Postoperative Nursing Care, Exams of Nursing

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NURS 320 Final Exam Questions and Answers 2025.

An adult male is scheduled for surgery and the nurse is assessing for risk factors. Which is the following are the greatest risk factors? 1.) He is 5ft 4 in tall and weighs 125 lb 2.) He expressed a fear of pain in the post-op period. 3.) He is 5ft 4 in tall, weighs 360lb, and is diabetic. 4.) He expresses fear of the unknown. 3.)He is 5ft 4 in tall, weighs 360lb, and is diabetic The nurse in an outclient department is interviewing an adult one week prior to her scheduled elective surgery. In planning for the surgery, which of the following should the nurse include in her teaching? 1.) The client will be able to return home alone following the surgery. 2.) Limitations of oral intake the day of the procedure. 3.) The laboratory studies ordered do not need to be done until after the surgery. 4.) The client should not take any of her routine medications the morning of the surgery. 2.) Instructions should be given to the client regarding limitations or oral intake to avoid nausea and vomiting for anesthesia. The nurse enters a woman's room to administer 10mg Valium PO, the ordered pre-op medication for her hysterectomy. During the conversation, the client tells the nurse that she and her husband are planning to have another child in the coming year. The best action for the nurse to take is which of the following? 1.) Do not administer the pre-op medication. NOtify the nursing supervisor and the physician. 2.) Go ahead and administer the medication as ordered. 3.) Check to see if the client has signed a surgical consent. 4.) Send the client to the OR without the medication. 1.) no client should be administered the per-op med until the informed consent has been obtained. Even if the consent form is signed, the nurse should withhold sedating meds because this client clearly does not understand the planned procedure. The nurse administers 10mg IM morphine as a pre-op medication, and then discovers that there is no signed operative permit. The best action for the nurse to take is to:

1.) Send the client to surgery as scheduled. 2.) notify the nursing supervisor, the OR, and the physician. 3.) cancel surgery immediately 4.) obtain the needed constent. 2.) is a narcotic, sedative, or tranquilizing drug has been administered before signing of the consent, the drug's effects must be allowed to wear off before consent can be given. An adult received atropine sulfate (Atropine) as a pre-op medication 30 minutes ago and is now complaining of dry mouth and her pulse rate is higher than before the medication was administered. The nurse's best interpretation of these findings is that: 1.) The client is having an allergic reaction to the drug. 2.) the client needs a higher dose of this drug 3.) this is a normal side effect of Atropine 4.) the client is anxious about the upcoming surgery. 3.) These are normal side effects of an anticholinergic drug; adverse side effects would include ECG changes, constipation, and urinary retention. An adult with COPD is scheduled for surgery and the physician has recommended an epidural anesthetic. The nurse should know that general anesthesia was not recommended for this client because: 1.) there is too high a risk for pressure sores to develop 2.) there is less effect on the respiratory system with epidural anesthesia. 3.) CNS control of the vascular constriction would be affected with general anesthesia. 4.) there is too high a risk of lacerations to the mouth, bruising of lips, and damage to teeth. 2.) Epidural anesthesia does not cause resp. depression, but general anesthesia can. especially in a client with COPD. A patient is now in the recovery room after having vaginal surgery. Due to the positioning of the procedure, you would want to assess for what while the patient is in recovery? A. Bowel Sounds B. Dysrhythmia C. Homan's Sign D. Hemoglobin Level C After surgery your patient is semicomatose with vital signs within normal limits. As the nurse, what position would be best for this patient? A. Semi-Fowlers B. Prone C. Low-Fowlers D. Side positioning preferably on the left side

