PCA is often used in post operative pts for which of the following reasons?

Promote sustained pain relief with pt in control

A patient understands the need for incentive spirometer when he states, “I use this device to...

“Expand my lungs after surgery”

An obese patient is at higher surgical risk bc of which of the following factors? (select all)

Ventilatory capacity is reduced, Fatty tissue has a poor blood supply

Which of the following findings would indicate a complication of a left fibula fracture?

The client has an absent left pedal pulse

Post-op discharge instructions should include (select all that apply)

medications, when to call the healthcare provider, wound care

Which of the following is an important nursing responsibility related to pain?

Believe what the client says about pain

How to confirm placement of NG insertion?

Aspirate GI contents, test for a ph of 4

What immediate action is taken, when the pt begins to cough & have difficult breathing?

Removes the tube and reinserts when distress subsides.

Post-op pt -B/P 90/52, HR 124, R 26; Dsg lg amt bld. The nurse would do all except:

Monitor vital signs q 15 minutes until condition stabilizes, Maintain IV infusion & prepare to give volume replacement, Notify the surgeon immediately

The OR is high-risk areas for latex allergy. What should nurse do to prevent a reaction? Select all

Communicate with OR asap when latex-sensitive pt is known, Screen pts 4 food allergies known to have cross-reactivity, Having a latex allergy cart available at all times

What is the purpose of a purse-string suture?

To close the thoracotomy site after chest tube removal

Pt has sedation score of 1 easy to rouse, in moderate/severe pain wanting pain relief.

Administer ordered pain protocol, monitoring sedation/vitals

Which measure promotes normal venous return and circulatory blood flow?

Get pt to perform leg exercises at least Q2hourly when awake

What is the purpose of corking a tracheostomy?

Preparing the client for decannulation

What is an appropriate reason to clamp a client's chest tube?

While changing the chest drainage system

NG tube insertion is done for the following reasons: (select all that apply)

Provide feedings, medications, Decompress the stomach, Treatment of obstruction

Which indicates a neurovascular problem during assessment of pt with a fracture?

Decreased sensation distal to the fracture site

Malignant hyperthermia is

considered a life threatening complication of anesthesia

Where could a nurse obtain teaching information for patient with a new ostomy ?

Canadian Cancer Society, Ostomy Canada Society, Coloplast, Hollister or Convatec websites, WOCN (Wound, Ostomy & Continence Nurses Society)

What is better to use for long lasting pain relief in a post operative environment (PACU)?

IV Oxycodone protocol with adjuncts (Paracetamol)

Pain assessment consists of?

Intensity, Quality, location, Duration, Aggravators?

Your client has a left femur # with Buck’s traction. His wife asks you what traction is for?

It is necessary to prevent displacement of the fracture

The LPN is preparing for NG insertion in an adult client. To determine the length the nurse

Measures from tip of nose - earlobe -xyphoid process

What observations should be done when administering opioids.

Sedation, Respirations, Blood Pressure, Heart rate, Pain.

