Which are effective strategies for enhancing a patient’s impaired vision?

Use of adjustable blinds, sheer curtains, or draperies, Use of yellow or amber lenses to decrease glare, Use of warm incandescent lighting

Moderate sedation is used routinely for procedures that requires

A depressed level of consciousness.

What should the nurse do after administeing an anxiolytic to the patient going to surgery?

Instruct the patient to call for help to go to the restroom.

Which nursing intervention is a priority for a post pt experiencing tachypnea 1 hour after surgery?

Elevate the head of the patient’s bed.

Which interventions are a priority for a pt surgical dressing saturated with serosanguineous drainage?

Notify surgeon, Reinforce the dressing

Which of the following places an elderly patient at risk during surgery?

Reduced diaphragmatic excursion, Stiffened lung tissue, Reduced blood flow to kidneys

During patient admission the nurse’s priority interventions with a pt that has bilateral eye trauma includes:

Telling nurses and health care providers about patient’s vision status, Orienting the patient to the environment, Placing necessary objects in front of the pt

The nurse is caring for a pt with expressive aphasia from a traumatic brain injury. Which desired outcome is included?

Patient will communicate nonverbally

Which health preventative measure is most appropriate to prevent blindness?

Include rubella and syphilis screening in the preconception care plan.

What explanation can the nurse provide that may encourage the patient to cough more effectively?

Coughing will not harm the incision if done correctly.

What action can the nurse implement to comfort an elderly patient with sensory deprivation to improve meaningful stimuli

Offering the patient a back rub

A pt has been assigned a physical status classification of P3, due to which assessment?

History of hypertension, 80 pounds overweight, history of asthma

Which are the correct nursing interventions to reduce sensory deprivation?

Turning on the lights and opening the blinds, Sitting down, speaking, touching, and listening to his feelings

What should the nurse do when a pt I feel like I need to go to the bathroom, but I cant?

Assess the patients intake and the patient for bladder distention.

The patient asks if he should bring family with him to the appointment. What is the best response?

We recommend including family in this appoint to ease everyone’s anxiety.

Which assessment of the patient would indicate an adaptation to Hearing deficit related to presbycusis?

The patient turns one ear toward the nurse during conversation.

The nurse would utilize the Snellen chart for assessment of which patient?

A patient who frequently reports the incorrect time from the clock

The nurse is caring for a patient intraoperatively. Primary roles of the circulating nurse include

Establishing and implementing the plan of care

The nurse is preparing a patient for surgery. Aims of assessment before surgery include

Establishing a patients baseline of normal function.

Which of the following teaching strategies does the nurse implement when teaching the pt how to use a hearing aid?

Review method to check volume on hearing aid., Discuss the importance of having wax buildup in the ear canal removed., Demonstrate hearing aid battery replacement.

Which nursing assessment best measures cognitive functioning?

Administer a Mini-Mental Status Exam (MMSE)

Which of these assessment findings does the nurse expect to find from a pt who suffered from a right hemisphere stroke?

Inattention and neglect, especially to the left side, Loss of sensation and motor function on the right side of the body

What does the nurse monitor for in a postoperative patient with a history of obstructive sleep apnea?

Choking and noisy, irregular respirations

Which nursing intervention would be effective in orienting a patient with a neurological deficit?

Keeping a day-by-day calendar at the patients bedside

Why should a med-surge nurse collect a complete set of VS before transporting a pt?

To compare and monitor for vital sign variation during transport.

A pt has multiple monitoring systems on that constantly make noise and is agitated they can't sleep. Nurses action?

Provide the patient with earplugs

Which discharge education points should be reviewed with a pt who reports continued nausea and vomiting?

Instruct and attempt to connect the patient with the physician.

Unmanaged surgical pain can lead to which of the following problems?

Retained pulmonary secretion, Delayed ambulation, Reduced ventilation

Which of the following indicates the need for additional education on pain relief measure?

I will have minimal pain because of the anesthesia

A pt came in from an accident after he thought the light was still green and asks if he should still drive. Response?

Yes, you just need to think of stoplights in a new way

The nurse is aware that which patient is most at risk for sensory deprivation?