D

After surgery your patient starts to shiver uncontrollably. What nursing intervention would you do FIRST?* A. Apply warm blankets & continue oxygen as prescribed B. Take the patient's rectal temperature C. Page the doctor for further orders D. Adjust the thermostat in the room A The nurse is monitoring the patient who is 24 hours post-opt from surgery. Which finding requires intervention?* A. BP 100/ B. 24 - hour urine output of 300 ml C. Pain rating of 4 on 1- 10 scale D. Temperature of 99.3' F B A patient is 6 days post-opt from abdominal surgery. The patient is to be discharged later today. The patient uses the call light and asks you to come to his room and look at his surgical site. On arrival, you see that approximately 2 inches of internal organs are protruding through the incision. What intervention would you NOT do?* A. Put the patient in prone position with knees extended to put pressure on the site B. Cover the wound with sterile normal saline dressing C. Monitor for signs of shock D. Notify the MD and administer as prescribed antiemetic to prevent vomiting A A patient reports he hasn't had a bowel movement or passed gas since surgery. On assessment, you note the abdomen is distended and no bowel sounds are noted in the four quadrants. You notify the MD. What non-invasive nursing interventions can you perform without a MD order? A. Insert a nasogastric attached to intermittent suction B. Administer IV fluids C. Encourage ambulation, maintain NPO status, and monitor intake & output D. Encourage at least 3000 ml of fluids per day C What is a potential postoperative concern regarding a patient who has already resumed a solid diet?* A. Failure to pass stool within 12 hours of eating solid foods B. Failure to pass stool within 48 hours of eating solid foods C. Passage of excessive flatus D. Patient reports a decreased appetite

B

A nurse is developing a care plan for a patient who is at risk for developing pneumonia after surgery. Which of the following is not an appropriate nursing intervention?* A. Encourage patient intake of 3000 ml/day of fluids if not contraindicated B. Encourage patient to use the incentive spirometer device 10 times every 1 - 2 hours while awake C. Encourage early ambulation and patient to eat meals in beside chair D. Repositioning every 3 - 4 hours D When assessing your patient who is post-opt, you notice that the patient's right calf vein feels hard, cord-like, and is tender to the touch. The patient reports it is aching and painful. What would NOT be an appropriate nursing intervention for this patient?* A. Allow the patient to dangle the legs to help increase circulation and alleviate pain B. Instruct the patient to not sit in one position for a long period of time C. Elevate the extremity 30 degrees without allowing any pressure on affected area D. Administer anticoagulants as ordered by MD A A patient is recovering from surgery. The patient is very restless, heart rate is 120 bpm and blood pressure is 70/53, skin is cool/clammy. As the nurse you would?* A. Continue to monitor the patient B. Notify the MD C. Obtain an EKG D. Check the patient's blood glucose B A patient is taking Aspirin 325 mg PO by mouth daily. The patient is scheduled for surgery in a week. What education do you provide the patient with before surgery?* A. Educate the patient to take the scheduled dose of Aspirin the day of surgery to help prevent blood clots B. To hold his morning dose of Aspirin because the nurse will give it to him before surgery C. None of the above are correct D. The medication should be discontinued for 48 hours prior to the scheduled surgery date D You are observing your patient use the incentive spirometry. What demonstration by the patient lets you know the patient understands how to use the device properly?* A. The patient inhales slowly on the device and maintains the flow indicator between 600 to 900 level B. The patient blows on the mouthpiece rapidly.

C. The patient uses the incentive spirometry once a day D. The patient rapidly inhales on the devices and exhales A As the nurse you are getting the patient ready for surgery. You are completing the preoperative checklist. Which of the following is not part of the preoperative checklist?* A. Assess for allergies B. Conducting the Time Out C. Informed consent is signed D. Ensuring that the history and physical examination has been completed B You are completing the history on a patient who is scheduled to have surgery. What health history increases the risk for surgery for the patient?* A. Urinary Tract infections B. History of Premature Ventricle Beats C. Abuse of street drugs D. Hyperthyroidism C As a nurse, which statement is incorrect regarding an informed consent signed by a patient?* A. The nurse is responsible for obtaining the consent for surgery B. Patients under 18 years of age may need a parent or legal guardian to sign a consent form C. The nurse can witness the client signing the consent form D. It is the nurse's responsibility to ensure the patient has been educated by the physician about the procedure before informed consent is obtained A The nurse is preparing a client for surgery. What is the most effective method for obtaining an accurate blood pressure reading from the client? A. Obtain a cuff that covers the upper one third of the client's arm B. Position the cuff approximately 4 inches above the antecubital arm C. Use a cuff that is wide enough to cover the upper two thirds of the client's arm D. Identify the Korotkoff sounds, and take a systolic reading at 10 mmHg after the first sound C Which of the following items on a client's presurgery laboratory results would indicate a need to contact the surgeon? A.