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316 Final Exam Quiz

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Questions 99

Answers

1
Client sprained her ankle 3 days ago. Which of the following is not appropriate intervention?
Compress
Apply warm compresses
Rest
Use ice packs
2
PCA is often used in post operative pts for which of the following reasons?
Promote sustained pain relief with pt in control
Decrease quantity of opioid medication use.
Improve nsg control over opioid administration
Enable family members to administer drug dosage
3
A patient understands the need for incentive spirometer when he states, “I use this device to...
“Increase my lung capacity.”
“Drain excess fluid from my lungs.”
“Help my cough reflex.”
“Expand my lungs after surgery”
4
Which IV is the largest?
20 ga
22 ga
18 ga
14 ga
5
Postoperatively, the nurse instructs the patient to perform leg exercises every hour to:
Exercise fatigued muscles
Maintain muscle tone
Increase venous return
Assess range of motion
6
An obese patient is at higher surgical risk bc of which of the following factors? (select all)
Ventilatory capacity is reduced
Metabolic demands are increased.
Risk for bleeding is increased
Fatty tissue has a poor blood supply
7
Which of the following findings would indicate a complication of a left fibula fracture?
The client has a decreased temperature
The client has a decreased lymphocyte count
The client has an absent left pedal pulse
The client has an increased red blood cell count
8
How much pleural fluid is normally found on each side of the pleural space?
10 mL
5 mL
25 mL
100 mL
9
What is the most common type of pain seen in recovery (PACU)?
Neuropathic pain
Nociceptive pain
Acute on Chronic Pain.
Psychogenic pain.
10
Who can type O patients receive donations from?
A, B, O
AB, O, A, B
O
A, O
11
Post-op discharge instructions should include (select all that apply)
need to limit visitors
medications
when to call the healthcare provider
wound care
12
Which of the following is an important nursing responsibility related to pain?
Believe what the client says about pain
Encourage the person to stay in bed
Assume responsibility for eliminating the client's pain
Help the pt to appear not to be in pain
13
How to confirm placement of NG insertion?
Insertion matches the length of the measurement.
Aspirate GI contents, test for a ph of 4
Ausculate over epigatric area uisng 20-30 mls of air.
Ausculate over diaphragm , presence of air
14
Who is NOT at risk for potential complications of enteral feeding
Facial trauma
Upper GI obstruction
Anyone with documented Gastroesophageal reflux
short term feedings
15
What immediate action is taken, when the pt begins to cough & have difficult breathing?
Notify HCP immediately
Quickly insert the tube
Removes the tube and reinserts when distress subsides.
Wait until the respiratory distress subsides
16
Which response would be corroborative data we would expect with pt experiencing moderate pain?
decreased heart rate
restlessness
Protection of painful area
increased blood pressure
17
Post-op pt -B/P 90/52, HR 124, R 26; Dsg lg amt bld. The nurse would do all except:
Monitor vital signs q 15 minutes until condition stabilizes
Maintain IV infusion & prepare to give volume replacement
Notify the surgeon immediately
perform dressing change
18
The OR is high-risk areas for latex allergy. What should nurse do to prevent a reaction? Select all
Communicate with OR asap when latex-sensitive pt is known
Screen pts 4 food allergies known to have cross-reactivity
Scheduling the latex-sensitive pt for last case of the day.
Having a latex allergy cart available at all times
19
What is the PN student role in informed consent
The PN student has no role
explain surgical procedure
explain possible complications
ensure consent is signed
20
Which of the following is most likely to result in a sucking chest wound?
Metastatic lung cancer
Blunt force trauma to the chest
Stab wound to the chest
Pneumonia
21
Which of the following is NOT a category of the GCS
verbal response
limb movement
leg strength
eye opening
22
Taping a ostomy will seal the wafer tight enough to prevent leakage. (True or False)
True
False
23
What is the purpose of a purse-string suture?
To prevent disconnection of the chest drainage system
To close the thoracotomy site after chest tube removal
To prevent bleeding into the pleural space
To securely attach the chest tube to the skin
24
