MED-SURG II HESI TEST BANK ACTUAL EXAM 350
QUESTIONS AND CORRECT DETAILED ANSWERS WITH
RATIONALES (VERIFIED ANSWERS) |AGRADE
risk factors for surgery - ANSWER: -age: old & young
-nutrition: obese & malnourished
-fluid & electrolyte status: dehydration & hypovolemia
-general health: infections or pathology
what general health condition would be a reason to delay surgery? - ANSWER:
current upper respiratory infection
what medications can increase surgical risks? - ANSWER: -anticoagulants
-tranquilizers (hypotension)
-heroin (CNS depression)
-antibiotics
-diuretics
-steroids
-OTC/herbs
-Vitamin E
what post operative plans should a nurse include in her pre-operative teaching? -
ANSWER: -respiratory care: ventilator? incentive spirometer?
-activity: ROM? early ambulation?
-pain control: PCA? IM meds?
-dietary restrictions
-ICU or PACU orientation
when is it appropriate for the nurse to mark the operative site on the patient? -
ANSWER: -right or left distinctions
-multiple structures: fingers/toes
-levels: spinal procedures
what assessments are made immediately of the patient arrival in the PACU? -
ANSWER: -vitals
-level of consciousness
-skin color & condition
-dressing location & condition
-IV fluids
-drainage tubes
-position
-o2 sat levels
when is a client moved from the PACU to the floor/unit? - ANSWER: when the client
is stabilized
,what should be monitored in the immediate post-operative period? - ANSWER:
monitor for signs of shock & hemorrhage
-hypotension
-narrow pulse pressure
-rapid weak pulse
-cold moist skin
-increased capillary filling time
what are some post-operative nursing interventions? - ANSWER: -position client on
side to prevent aspiration
-keep warm - heated blanket
-anti-emetics & NG suctioning for N/V
-analgesics for pain
post-op complications: urinary retention - ANSWER: -occurs 8-12 hrs post op
-monitor hydration status
-encourage oral intake
-offer bedpan or assist to commode
post-op complications: pulmonary probs - ANSWER: -atelectasis, pneumonia,
embolus
-occurs 1-2 days post op
-assist pt to TCDB
-keep hydrated
-enable early ambulation
-provide incentive spirometer
post-op complications: wound healing probs - ANSWER: -occurs 5-6 days post op
-splint incision when coughing
-monitor for s/s of infection, malnutrition, dehydration
-provide high protein diet
wound dehiscence - ANSWER: the separation of the wound edges that is more likely
to occur with vertical incisions
wound evisceration - ANSWER: the protrusion of intestinal contents more likely to
occur in older, diabetic, obese, malnourished, or prolonged paralytic ileus pts
post-op complications: UTI's - ANSWER: -occurs 5-8 days post op
-oral fluid intake
-empty bladder q 4-6 hrs
-monitor I & O's
-avoid catheterization if possible
post-op complications: thrombophlebitis - ANSWER: -occurs 5-8 days post op
-leg exercises q 8 hrs while in bed
-early ambuation
,-TED hose or sequential compression devices
-DO NOT raise knee gatch on bed
-DO NOT place pillows beneath knees
-no crossing legs at knees
-low-dose heparin
post-op complications: decreased GI peristalsis - ANSWER: -constipation & paralytic
ileus
-occurs 2-4 days post op
-NG tube: decompression
-limit use of narcotic analgesics (dec peristalsis)
-early ambulation
why do we prep the bowels before a surgery involving the intestinal tract? -
ANSWER: -to decrease the bacterial count w/in the intestinal tract
-to empty the intestine of stool