Platelet count of 250,000/cu.mm B. Total cholesterol of 325 mg/dl C. Blood urea nitrogen (BUN)) 17 mg/dl D. Hemoglobin 9.5 mg/dl D To prevent complications of immobility, which activities would the nurse plan for the first postoperative day after a colon resection? Discuss A. Turn, cough, and deep breathe every 30 minutes around the clock B. Get the client out of bed and ambulate to a bedside chair C. Provide passive range of motion three times a day D. It is not necessary to worry about complications of immobility on the first postoperative day B In the recovery room, the postoperative client suddenly becomes cyanotic. What is the most appropriate nursing action? Discuss A. Start administration of oxygen through a nasal cannula B. Call for assistance C. Reposition the head and determine patency of airway D. Insert an oral airway and suction the nasopharynx C A client is scheduled for surgery in the morning. Preoperative orders have been written. What is the most important to do before surgery? A. Remove all jewelries or tape wedding ring B. Verify that all laboratory work is complete C. Inform family or next of kin

D.

Have all consent forms signed D The nurse is caring for a first day postoperative surgical client. Prioritize the patient's desired dietary progression. Arrange in sequence the dietary progression from 1 to 4: 1. Full liquid; 2. NPO; 3. Clear liquid; 4. Soft Discuss A. 1, 2, 3, 4 B. 2, 3, 1, 4 C. 2, 1, 4, 3 D. 4, 3, 2, 1 B A postoperative client receives a dinner tray with gelatin, pudding, and vanilla ice cream. Based on the foods on the client's tray, what would the nurse anticipate the client's current diet order to be: A. Bland diet B. Soft diet C. Full liquid diet D. Regular diet C The nurse is preparing the preoperative client for surgery. The following statements that indicate the client is knowledgeable about his impending surgery, except: Discuss A. "After surgery, I will need to wear the pneumatic compression device while sitting in the chair" B. "The skin prep area is going to be longer and wider than the anticipated incision" C. "I cannot have anything to drink or eat after midnight on the night before the surgery" D. "To ensure my safety, a 'time out' will be conducted in the operating room"

A

Which of the following is the primary purpose of maintaining NPO for 6 to 8 hours before surgery? Discuss A. To prevent malnutrition B. To prevent electrolyte imbalance C. To prevent aspiration pneumonia D. To prevent intestinal obstruction C The nurse will provide preoperative teaching on deep breathing, coughing and turning exercises. When is the best time to provide the preoperative teachings? Discuss A. Before administration of preoperative medications B. The afternoon or evening prior to surgery C. Several days prior to surgery D. Upon admission of the client in the recovery room B Which of the following factors ensure validity of informed written consent, except: Discuss A. The patient is of legal age with proper mental disposition B. If the patient is a child, secure consent from the parents or legal guardian C. The consent is secured before administration of preoperative medications D. If the patient is unable to write, the nurse signs the consent for the patient D Which of the following drugs is administered to minimize respiratory secretions preoperatively? A. Valium (diazepam)

B.

Phenergan (promethazine) C. Atropine sulfate D. Demerol (Meperidine) C Which of the following is experienced by the patient who is under general anesthesia? Discuss A. The patient is unconscious B. The patient is awake C. The patient experiences slight pain D. The patient experiences loss of sensation in the lower half of the body A Which of the following is most dangerous complication during induction of spinal anesthesia? A. Cardiac arrest B. Hypotension C. Hyperthermia D. Respiratory paralysis B Which of the following postoperative patients is at risk for respiratory complications? A. The obese patient with long history of smoking who had undergone upper abdominal surgery B. The patient with normal pulmonary function who had undergone upper abdominal surgery C. An adolescent patient with diabetes mellitus who had undergone cholecystectomy D. A football player who had undergone knee replacement surgery A

The patient had undergone spinal anesthesia for appendectomy. To prevent spinal headache, the nurse should place the patient in which of the following positions? Discuss A. Semi-Fowler's B. Flat on bed for 6 to 8 hours C. Prone position D. Modified Trendelenburg position B The nurse is admitting a patient to the operating room. Which of the following nursing actions should be given highest priority by the nurse? Discuss A. Assessing the patient's level of consciousness B. Checking the patient's vital signs C. Checking the patient's identification and correct operative permit D. Positioning and performing skin preparation to the patient C Which of the following assessment data is most important to determine when caring for a patient who has received spinal anesthesia? Discuss A. The time of return of motion and sensation in the patient's legs and toes B. The character if the patient's respiration C. The patient's level of consciousness D. The amount of wound drainage A The nurse is transferring the patient from the postanesthesia care unit to the surgical unit. Which of the following is the primary reason for gradual change of position of the patient? Discuss A.