Pt has sedation score of 1 easy to rouse, in moderate/severe pain wanting pain relief.
Administer ordered pain protocol, monitoring sedation/vitals
Administer MORPHINE protocol
Tell the patient to deal with it
Wait and see what happens
25
Which measure promotes normal venous return and circulatory blood flow?
Suctioning artificial airways and the oral cavity
Get pt to perform leg exercises at least Q2hourly when awake
Having the pt DB&C
Monitoring fluid and electrolyte status during every shift
26
When should an N95 mask be worn?
TB
C. Diff
MRSA
VRE
27
What is the purpose of corking a tracheostomy?
Preparing the client for decannulation
Preventing the development of a granuloma
Preventing aspiration
To remove tenacious secretions
28
What is an appropriate reason to clamp a client's chest tube?
If the client develops sudden dyspnea
If the client has an existing air leak
If the chest tube begins to drain blood
While changing the chest drainage system
29
Which foley catheter is the largest?
14 Fr
22 Fr
18 Fr
12 Fr
30
What size of large bore IV cannula is preferably used for blood transfusions?
22 guage
18 guage
20 guage
14 guage
31
NG tube insertion is done for the following reasons: (select all that apply)
Provide feedings, medications
Decompress the stomach
As part of bariatric program
Treatment of obstruction
32
2 hrs post arthroscopy you assess ↓ pedal pulses from the previous assessment. What's next?
Change the dressing and rewrap the elastic wrap
Notify the physician
Perform neurovascular assessment in 30 minutes
Take vital signs
33
Which indicates a neurovascular problem during assessment of pt with a fracture?
Purulent drainage at the site of an open fracture
Exaggeration of extremity movement
Increased redness and heat below the injury
Decreased sensation distal to the fracture site
34
Why might bubbling suddenly develop in the water seal chamber of a chest drainage system?
The client takes a deep breath
The client is lying on the tubing
Development of an air leak
Sudden development of a pleural effusion
35
Empyema refers to ______ in the pleural space
Lymphatic fluid
Pus
Blood
Excess pleural fluid
36
Malignant hyperthermia is
considered a life threatening complication of anesthesia
handled with the administration of aspirin
is a complication of certain orthopedic surgeries only
is considered a minor complication
37
Where could a nurse obtain teaching information for patient with a new ostomy ?
Canadian Cancer Society
Ostomy Canada Society
Coloplast, Hollister or Convatec websites
WOCN (Wound, Ostomy & Continence Nurses Society)
38
Fecal matter around the stoma can cause...
Fungal Infection
All of the above
Yeast infection
bacterial infection
39
Which is not a sign of IV infiltration
Pain
Hot to touch
Swelling
Cool to touch
40
What is better to use for long lasting pain relief in a post operative environment (PACU)?
PRN Paracetamol
IV Oxycodone protocol with adjuncts (Paracetamol)
50mg Oral Tramadol once only
Cup of tea and biccy.
41
Pain assessment consists of?
Intensity, Quality, location, Duration, Aggravators?
Doing a set of vital signs.
Asking the patient where it is painful?
Assessing the wound.
42
In the postoperative period, measuring I&O helps assess which of the following?
Patient comfort
Renal and circulatory function
Gastrointestinal function
Neurological function
43
What should a nurse teach a pt following total hip replacement to avoid?
sitting with legs crossed
sleeping on abdomen
bearing weight on affected leg for 6 weeks
abduction exercises of the affected leg
44
Although D₅W is isotonic, it acts as a __________ solution once in the bloodstream
Isotonic
Hypertonic
Hypotonic
45
GCS for a Pt who can not open their eyes, has no limb movement, and does not respond verbally
9
0
3
6
46
Hives, itching 20 minutes after start of transfusion;
Anaphylactic
TRALI (Transfusion-Related Lung Injury)
No Reaction
Allergic
47
Your client has a left femur # with Buck’s traction. His wife asks you what traction is for?
It will help prevent contractures of the affected hip
It will decrease the incidence of painful muscle spasms
It is necessary to prevent displacement of the fracture
It is used to maintain the leg in external rotation position
48
The LPN is preparing for NG insertion in an adult client. To determine the length the nurse
Measures from tip of nose - earlobe - top of sternum
Marks the tube at 10"
Marks the tube at 32"
Measures from tip of nose - earlobe -xyphoid process
49