A patient on the unit with tuberculosis on airborne precautions

The nurse directs the nursing assistant to

Inform the nurse if the patient is unwilling to perform exercises.

What points should the nurse include when telling the patient what it will be like to be in the surgical environment?

The surgical area is cold but warm blankets will be provided., The surgical staff will be dressed in special clothing with hats and masks.

Which of the following actions should the nurse take if a presurgical pt is taking warfarin (Coumadin)?

Ask for an international normalized ratio (INR).

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Skills exam pt 3

90 termsStudBud Administration15 plays

Sensory alterations and perioperative nursing care

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Questions 90

Answers

1
Which are effective strategies for enhancing a patient’s impaired vision?
Use of fluorescent lighting
Use of adjustable blinds, sheer curtains, or draperies
Use of yellow or amber lenses to decrease glare
Use of warm incandescent lighting
2
Moderate sedation is used routinely for procedures that requires
Performance on an outpatient basis.
A depressed level of consciousness.
The patient to be immobile.
Loss of sensation in an area of the body.
3
What should the nurse do after administeing an anxiolytic to the patient going to surgery?
Instruct the patient to call for help to go to the restroom.
Notify the operating suite that the medication has been given.
Waste any unused medication according to policy.
Ask the patient to sign the consent for surgery.
4
Which factors increase an obese patient’s risk for surgical complications if they also have type 2 diabetes?
Delayed wound healing
Obesity
Prolonged bleeding time
Ineffective vital capacity
5
Which nursing intervention is a priority for a post pt experiencing tachypnea 1 hour after surgery?
Give ordered oxygen through a mask at 4 L/min
Position pt on one side with the face down and the neck slightly extended
Elevate the head of the patient’s bed.
Ask the patient to use an incentive spirometer
6
Which interventions are a priority for a pt surgical dressing saturated with serosanguineous drainage?
Maintain the intravenous fluid infusion
Monitor the patient’s vital signs every 5 to 10 minutes
Notify surgeon
Reinforce the dressing
7
The nurse caring for a patient who is having difficulty understanding written and spoken word has ___ aphasia
Expressive
Brocas
Receptive
Wernickes
8
Why do nurses encouraging diaphragmatic breathing in postoperative patients?
Prevention of atelectasis.
Decreased healing time.
Management of pain.
Decreased thrombus formation.
9
Which of the following places an elderly patient at risk during surgery?
Reduced diaphragmatic excursion
Stiffened lung tissue
Increased cholinergic transmission
Reduced blood flow to kidneys
10
Which of the following medications should the nurse instruct the patient to hold in preparation for surgery?
Vitamin C
Acetaminophen
Miconazole
Ibuprofen
11
During patient admission the nurse’s priority interventions with a pt that has bilateral eye trauma includes:
Telling nurses and health care providers about patient’s vision status
Orienting the patient to the environment
Placing necessary objects in front of the pt
Reinforcing eye safety at work
12
The nurse is caring for a pt with expressive aphasia from a traumatic brain injury. Which desired outcome is included?
Patient will carry a pen and a pad of paper around for communication.
Patient will thicken drinks to prevent aspiration
Patient will communicate nonverbally
Patient will recover full use of speech vocabulary in 1 week.
13
Why does a postop patient who had a carpel tunnel repair have a temperature of 97 F and is shivering?
The patient is dressed only in a gown.
Anesthesia lowers metabolism.
The surgical suite has laminar flow.
The open body cavity contributed to heat loss.
14
Which health preventative measure is most appropriate to prevent blindness?
Include rubella and syphilis screening in the preconception care plan.
Instruct parents to report reduced eye contact from their child immediately
Administer prophylactic antibiotics to all newborns.
Screen young children early for visual impairments.
15
Which nursing diagnosis addresses psychological concerns for a patient with both hearing and visual sensory impairment?
Risk for falls
Social isolation
Impaired physical mobility
Self-care deficit
16
What explanation can the nurse provide that may encourage the patient to cough more effectively?
If you dont deep breathe and cough, you will get pneumonia
Coughing will not harm the incision if done correctly.
You will need to cough only a few times during this shift.
Deep breathing and coughing will clear out the anesthesia
17
What action can the nurse implement to comfort an elderly patient with sensory deprivation to improve meaningful stimuli