To prevent muscle injury B. To prevent sudden drop of blood pressure C. To prevent respiratory distress D. To promote comfort B The nurse is caring for a patient who had undergone exploratory laparotomy. Which of the following postop findings should the nurse report to the physician? Discuss A. The patient pushes out the oral airway with his tongue B. The patient's urine output is 20 ml/hr for the past 2 hours C. The patient's vital signs are as follows: BP = 100/70 mmHg; PR = 95 bpm; RR = 9 minute; T = 36.8°C D. The patient's wound drainage B The patient had undergone thyroidectomy. Which of the following are the earliest signs of poor tissue perfusion and poor respiratory function? Discuss A. Cyanosis, lethargy B. Fast, thready pulse, bradypnea C. Apprehension and restlessness D. Faintness, pallor C The diabetic patient who had undergone abdominal surgery experiences wound evisceration. Which of the following is the most appropriate immediate nursing action? Discuss A. Cover the wound with sterile gauze moistened with sterile normal saline B. Cover the wound with sterile dry gauze

C.

Cover the wound with water-soaked gauze D. Leave the wound uncovered and pull the skin edges together A The patient had undergone total hip replacement. He complains of pain in the operative site. Which of the following is the appropriate initial nursing action? Discuss A. Administer the ordered analgesic B. Instruct the patient to do deep breathing and coughing exercises C. Assess the patient's pain level and vital signs D. Change the patient's position C Which of the following are not members of the sterile team in the operating room, except: A. Surgeon B. Scrub nurse C. Radiology technician D. Circulating nurse D The best position for kidney, chest, or hip surgery is: A. Supine B. Trendelenburg C. Lithotomy D. Lateral D An adult man is in the postanesthesia care unit (PACU) following a hemicolectomy. While in the PACU, the nurse will monitor his vital signs:

1.) continuously 2.) every 5 minutes 3.) every 15 minutes 4.) on a prn basis 3 in the PACU, vital signs are assessed every 15 minutes An adult who has had general anesthesia for major surgery is in the PACU. One of the signs that may indicate that his artificial airway should be removed is: 1.) gagging 2.) restlessness 3.) in increase in pain 4.) clear lungs on auscultation. 1 Gagging with the return of the gag reflex indicates that the client is able to manage his own secretions and patent airway. An adult is 6 days post abdominal surgery. Which sign alerts the nurse to wound evisceration? 1.) Acute bleeding 2.) Pink serous drainage 3.) Purple drainage 4.) severe pain 2 Pink serous drainage (looks like pink lemonade) suddenly gushing is usually the major symptom of wound dehiscence. An adult client's wound has been eviscerated. The nurse assesses his respiratory status because: 1.) dehiscence elevates the diaphragm. 2.) coughing increases the risk of evisceration. 3.) respiratory arrest commonly accompanies wound dehiscence. 4.) Splinting the wound will compromise respiratory status. 2 Coughing increases intra-abdominal pressure, which could force loops of bowel out through the open wound. An adult client has acute leukemia and is scheduled for a Hickman catheter insertion under local anesthesia. A MAJOR advantage of regional anesthesia is that the client: 1.) retains all reflexes 2.) remains conscious 3.) has retroactive amnesia 4.) is in the OR for a short period of time.