A confused client pulls out his chest tube. What should the nurse do FIRST?
Put on gloves
Apply a dressing, and tape it on 3 sides
Apply supplemental oxygen at 6-8 L/min
Apply direct pressure to the chest tube site
50
What observations should be done when administering opioids.
Sedation and Pain score.
Temperature and Sedation score.
Wound care.
Sedation, Respirations, Blood Pressure, Heart rate, Pain.
51
What solution should be used to clean a tracheostomy?
Undiluted hydrogen peroxide
Chlorhexidine gluconate
Sterile saline
Isopropyl alcohol
52
A client with a laryngectomy goes into respiratory arrest. How should the client be ventilated?
The client will need a tracheostomy
Place the bag-valve-mask over the mouth & nose
Place the bag-valve-mask over the stoma
Insert an endotracheal tube
53
Family should be included in teaching post op exercise so that they can
Relieve nurse by getting the pt to do their exercises Q2H
supervise the patient at home
Practice with the patient while waiting to be taken to OR
Coach the patient postoperatively
54
All of the following are spread by airborne transmission except
Chicken pox
Measles
Influenza
TB
55
Which of your post-op patients should you see first?
57y/o 6 hr post-op pt on PCA pump, hx of OSA, O2 sat at 85%
48y/o post-op knee replacement needs help repositioning
75y/o post-op hip surg c/o mod pain at surgical site, HR 92.
36y/o post-op, 1 hour late to receive post-op antibiotic
56
Hand-off communications between PACU nurse & floor nurse should include which two components?
Review of pertinent info from OR while at the nurses station
Uninterrupted time to review pertinent events & ask question
Verification of the pt using 1 identifier & type of surgery
Vital signs, type of anesthesia , blood loss, & LOC
57
What makes blood type O the "Universal Donor?"
they produce both A and B antigens
they do not produce either A or B antigens
it determines your personality
they usually are really nice people
58
1 hour post blood transfusion. Acute respiratory distress, left heart failure, positive fluid balance
Not transfusion related
Delayed Hemolytic
Allergic
TACO (Transfusion Associated Circulatory Overload)
59
Ileostomies are permanent for irritable bowel disease. (true of false)
False
True
60
What personal protective equipment is UNNECESSARY for tracheostomy care and suctioning?
Sterile gown
Goggles
N95 mask
Sterile gloves
61
Chlorothorax is lymphatic fluid in lung
True
False
62
the LPN can not perform the following in managing an continuous epidural infusion?
Remove Epidural catheter prior to discharge
Assess sensory function
Document epidural catheter length
Assess Motor function
63
With blood transfusions, which is NOT the role of the LPN?
Monitoring stable patients
Pick blood up at the lab
Being the second verifier
Transfusionist
64
What safety equipment must be kept at the bedside of a patient with a chest tube?
Obturator
Wire cutters
2 Kelly (hemostat) clamps
18 gauge sterile needle
65
Does having a history of chronic pain and opiate use matter to PACU nurses?
No, This is acute pain.
Yes, Opiate tolerance and existing expected pain.
66
The nurse is preparing for a NG insertion. The client is in what position for insertion?
High Fowlers
Supine with head flat
Right Side
Low Fowlers
67
IV Tubing should be changed ;
Weekly
Every 24 hrs
Q 72-96 hrs
With each NEW type of infusion
68
To avoid leakage of an ostomy what position should you be in when placing the pouch?
Supine
Prone
High Fowler
Standing
69
Immediately following a ileal conduit the nurse should report which assessment?
Deep breathing
Abdominal Distention
Temperature of 98.1
Edema
70
Hypertonic solutions:
commonly used for fluid volume deficit
Cause the cell to swell
administered for hyponatremia
cause no definitive change in the cell
71
When should you wear a mask and goggles?
During Contact Precautions
During Standard Precautions
During Droplet Precautions
During Airborne Precautions
72
Catheter insertion is considered a _________ procedure
No touch
Sterile
Clean
73
A Pt with a GCS of 9-12 would be catagorized as having a ____________ head injury.
moderate
severe
mild
74
Which is an advantage of conscious sedation over general anesthesia?
Loss of sensation at the surgical site
need for mechanical ventilation.
Monitoring in phase I recovery
Amnesia and relief of pain
75
Which of the following is a barrier to effective pain management by health care providers
Doing a thorough pain assessment
Belief that pain medication will mask the symptoms
