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A nurse is caring for a client who is post-op and has a
Jackson-Pratt drain in place. Which of the following
interventions should the nurse use to ensure proper
functioning of the drain?a. secure the drain to the client's bed
sheetb. clamp the drain when the client is ambulatingc. empty
and compress the drain reservoir as needed d. keep the drain
higher than the surgical incision -
ANSWER-c
A nurse is providing teaching for a client who is scheduled to
undergo moderate
(conscious) sedation for a bronchoscopy. The nurse should
verify that the client
understands the procedure when the client states which of the
following?a. "I
will need to complete a bowel prep the day before the
procedure."b. "I will drink
plenty of fluids the morning of the procedure."c. "I can eat
as soon as the
,procedure is over."d. "I can expect to feel sleepy for several
hours after the
procedure." -
ANSWER-d
A nurse is taking a preoperative medication history on a client
who is scheduled for surgery. Which of the following
medications should the nurse recognize as placing the client at
risk for complications due to interaction with anesthetic
agents?a. captopril
lb. atorvastatinc. ranitidined. ciprofloxacin - ANSWER-a
A nurse is caring for a client who is post-op following
abdominal surgery. Which of the following nursing
interventions should the nurse perform to prevent respiratory
complications?a. instruct the client to exhale into incentive
spirometer ever 1-2 hrb. minimize amount of pain med the
client receives to prevent sedationc. advise the client to splint
the surgical incision when coughing and deep breathing
d. reposition the client every 8 hours for the first 48 hours -
ANSWER-c
A nurse is providing preoperative teaching for a client who is
scheduled for a mastestomy. Which of the following statements
by the client indicated a need for further teaching?a. "I should
wait 3-4 weeks after surgery to do water aerobics."b. "Ill wait
until a week after surgery to start hand strengthening
exercises."c. I should avoid having blood from the arm on the
,side I had my mastectomy."D. "ill be able to shower after the
doctor moves the drain." -
ANSWER-b
A nurse is providing teaching for a client who is in the
immediate post-op period and has a PCA pump. Which of the
following statements should the nurse include in the
teaching?a. "You will receive a dose of medication every time
you push the button."b. "do not allow your family to push the
PCA button if you are sleeping."C. " you cannot receive too
much medication by pushing the button."d. "Do not push the
PCA button until your pain reached a severe level" -
ANSWER-b
A nurse is assessing a client in the PACU to determine if he is
ready for discharge. Which of the following assessment
findings indicated that the client is ready for discharge?a. the
clients pre-op BP was 140/90 mmHg and her postop BP is
100/65 mmHgb. the client rates her pain at 4 on a 0-10 scalec.
the client is able to move all four extremities on command
d. the client requires tactile stimulation - ANSWER-c
A nurse is receiving afternoon report on four clients who have
returned from the PACU this morning. The nurse should assess
which of the following clients first?a. a client who is post-op
following a thoractomy has a chest tube with 150 mL bright-red
of blood in the collection chamber from the past hour.b. a client
who is post-op following a small bowel resection and has a
temporary colostomy has absent bowel sounds in all four
, quadrantsc. a client who is postop following a tonsillectomy
has had one episode of coffee-ground emesisd. a client who is
post-op following a total knee arthroplasty and has a PCA
pump is reporting a knee pain level of 7/10 - ANSWER-a
A client is transferred from the surgical suite to the PACU
following oral surgery. While monitoring the client's vital signs,
the nurse finds that the tongue has become swollen and is
obstructing the airway. Which of the following actions should
the nurse take first?a. contact the anesthesiologistb. assist
with endotracheal intubationc. increase the clients flow of
oxygend. use the head-tilt, chin-lift method to open the airway -
ANSWER-d
A client had an open transverse colectomy 5 days ago. The
nurse enters the client's room and recognizes that the wound
has eviscerated. After covering the wound with a sterile, saline-
soaked dressing, which of the following actions should the
nurse take?a. go to the nurses station to seek assistanceb.
reinsert the organs into the abdominal cavityc. place the client
in reverse Trendelenburg positiond. obtain vital signs to
assess for shock - ANSWER-d
A nurse is caring for a client who is 2 days post-op following a
cholecystectomy. The client has been vomiting for the past 24
hours and reports a pain level of 8/10. The nurse notes a hard,
distended abdomen and absent bowel sounds. After conferring
with the provider, which of the following actions should the