2.)The client receiving regional anesthesia has nerve impulses blocked but does not lose consciousness. An adult had a bunion removed under an epidural block. In the immediate Post-op period the nurse plans to assess the client for side effects of the epidural block that include which of the following: 1.) headache 2.) hypotension, bradycardia, nausea, vomiting 3.)hypertension, muscular rigidity, fever, and tachypnea. 4.) urinary retention 2.) hypotension, bradycardia, nausea and vomiting are all symptoms of sympathetic nervous system blockade, so the client should be closely monitored for these. An adult has just arrived on the general surgery unit from the PACU. Which of the following needs to be the initial intervention the nurse takes? 1.) assess the surgical site, noting the amount and character of drainage. 2.) assess for amount of urinary output and the presence of any distention. 3.) allow the family to visit with the client to decrease the anxiety of the client. 4.) take vital signs, assessing the first for a patient airway and the quality of respirations. 4.) a specific assessment priority is the evaluation of a patent airway and respiratory and circulatory adequacy. In the Per-op phase, a physicial orders a patient taken off of Coumadin (warfarin) and put on IV heparin. This change in medication will: 1.) Help the patient be more relaxed before her surgical procedure. 2.) Prevent blood clots. 3.) be more quickly reversible during surgery if needed. 4.) shortens the length of recovery time for post-op patients. 3.) Heparin is quickly reversible in the event of hemorrhage with Protamine sulfate, (Coumadin can be reversed with Vitamin K, but the results are much slower than with the heparin/protamine reversal) The nurse obtains a diet history from a pregnant 16 - year-old girl. The girl tells the nurse that her typical daily diet includes cereal and milk for breakfast, pizza and soda for lunch, and a cheeseburger, milk shake, fries, and salad for dinner. Which of the following is the MOST accurate nursing diagnosis based on this data?

1. Altered nutrition: more than body requirements related to high-fat intake
2. Knowledge deficit: nutrition in pregnancy
3. Altered nutrition: less than body requirements related to increased nutritional

demands of pregnancy

4. Risk for injury: fetal malnutrition related to poor maternal diet 3 A boy was riding his bike to school when he hit the curb. He fell and hurt his leg. The school nurse was called and found him alert and conscious, but in severe pain with a possible fracture of the right femur. Which of the following is the FIRST action that the nurse should take?
5. Immobilize the affected limb with a splint and ask him not to move.
6. Make a thorough assessment of the circumstances surrounding the accident.
7. Put him in semi-Fowler's position for comfort.
8. Check the pedal pulse and blanching sign in both legs. 1 A child undergoes a tonsillectomy for treatment of chronic tonsillitis unresponsive to antibiotic therapy. After surgery, the child is brought to the recovery room. Which of the following actions should the nurse include in the child's plan of care?
9. Institute measures to minimize crying.
10. Perform postural drainage every 2 hours.
11. Cough and deep-breathe every hour.
12. Give ice cream as tolerated. 1 A 16-year old patient with cystic fibrosis is admitted with increased shortness of breath and possible pneumonia. Which nursing activity is most important to include in the patient's care? A Perform postural drainage and chest physiotherapy every 4 hours B Allow the patient to decide whether she needs aerosolized medications C Place the patient in a private room to decrease the risk of further infection D Plan activities to allow at least 8 hours of uninterrupted sleep A A patient with a pulmonary embolus is receiving anticoagulation with IV heparin. What instructions would you give the nursing assistant who will help the patient with activities of daily living? Select all that apply. A Use a lift sheet when moving and positioning the patient in bed B Use an electric razor when shaving the patient each day C Use a soft-bristled toothbrush or tooth sponge for oral care D Use a rectal thermometer to obtain a more accurate body temperature E Be sure the patient's footwear has a firm sole when the patient ambulates A, B, C, E A patient with acute respiratory distress syndrome (ARDS) is receiving oxygen by a nonrebreather mask, but arterial blood gas measurements still show poor oxygenation. As the nurse responsible for this patient's care, you would anticipate a physician order for what action?