cost of opioids
Belief that no one should have to live with pain
76
Post insertion care DOES NOT include:
Oral hygiene
Nasal hygiene
Assessments to include GI
HOB at 45 degrees at all times
77
Which client would be most appropriate to have a Heimlich (Pneumostat) chest drain valve?
A client with a pneumothorax
A client with a hemothorax
A client with a pleural effusion
A client immediately following a pneumonectomy
78
Which is incorrect when checking GCS for pupil reaction
Reaction checked after pupil size
Rx checked in dim light
Rx checked first, then pupil size
79
Since older adults are at increased risk for respiratory complications after surgery, the nurse should
Withhold pain medications and ambulate the pt every 2 hours
Encourage pt to turn, cough & deep breathe & control pain
Monitor fluid status q 8 hr & vital signs q 4 hr
Orient pt to environment & ambulate every 2 hours.
80
Your patient has skeletal traction for a femur #. Which finding warrants possible intervention?
The patient can move his or her toes below the fracture site
The patient can evert and dorsiflex the foot.
The skeletal pin moves or slides in the pin tract.
The patient reports a decrease in muscle spasms.
81
If you receive a patient that appears calm, vitals stable, with a pain score 9/10, do you?
Give them paracetamol and a cup of tea.
Give them 10mg oxycodone protocol because they said 9/10.
Tell them to suck it up.
Reassess pain with another tool and educate the patient.
82
A NG tube can be inserted in an unconscious pt?
False
True
83
What position should the nurse place the client in, when suctioning a tracheostomy?
Prone
Semi-Fowlers
Flat
Lateral
84
Which skill best reflects the BCCNM Scope of Practice for an LPN?
Suctioning a new tracheostomy
Tracheostomy care on an established trach
Changing the outer cannula of a trach
85
What is the CORRECT technique to suction a tracheostomy?
Apply suction while withdrawing the suction catheter
Wear clean gloves to suction a tracheostomy
Apply suction for no more than 2 minutes at a time
Always instill saline before suctioning a tracheostomy
86
Performing this skill keeps the IV line patent
Saline Flush
TKVO
Hep Lock
Continuous Infusion
87
Irrational anger following an ostomy is related to which nursing diagnosis?
Sexual Dysfunction
Disturbed Body Image
Deficient Knowledge
Ineffective Self-Health Management
88
Common side effects of opiates in PACU?
GI upset, Nausea and Vomiting.
Sedation, Hypotension, Decreased respirations.
Dizziness, Tachycardia.
Paranoia.
89
Signs of Cushing's Triad include all except:
Bradycardia
Irregular respirations
Tachycardia
Widening pulse pressure
90
Which blood type is the "Universal Recipient"?
O
AB
A
B
91
Appropriate non-pharmacological pain interventions for PACU pts?
3 Course dinner and drinks.
Warm blankets, Dim lights, Education, Distraction.
Mobilise patient in PACU.
IV opiates.
92
You need to administer medication via the NG tube that is attached to suction. What do you do?
Reposition the client to assist in absorption
Change suction settings
Aspirate NG tube after administration to maintain patency
Clamp the NG for 30-60 min following administraton
93
When pt engages in DB&C exercises, it is important to have them sitting because this position:
helps the patient to splint with a pillow
is more comfortable
facilitates expansion of the thorax
increases pt view of room and is more relaxing
94
What is Naloxone administered for?
Heparin reversal.
Nausea and vomiting.
Opioid reversal.
Pain relief.
95
Which is NOT a complications of NG tube insertion.
aspiration
Ulcerations to nares
pneumothorax
hemothorax
96
What is not a potential complication of unmanaged acute pain?
ascites
Atelectasis
arrhythmias
thromboembolism
97
If a foley catheter is bypassing, the nurse should first
deflate the balloon
check for kinks in tubing
remove the catheter
give a suppository
98
When performing tracheostomy care, which intervention should the nurse perform FIRST?
Suction the tracheostomy
Change the tracheostomy inner cannula
Cleanse the skin around the tracheostomy site
Change the tracheostomy dressing
99
After a pt has been given pre-op sedatives, which safety precaution should nurse take?
Obtain informed consent immediately after sedative given
Raise the side rails & keep the bed in the high position
Reinforce to the pt to remain in bed
Determine if the patient has any allergies to latex

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