Placing a Do not disturb sign on the patients door
Placing the patient in a room farthest from the nursing station
Offering the patient a back rub
Asking the patient if he would like a newspaper to read d.
18
A pt has been assigned a physical status classification of P3, due to which assessment?
Denial of any major illnesses or conditions
History of MI that limits activity
Normal, healthy patient
History of hypertension, 80 pounds overweight, history of asthma
19
Which are the correct nursing interventions to reduce sensory deprivation?
Turning on the lights and opening the blinds
Keeping the television on continuously
Moving him to a room away from the nurses’ station
Sitting down, speaking, touching, and listening to his feelings
20
Which is the best intervention the nurse should implement to promote bowel function?
Lowering the head of the patient’s bed
Deep-breathing exercises
Early ambulation
Repositioning on the left side
21
What should the nurse do when a pt I feel like I need to go to the bathroom, but I cant?
Call the physician and obtain an order for catheterization.
Encourage the patient to wait a minute and try again.
Assess the patients intake and the patient for bladder distention.
Inform the patient that everyone feels this way after surgery.
22
The patient asks if he should bring family with him to the appointment. What is the best response?
We recommend including family in this appoint to ease everyone’s anxiety.
It is required that you have a family member at this appointment.
There is no need for an additional person at the appointment.
Your family can come and wait with you in the waiting room.
23
How can you prevent DVT?
Strict aseptic technique
Deep breathing exercise
Hydration
Early ambulation
24
Which assessment of the patient would indicate an adaptation to Hearing deficit related to presbycusis?
The patient frequently cleans out his ears with a cotton swab
The patient isolates himself from social situations.
The patient turns one ear toward the nurse during conversation.
The patient asks the nurse to speak loudly during conversations.
25
The nurse would utilize the Snellen chart for assessment of which patient?
A patient who is having difficulty remembering how to perform familiar task
A patient who frequently reports the incorrect time from the clock
A patient who turns the television up as loud as possible
A patient who holds his newspaper 2 inches from his face
26
What should the nurse do for a patient in the preoperative holding area of an ambulatory surgery center?
Monitor vital signs every 15 minutes.
Apply a warm blanket.
Check the surgical dressing.
Empty the urinary drainage bag.
27
Which nursing diagnosis related to patient safety is the priority for the nurse to include in the plan of care?
Risk for injury
Self-care deficit
Body image disturbance
Anxiety
28
A pt that becomes nauseated when riding in motor vehicles most likely has which sensory deficit?
Visual deficit
Neurological deficit
Hearing deficit
Balance deficit
29
What level of care will a pt who underwent a coronary artery bypass graft procedure require immediately post procedure?
Ambulatory surgery extended stay
Ambulatory surgery
Acute care intensive care unit
Acute care medical-surgical unit
30
The nurse is caring for a patient intraoperatively. Primary roles of the circulating nurse include
Maintaining a sterile field
Assisting with applying sterile drapes.
Establishing and implementing the plan of care
Handing sterile instruments and supplies to the surgeon.
31
A pt has bleeding from the surgical site, and the surgeon determines the need to return to perform a ___ procedure
Major.
Urgent.
Emergency.
Elective.
32
The nurse is preparing a patient for surgery. Aims of assessment before surgery include
Gathering appropriate equipment for the patients needs.
Establishing a patients baseline of normal function.
Educating the patient and family about the procedure.
Planning for care after the procedure.
33
Which of the following teaching strategies does the nurse implement when teaching the pt how to use a hearing aid?
Recommend a chemical cleaner to remove difficult buildup.
Review method to check volume on hearing aid.
Discuss the importance of having wax buildup in the ear canal removed.
Demonstrate hearing aid battery replacement.
34
Which nursing assessment best measures cognitive functioning?
Ask the patients family if the patient is behaving normally
Administer a Mini-Mental Status Exam (MMSE)
Evaluate the patients ability to read the newspaper
Ask the patient his name, where he is, and what month it is
35
Which of these assessment findings does the nurse expect to find from a pt who suffered from a right hemisphere stroke?
Slow, cautious behavioral style
Inattention and neglect, especially to the left side
Loss of sensation and motor function on the right side of the body
Visual spatial alterations
36