A Perform endotracheal intubation and initiate mechanical ventilation B Immediately begin continuous positive airway pressure (CPAP) via the patient's nose and mouth C Administer furosemide (Lasix) 100 mg IV push stat D Call a code for respiratory arrest A A patient with chronic obstructive pulmonary disease (COPD). Which intervention for airway management should you delegate to a nursing assistant (PCT)? A Assisting the patient to sit up on the side of the bed B Instructing the patient to cough effectively C Teaching the patient to use incentive spirometry D Auscultation of breath sounds every 4 hours A A patient with sleep apnea has a nursing diagnosis of Sleep Deprivation related to disrupted sleep cycle. Which action should you delegate to the nursing assistant (PCT)? A Discuss weight-loss strategies such as diet and exercise with the patient B Teach the patient how to set up the BiPAP machine before sleeping C Remind the patient to sleep on his side instead of his back D Administer modafinil (Provigil) to promote daytime wakefulness C After change of shift, you are assigned to care for the following patients. Which patient should you assess first? A A 60 - year old patient on a ventilator for whom a sterile sputum specimen must be sent to the lab B A 55 - year old with COPD and a pulse oximetry reading from the previous shift of 90% saturation C A 70 - year old with pneumonia who needs to be started on intravenous (IV) antibiotics D A 50 - year old with asthma who complains of shortness of breath after using a bronchodilator D After the respiratory therapist performs suctioning on a patient who is intubated, the nursing assistant measures vital signs for the patient. Which vital sign value should the nursing assistant report to the RN immediately? A Heart rate of 98 beats/min B Respiratory rate of 24 breaths/min C Blood pressure of 168/90 mm Hg D Tympanic temperature of 101.4 F (38.6 C) D

An experienced LPN, under the supervision of the team leader RN, is providing nursing care for a patient with a respiratory problem. Which actions are appropriate to the scope of practice of an experienced LPN? Select all that apply. A Auscultate breath sounds B Administer medications via metered-dose inhaler (MDI) C Complete in-depth admission assessment D Initiate the nursing care plan E Evaluate the patient's technique for using MDI's A, B The charge nurse is making assignments for the next shift. Which patient should be assigned to the fairly new nurse (6 months experience) pulled from the surgical unit to the medical unit? A A 58 - year old on airborne precautions for tuberculosis (TB) B A 68-year old just returned from bronchoscopy and biopsy C A 72 - year old who needs teaching about the use of incentive spirometry D A 69 - year old with COPD who is ventilator dependent C The high-pressure alarm on a patient's ventilator goes off. When you enter the room to assess the patient, who has ARDS, the oxygen saturation monitor reads 87% and the patient is struggling to sit up. Which action should you take next? A Reassure the patient that the ventilator will do the work of breathing for him B Manually ventilate the patient while assessing possible reasons for the high-pressure alarm C Increase the fraction of inspired oxygen on the ventilator to 100% in preparation for endotracheal suctioning D Insert an oral airway to prevent the patient from biting on the endotracheal tube B The nursing assistant tells you that a patient who is receiving oxygen at a flow rate of 6 L/min by nasal cannula is complaining of nasal passage discomfort. What intervention should you suggest to improve the patient's comfort for this problem? A Suggest that the patient's oxygen be humidified B Suggest that a simple face mask be used instead of a nasal cannula C Suggest that the patient be provided with an extra pillow D Suggest that the patient sit up in a chair at the bedside A The patient with COPD has a nursing diagnosis of Ineffective Breathing Pattern. Which is an appropriate action to delegate to the experienced LPN under your supervision? A Observe how well the patient performs pursed-lip breathing B Plan a nursing care regimen that gradually increases activity intolerance C Assist the patient with basic activities of daily living D Consult with the physical therapy department about reconditioning exercises

A

The patient with COPD tells the nursing assistant that he did not get his annual flu shot this year and has not had a pneumonia vaccination. You would be sure to instruct the nursing assistant to report which of these? A Blood pressure of 152/84 mm Hg B Respiratory rate of 27 breaths/min C Heart rate of 92 beats/min D Oral temperature of 101.2 F (38.4C) D To improve respiratory status, which medication should you be prepared to administer to the newborn infant with RDS? A Theophylline (Theolair, Theochron) B Surfactant (Exosurf) C Dexamethasone (Decadron) D Albuterol (Proventil) B When a patient with TB is being prepared for discharge, which statement by the patient indicates the need for further teaching? A "Everyone in my family needs to go and see the doctor for TB testing." B "I will continue to take my isoniazid until I am feeling completely well." C "I will cover my mouth and nose when I sneeze or cough and put my used tissues in a plastic bag." D "I will change my diet to include more foods rich in iron, protein, and vitamin C." B When assessing a 22 - year old patient who required emergency surgery and multiple transfusion 3 days ago, you find that the patient looks anxious and has labored respirations at the rate of 38 breaths/min. The oxygen saturation is 90% with the oxygen delivery at 6 L/min via nasal cannula. Which action is most appropriate? A Increase the flow rate on the oxygen to 10 L/min and reassess the patient after about 10 minutes B Assist the patient in using the incentive spirometer and splint his chest with a pillow while he coughs C Administer the ordered morphine sulfate to the patient to decrease his anxiety and reduce the hyperventilation D Switch the patient to a nonrebreather mask at 95% to 100% oxygen and call the physician to discuss the patient's status D