-ultimately: to help reduce the risk of infection in the postoperative period
roles of the circulating nurse - ANSWER: -pt advocate
-obtains necessary supplies for the procedure
-ensures diagnostic studies & bld products are available
-prepares OR table
-positions the pt (pads bony prominences prn)
-cleanses skin in operative area before positioning surgical drapes
-assists other team members into gowns & gloves
roles of the scrub nurse - ANSWER: -sets up the sterile field
-assists w/ draping the pt
-hands sterile supplies into the operative field & takes used instruments from the
surgeon
roles of holding area nurse - ANSWER: -cares for/manages the pts who have been
brought into the OR suite but are not yet ready to go into the actual OR
-helps transport & transfer pts
how must a patient be positioned after a procedure that used spinal anesthesia? -
ANSWER: the pt must remain FLAT to avoid leakage of CSF from the puncture site
describe priority of assessments in the PACU - ANSWER: -initial: ABC's (airway,
breathing, circulation); watch for stridor from edema or bronchospasms
-next: CV status
-vitals q 15 min until stable
-neuro: level of consciousness
-GI: n/v
-labs
, what are some major CV post-op complications? - ANSWER: -MI: elevated troponin
levels, ST elevation or T wave inversion for ischemia
-arrhythmias
-hypotension (orthostatic)
-DVT: clots on ultasound
what are some major respiratory post-op complications? - ANSWER: -atelectasis
(CXR shows collapsed area)
-pneumonia (CXR shows area of infiltration)
-pulmonary embolism (CXR shows wedge infiltrate)
what are some major GI post-op complications? - ANSWER: -N/V
-constipation (x-ray shows stool; slow/dec bowel sounds)
-paralytic ileus (x-ray shows gas in intestines; absent bowel sounds)
what are the s/s of malignant hyperthermia? - ANSWER: -tachycardia, tachypnea
-cyanosis
-fever
-muscle rigidity
-diaphoresis
-mottled skin
-hypotension
-dec UOP
-cardiac arrest
what is the earliest sign of malignant hyperthermia? - ANSWER: tachycardia
when should the nurse expect malignant hyperthermia to occur in the peri-operative
period? - ANSWER: -10-20 after anesthesia started
-first 24 hrs post-op
what are the s/s of hypovolemic shock? - ANSWER: -pallor
-rapid weak thready pulse
-low BP
-rapid breathing
how far in advance should a patient stop taking aspirin before surgery? - ANSWER: 7-
10 days
why is NPO status so important prior to surgery? - ANSWER: to avoid aspiration
s/s of IV infiltration - ANSWER: -edema, discomfort/pain, redness, coolness at site,
leakage
s/s of extravasation of IV - ANSWER: -inflammation, blistering, & necrosis at site
QUESTIONS AND CORRECT DETAILED ANSWERS WITH
RATIONALES (VERIFIED ANSWERS) |AGRADE
risk factors for surgery - ANSWER: -age: old & young
-nutrition: obese & malnourished
-fluid & electrolyte status: dehydration & hypovolemia
-general health: infections or pathology
what general health condition would be a reason to delay surgery? - ANSWER:
current upper respiratory infection
what medications can increase surgical risks? - ANSWER: -anticoagulants
-tranquilizers (hypotension)
-heroin (CNS depression)
-antibiotics
-diuretics
-steroids
-OTC/herbs
-Vitamin E
what post operative plans should a nurse include in her pre-operative teaching? -
ANSWER: -respiratory care: ventilator? incentive spirometer?
-activity: ROM? early ambulation?
-pain control: PCA? IM meds?