What does the nurse monitor for in a postoperative patient with a history of obstructive sleep apnea?
Shallow respirations
Disorientation
Choking and noisy, irregular respirations
Moaning and reports of pain
37
In which perioperative nursing phase would reviewing laboratory tests and allergies be completed?
Intraoperative
Perioperative
Preoperative
Postoperative
38
Which nursing intervention would be effective in orienting a patient with a neurological deficit?
Assessing the patients level of consciousness and documenting every 4 hours
Keeping a day-by-day calendar at the patients bedside
Placing a patient observer in the patients room for safety
Inform the pt they cannot be discharged unless she is awake/alert/oriented
39
Why should a med-surge nurse collect a complete set of VS before transporting a pt?
To follow hospital policy and procedure for care of the surgical patient.
The first action in a head-to-toe assessment is vital signs.
To ensure that they check on the postoperative patient.
To compare and monitor for vital sign variation during transport.
40
A pt has multiple monitoring systems on that constantly make noise and is agitated they can't sleep. Nurses action?
Administer an opioid medication to help the patient sleep
Provide the patient with earplugs
Provide the patient with a therapeutic back rub
Turn off the alarms on the monitor device
41
Which discharge education points should be reviewed with a pt who reports continued nausea and vomiting?
Instruct the patient to go to the emergency department.
Instruct and attempt to connect the patient with the physician.
Instruct the patient to take deep breaths.
Instruct the patient to drink ginger ale and eat crackers.
42
Unmanaged surgical pain can lead to which of the following problems?
Retained pulmonary secretion
Delayed ambulation
Reduced ventilation
Catheter-associated urinary tract infection
43
Which of the following indicates the need for additional education on pain relief measure?
I will be asked to rate my pain on a pain scale.
I will take my pain medications before doing postoperative exercises.
I will have minimal pain because of the anesthesia
I will take the pain medication as the physician prescribes it.
44
A pt came in from an accident after he thought the light was still green and asks if he should still drive. Response?
Yes, but you should see your ophthalmologist and get some glasses
No, you should ask family members to drive you around due to limited reflex
No, you should stop driving, you are confused and putting everyone at risk
Yes, you just need to think of stoplights in a new way
45
To prevent venous stasis and the formation of thrombus after general anesthesia, the nurse encourages
Diaphragmatic breathing.
Leg exercises.
Incentive spirometry.
Coughing.
46
The nurse is aware that which patient is most at risk for sensory deprivation?
A patient receiving hospice care for end-stage brain cancer
A patient on the unit with tuberculosis on airborne precautions
patient who recently had a stroke and has left-sided weakness
A patient in the ICU under constant monitoring following an MI
47
An elderly pt having difficulty connecting two puzzle pieces is most likely related to which sensory deprivation?
Cognitive
Perceptual
Affective
Social
48
The nurse directs the nursing assistant to
Document in the medical record when exercises are complete
Inform the nurse if the patient is unwilling to perform exercises.
Teach and demonstrate postoperative exercises.
Do nothing associated with postoperative exercises.
49
What points should the nurse include when telling the patient what it will be like to be in the surgical environment?
The operating table or bed will be comfortable and soft.
The operative suite will be very dark.
The surgical area is cold but warm blankets will be provided.
The surgical staff will be dressed in special clothing with hats and masks.
50
hypercarbia, tachypnea, tachycardia, premature ventricular contractions, and muscle rigidity indicates:
Hypoxia
Fluid imbalance.
Malignant hyperthermia
Hemorrhage.
51
Which of the following actions should the nurse take if a presurgical pt is taking warfarin (Coumadin)?
Ask for an international normalized ratio (INR).
Ask for a radiological examination of the chest.
Consult with the physician regarding blood urea nitrogen (BUN).
Consult with the physician regarding a complete blood count (CBC).
52
Which nursing intervention would assist the patient in controlling vertigo?
Avoiding riding in vehicles and making sudden motions
Placing several antiemetic patches on the patient
Increasing fluid intake to 3 liters a day
Watching television instead of reading books
53
Which of the following nursing interventions have been found to decrease wound infections?
Perform first dressing change 1 week postoperatively.
Use hair clippers to remove hair.
Administer antibiotics within 30 to 60 minutes of incision time.
Maintain normoglycemia
54