Which intervention for a patient with a pulmonary embolus could be delegated to the LPN on your patient care team? A Evaluating the patient's complaint of chest pain B Monitoring laboratory values for changes in oxygenation C Assessing for symptoms of respiratory failure D Auscultating the lungs for crackles D Which of these medication orders for a patient with a pulmonary embolism is more important to clarify with the prescribing physician before administration? A Warfarin (Coumadin) 1.0 mg by mouth (PO) B Morphine sulfate 2 to 4 mg IV C Cephalexin (Keflex) 250 mg PO D Heparin infusion at 900 units/hr A You are a team leader RN working with a student nurse. The student nurse is to teach a patient how to use and MDI without a spacer. Put in correct order the steps that the student nurse should teach the patient.

• A. Remove the inhaler cap and shake the inhaler
• B. Open your mouth and place the mouthpiece 1 to 2 inches away
• C. Tilt your head back and breathe out fully
• D. Hold your breath for at least 10 seconds
• E. Press down firmly on the canister and breathe deeply through your mouth
• F. Wait at least 1 minute between puffs. A A, C, B, D, E, F. B A, C, B, E, D, F. C C, A, B, E, D, F. D C, A, B, D, E, F. B You are acting as preceptor for a newly graduated RN during her second week of orientation. You would assign the new RN under your supervision to provide care to which patients? Select all that apply. A A 38 - year old with moderate persistent asthma awaiting discharge B A 63-year old with a tracheostomy needing tracheostomy care every shift. C A 56 - year old with lung cancer who has just undergone left lower lobectomy D A 49 - year old just admitted with a new diagnosis of esophageal cancer. A, B The nurse advises unlicensed personnel to provide oral hygiene for clients who are unable to perform it for themselves. Which technique should be emphasized?

A. Soft bristle brushing of teeth and tongue after every meal B. Moistened foam applicator swabbing of tongue, gums, and lips every 4 hours C. Frequent rinsing of the client's oral cavity with mouthwash D. Record observations about the client's oral cavity after each instance of oral care A A client admitted for a myocardial infarction is now stable. Appropriate activities to assign to unlicensed personnel would include all the following EXCEPT: A. Teaching about what foods are high in sodium B. Recording intake and output (I/O) C. Assisting with ambulation to the restroom D. Reporting to the nurse that the patient complained of chest pain A A client's total parenteral nutrition (TPN) infusion rate was too slow, and is now 3 hours behind schedule. The nurse should: A. Contact the health care provider B. Increase the rate to catch up to schedule C. Run the next bag of infusion at a slightly higher rate to make up the volume deficit D. Double the infusion rate until desired amount has infused A A telephonic case management nurse notes that a cardiac client's weight has increased 5 pounds in the last two days and the client's blood pressure is elevated, as measured by the client's home telephonic equipment. When calling the client to evaluate, which of the following questions should the nurse ask FIRST? A. "How are you feeling today?" B. "Are you experiencing any shortness of breath?" C. "How is the swelling in your legs?" D. "When did you last calibrate your equipment?" B A major hospital has received notification of a mass casualty event in the area. Which of the following actions should a charge nurse of an inpatient neurovascular floor do FIRST? A. Expedite discharge of appropriate clients B. Reallocate staff according to mass casualty plan of action C. Initiate paper charting methods for consistency D. Reduce vital sign frequency to every 8 hours for patients currently on the unit

