours before surgery 4. Instruct the client to avoid oral hygiene on the morning of surgery Answer: 1 Rationale: The nurse needs to review the results of the preoperative laboratory studies 3 PN~CD~Questions~ - - and the physician is notified if any abnormal results are present. Some increase in both blood pressure and pulse is common because of client anxiety regarding surgery. The client usually has a restriction of food and fluids for 8 hours before surgery instead of 24 hours. Oral hygiene is allowed, but the client should not swallow any water. Test-Taking Strategy: Read the options carefully and use the process of elimination to answer the question. Recalling that surgery can produce anxiety in the client will assist in eliminating option 2. Option 4 can be eliminated because there is no reason to avoid oral hygiene as long as the client does not swallow any water. Careful reading of option 3 will assist in eliminating this option and direct you to option 1. Review general preoperative care if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Physiological Integrity Integrated Process: Nursing Process/Planning Content Area: Fundamental Skills References: Perry, A., & Potter, P. (2004). Clinical nursing skills & techniques (5th ed.). St. Louis: Mosby, p. 964. Potter, P., & Perry, A. (2005). Fundamentals of nursing (6th ed.). St. Louis: Mosby, p. 1606. 1606. A client with arthritis is scheduled for a surgical knee joint replacement. The client will be admitted to the hospital on the day of the surgical procedure, and the nurse is reinforcing instructions to the client regarding preparation for the surgical procedure. Which statement by the client indicates an understanding of the preoperative instructions? 1. “I cannot drink or eat anything after midnight on the night before surgery.” 2. “My last dose of prescribed acetylsalicylic acid (aspirin) should be taken the evening before surgery.” 3. “I need to stop taking my prescribed prednisone (Deltasone) 48 hours before the scheduled surgery.” 4. “I need to discontinue my prescribed knee exercises at least 1 week before surgery.” Answer: 1 Rationale: Antiplatelet medications, such as acetylsalicylic acid, alter normal clotting factors and increase the risk of hemorrhage. Acetylsalicylic acid has properties that can alter the clotting mechanism and should be discontinued at least 48 hours before surgery. Prednisone, a corticosteroid, should not be abruptly discontinued. In fact it may be necessary to provide additional doses of the corticosteroid before situations that are stressful, such as surgery. There is no reason to discontinue prescribed exercises, and discontinuing exercises in this client may be harmful. The client should be instructed to maintain an NPO status in preparation for surgery. Test-Taking Strategy: Use the process of elimination and eliminate option 4 first because discontinuing exercises can be harmful to the client. Knowledge regarding the medications that affect the surgical client will assist in eliminating options 2 and 3. General principles related to preparing a client for surgery will direct you to option 1. If you had difficulty with this question, review medications that affect the client preparing for surgery and the specific p