Which assessment would be an expected finding for a patient with a left femoral peripheral nerve block?
Sensation decreased in the left leg
Patient report of pain in the left foot
Decreased pulse at the left posterior tibia
Left toes cool to touch and slightly cyanotic
55
Which of the following approaches best facilitates communication with a pt with hearing loss?
speak directly into the patient’s good ear
Verify that the information that has been given has been clearly understood
Position the patient so that the light is on his or her face when speaking
Face the patient so they can read your lips
56
The nurse is caring for a postoperative patient with an abdominal incision. A pillow is used during coughing to provide
Distraction.
Anxiety reduction.
Pain relief.
Splinting.
57
Which of the following actions helps to minimize skin breakdown in the intraoperative phase?
Measuring the time a patient is in one position during surgery
Securing attachments to the operating table with foam padding
Periodically adjusting the patient during the surgical procedure
Encouraging the patient to bathe before surgery
58
What should the nurse do when monitoring for postoperative fluid and electrolyte imbalance?
Measure and record all intake and output.
Encourage copious amounts of water.
Weigh the patient and compare with preoperative weight.
Start an additional intravenous (IV) line.
59
Perioperative nursing is based on certain principles and includes
Providing advocacy for the patient.
Conducting multidisciplinary teamwork.
Providing high-quality and patient safetyfocused care.
Purchasing the correct equipment.
60
To assist in minimizing discomfort with positioning which instruction should the nurse provide to the patient?
Place your hand over your incision.
Hold your breath and count to three.
Hold my shoulders with your hands.
Close your eyes and think about something pleasant.
61
Which risk factors can increase a persons risks in surgery?
Age
Nutrition
Race
Ambulatory surgery
62
What should the nurse do after completing a preoperative assessment on a pt going to surgery?
Document that the patient had a bath at home this morning.
Notify the operating suite that the patient has a latex allergy.
Ask the nursing assistant to obtain vital signs.
Administer the ordered preoperative intravenous antibiotic
63
Which would be the best explanation for diet progression after surgery?
Stay on clear liquids for 24 hours. Then you can progress to a normal diet.
Start with clear liquids then full liquids for 2 hours and then progress
Start with clear liquids and advance as you tolerate.
There is no limitation on your diet. You can have whatever you want.
64
What does a preoperative checklist to assist in preparing a patient on the day of surgery include?
living will
Vital signs
Family location
Identification (ID) band on
65
Which of the following outcomes would be most appropriate for a pt in the operating suite?
free of burns at the grounding pad
free of pain.
free of nausea and vomiting.
free of infection.
66
The nurse is precepting a student nurse and explains that perioperative nursing care occurs
During the surgical procedure.
Before, during, and after surgery.
In the postanesthesia care unit
In preadmission testing.
67
How does a nurse establish communication with a pt that has conductive hearing loss due to prolonged cerumen impaction?
If the pt does not understand, repeat it
Have direct conversation with the patient in his affected ear
Speak in a loud voice, enunciating every syllable
Speak with hands, face, and expressions
68
A nurse is caring for a pt with a Do not disturb sign placed on the door and sees a Dr try to enter the room. Response?
Firmly explaining that the patient does not wish to have visitors
Scolding the physician for not obeying the signs on the door
Allowing the physician to enter because he has higher authority
Calling for security to remove the visitor
69
Which of the following approaches will you teach the family to do to assist the pt ambulate due to vision loss?
Stand next to the pt at the top and bottom of stairs.
Place yourself alongside the pt and hold onto their waist.
Have her grasp your arm just above the elbow and walk at a comfortable pace
Walk one-half step behind and slightly to their side
70
Which assessment question should the nurse ask to understand how visual alterations are affecting the patients self-care
How does your vision impairment make you feel?
Have you stopped reading books or switched to books on audiotape?
Are you able to prepare a meal or write a check?
How do you protect yourself from injury at work?
71
The nurse would be most concerned about the risk of malnutrition for a patient with which sensory deficit?
Disequilibrium
Cataracts
Peripheral neuropathy
Xerostomia
72
Which is the most appropriate method to teach a blind patient how to contact the nurse for assistance?