-dietary restrictions
-ICU or PACU orientation
when is it appropriate for the nurse to mark the operative site on the patient? -
ANSWER: -right or left distinctions
-multiple structures: fingers/toes
-levels: spinal procedures
what assessments are made immediately of the patient arrival in the PACU? -
ANSWER: -vitals
-level of consciousness
-skin color & condition
-dressing location & condition
-IV fluids
-drainage tubes
-position
-o2 sat levels
when is a client moved from the PACU to the floor/unit? - ANSWER: when the client
is stabilized
,what should be monitored in the immediate post-operative period? - ANSWER:
monitor for signs of shock & hemorrhage
-hypotension
-narrow pulse pressure
-rapid weak pulse
-cold moist skin
-increased capillary filling time
what are some post-operative nursing interventions? - ANSWER: -position client on
side to prevent aspiration
-keep warm - heated blanket
-anti-emetics & NG suctioning for N/V
-analgesics for pain
post-op complications: urinary retention - ANSWER: -occurs 8-12 hrs post op
-monitor hydration status
-encourage oral intake
-offer bedpan or assist to commode
post-op complications: pulmonary probs - ANSWER: -atelectasis, pneumonia,
embolus
-occurs 1-2 days post op
-assist pt to TCDB
-keep hydrated
-enable early ambulation
-provide incentive spirometer
post-op complications: wound healing probs - ANSWER: -occurs 5-6 days post op
-splint incision when coughing
-monitor for s/s of infection, malnutrition, dehydration
-provide high protein diet
wound dehiscence - ANSWER: the separation of the wound edges that is more likely
to occur with vertical incisions
wound evisceration - ANSWER: the protrusion of intestinal contents more likely to
occur in older, diabetic, obese, malnourished, or prolonged paralytic ileus pts
post-op complications: UTI's - ANSWER: -occurs 5-8 days post op
-oral fluid intake
-empty bladder q 4-6 hrs
-monitor I & O's
-avoid catheterization if possible
post-op complications: thrombophlebitis - ANSWER: -occurs 5-8 days post op
-leg exercises q 8 hrs while in bed
-early ambuation
,-TED hose or sequential compression devices
-DO NOT raise knee gatch on bed
-DO NOT place pillows beneath knees
-no crossing legs at knees
-low-dose heparin
post-op complications: decreased GI peristalsis - ANSWER: -constipation & paralytic
ileus
-occurs 2-4 days post op
-NG tube: decompression
-limit use of narcotic analgesics (dec peristalsis)
-early ambulation
why do we prep the bowels before a surgery involving the intestinal tract? -
ANSWER: -to decrease the bacterial count w/in the intestinal tract
-to empty the intestine of stool
-ultimately: to help reduce the risk of infection in the postoperative period
roles of the circulating nurse - ANSWER: -pt advocate
-obtains necessary supplies for the procedure
-ensures diagnostic studies & bld products are available
-prepares OR table
-positions the pt (pads bony prominences prn)
-cleanses skin in operative area before positioning surgical drapes
-assists other team members into gowns & gloves
roles of the scrub nurse - ANSWER: -sets up the sterile field
-assists w/ draping the pt
-hands sterile supplies into the operative field & takes used instruments from the
surgeon
roles of holding area nurse - ANSWER: -cares for/manages the pts who have been
brought into the OR suite but are not yet ready to go into the actual OR
-helps transport & transfer pts
how must a patient be positioned after a procedure that used spinal anesthesia? -
ANSWER: the pt must remain FLAT to avoid leakage of CSF from the puncture site
describe priority of assessments in the PACU - ANSWER: -initial: ABC's (airway,
breathing, circulation); watch for stridor from edema or bronchospasms
-next: CV status
-vitals q 15 min until stable
-neuro: level of consciousness
-GI: n/v
-labs
, what are some major CV post-op complications? - ANSWER: -MI: elevated troponin
levels, ST elevation or T wave inversion for ischemia
-arrhythmias
-hypotension (orthostatic)
-DVT: clots on ultasound
what are some major respiratory post-op complications? - ANSWER: -atelectasis
(CXR shows collapsed area)
-pneumonia (CXR shows area of infiltration)
-pulmonary embolism (CXR shows wedge infiltrate)
what are some major GI post-op complications? - ANSWER: -N/V
-constipation (x-ray shows stool; slow/dec bowel sounds)
-paralytic ileus (x-ray shows gas in intestines; absent bowel sounds)
what are the s/s of malignant hyperthermia? - ANSWER: -tachycardia, tachypnea
-cyanosis
-fever
-muscle rigidity
-diaphoresis
-mottled skin
-hypotension
-dec UOP
-cardiac arrest
what is the earliest sign of malignant hyperthermia? - ANSWER: tachycardia
when should the nurse expect malignant hyperthermia to occur in the peri-operative
period? - ANSWER: -10-20 after anesthesia started
-first 24 hrs post-op
what are the s/s of hypovolemic shock? - ANSWER: -pallor
-rapid weak thready pulse
-low BP
-rapid breathing
how far in advance should a patient stop taking aspirin before surgery? - ANSWER: 7-
10 days
why is NPO status so important prior to surgery? - ANSWER: to avoid aspiration
s/s of IV infiltration - ANSWER: -edema, discomfort/pain, redness, coolness at site,
leakage
s/s of extravasation of IV - ANSWER: -inflammation, blistering, & necrosis at site