Explain to the patient that a staff person will stop by once an hour
Instruct the patient to yell
place a raised Braille sticker on the call button and instruct the patient
Share cell phone numbers with the patient
73
Which nursing diagnosis addresses the complication of glaucoma that places the patient at greatest risk for injury?
Body image disturbance
Fear
Risk for falls
Social isolation
74
The nurse evaluates that the patient is able to safely care for himself when the patient demonstrates which action?
Asks the nurse to test the temperature of the water before entering a bath
Places colored stickers on faucet handles to indicate temperature and keeps
Dispenses all medications onto a plate for easy access in the morning
Replaces all lace-up shoes with Velcro ones and purchases shampoo caps
75
The patient is becoming malnourished because nothing tastes good. Which recommendation is most appropriate?
Blend foods together in interesting flavor combinations.
Rinse your mouth several times a day to hydrate your taste buds.
Eat soft foods that are easy to chew and swallow.
Avoid adding spices or aromatic ingredients to food to prevent nausea.
76
Which of the following sensory changes are normal with aging?
Increase in taste discrimination
Impaired night vision
Heightened sense of smell
Difficulty hearing low pitch
77
How can communication between a preop nurse and a circulating nurse best be enhanced?
Giving specific information to a transport technician
Using a standardized SBAR tool
Listening to the OR nurse’s questions
Being responsive in using nonverbal communication techniques
78
What does a nurse do if a preop patient is unable to perform leg exercises correctly?
Encourage the patient to practice at a later date.
Assess for the presence of anxiety, pain, or fatigue.
Ask the patient why he does not want to do the exercises.
Assess the educational methods used to educate the patient.
79
Which assessment questions should the nurse ask a preoperative patient preparing for surgery?
“Are you experiencing any pain?”
“When do you regularly take your medications?”
“Do you have any medication allergies?"
“Do you exercise on a daily basis?”
80
Which of the following interventions reduce loneliness?
Sharing information about senior transportation services
Maintaining distance while talking to avoid overstimulating the patient
Providing information about local social groups
Reassuring the patient that loneliness is a normal part of aging
81
Which nursing action would be least effective in promoting positive adaptation ofright-sided weakness following a stroke
Teaching the patient how to create a safe environmen
Approaching the patient from the affected side
Placing the patients belongings on the affected side
Completing sentences that the patient cannot finish
82
What is the involuntary motion of retracting the body from painful stimuli?
Reaction
Sensation
Perception
Reception
83
To be discharged home, what criteria must the patient meet?
Able to drink fluids
Dry and intact dressing
Able to dress self
Able to eat crackers
84
After the needle enters the arm, the child says, Ow, that was sharp! The ability to recognize and interpret stimuli is
Perception
Sensation
Reaction
Reception
85
Which nursing assessment would indicate that the patient is performing diaphragmatic breathing correctly?
The patient will feel downward movement of the diaphragm during expiration.
patient will feel upward movement of the diaphragm during inspiration.
fingers separates as chest wall contracts.
FIngers touch as chest wall contracts.
86
What should the nurse do first when preparing to assist the patient in using the incentive spirometer?
Perform hand hygiene.
Explain use of the mouthpiece.
Instruct the patient to inhale slowly.
Place in reverse Trendelenburg position.
87
What intervention should a nurse do for a stroke pt whos having difficulty with attempting to eat his meal and tearful?
Teach the patient about special devices used to assist patients with eating
Obtain an order for antidepressant medications.
Order the patient food that does not require utensils.
Place a consult for a home health nurse.
88
The nurse assists in positioning the patient in the operating suite to
Provide warmth and comfort
Maintain neuromuscular structures
Sustain adequate circulatory and respiratory function
Ensure patient safety and skin integrity
89
Which of the following actions would be most important to include in a preop patients preparation?
Ascertain where the family will be located during the procedure.
Ask the patient to remove all hairpins and cosmetics.
Place the patient in a clean surgical gown.
Ascertain that the surgical site has been correctly marked
90
Which postoperative intervention best prevents atelectasis?
Use of intermittent compression stockings
Heel-toe flexion
Use of the incentive spirometer
Abdominal splinting when coughing

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