B

Two clients have orders for blood transfusions. The first client is dehydrated and anemic secondary to pneumonia. The second client is postoperative with a blood pressure change from 134/62 preoperatively to 102/48 currently. The nurse should: A. Request both clients' blood transfusions at the same time B. Request a coworker to verify the compatibility of both units C. Ask another nurse to hang the first client's blood transfusion D. Call for and hang the second client's transfusion now D Which of the following interventions is most important when working with a rape victim? A. Affirming to the client that she did not deserve or cause the rape B. Encouraging the client to report the rape to legal authorities C. Reassuring the client that the attacker will be caught, put on trial, and jailed D. Telling the client she should resume sexual relations with her partner as soon as possible A In an effort to update the practice of unit nurses, which of the following methods is likely to be most effective and efficient for reeducating staff on the unit? A. Poster presentation with a required computer post-test B. Group email explaining the change in practice and linking to current research articles C. Interview each staff member about the updates D. Post the latest evidence-based articles inside each staff toilet stall A An emergency nurse is injured while restraining a client. The nurse manager debriefs uninjured personnel, and addresses which of the following about the injured coworker? A. Resignation of the coworker is expected B. Legal action against the client would be time-consuming C. The injured coworker can only return to work after a debriefing between client and coworker D. The coworker's emotional response may be similar to a crime victim's reponse D A patient arrives at the emergency department complaining of mid-sternal chest pain. Which of the following nursing actions should take priority? a. A complete history with emphasis on preceding events b. An electrocardiogram (EKG)

c. Careful assessment of vital signs d. Chest exam with auscultation C A nurse from medical-surgical unit is asked to work on the orthopedic unit. The medical-surgical nurse has no orthopedic nursing experience. Which client should be assigned to the medical- surgical nurse? Discuss o A. A client with a cast for a fractured femur and who has numbness and discoloration of the toes o B. A client with balanced skeletal traction and who needs assistance with morning care o C. a client who had an above-the-knee amputation yesterday and has a temperature of 101.4F o D. a client who had a total hip replacement 2 days ago and needs blood glucose monitoring D A nurse preceptor is working with a new nurse and notes that the new nurse is reluctant to delegate tasks to members of the care team. The nurse preceptor recognizes that this reluctance most likely is due to Discuss o A. Role modeling behaviors of the preceptor o B. The philosophy of the new nurse's school of nursing o C. The orientation provided to the new nurse o D. Lack of trust in the team members D The measurement and documentation of vital signs is expected for clients in a long term facility. Which staff type would it be a priority to delegate these tasks to? Discuss o A. Practical nurse (PN) o B. Registered Nurse (RN) o C. Unlicensed assistive personnel (UAP) o D. Volunteer

C

A client has had a tracheostomy for 2 weeks after a motor vehicle accident. Which task could the RN safely delegate to unlicensed assistive personnel (UAP)? Discuss o A. Teach the client how to cough up secretions o B. Changes the tracheostomy trach ties o C. Monitor if client has shortness of breath o D. Perform routine tracheostomy dressing care D An RN from the women's health clinic is temporarily reassigned to a medical-surgical unit. Which of these client assignments would be most appropriate for this nurse? o A. A newly diagnosed client with type 2 diabetes mellitus who is learning foot care o B. A client from a motor vehicle accident with an external fixation device on the leg o C. A client admitted for a barium swallow after a transient ischemic attack o D. A newly admitted client with a diagnosis of pancreatic cancer B The RN delegates the task of taking vital signs of all the clients on the medical-surgical unit to an unlicensed assistive personnel (UAP). Specific written and verbal instructions are given to not take a post-mastectomy client's blood pressure on the left arm. Later as the RN is making rounds, the nurse finds the blood pressure cuff on that client's left arm. Which of these statements is most immediately accurate? Discuss o A. The RN has no accountability for this situation o B. The RN did not delegate appropriately o C. The UAP is covered by the RN's license o D. The UAP is responsible for following instructions D

The nurse in a same-day surgery unit assigns the unlicensed assistive personnel (UAP) to provide a hernia patient with a lunch tray. Which statement by the nurse is most appropriate? Discuss o A. "Tell the family they can bring in a pizza if the patient would prefer that." o B. "Make sure the patient gets at least 2 cartons of milk." o C. "Stop the IV if the patient is able to eat solid food." o D. "Encourage the patient to eat slowly to prevent gas." D A staff nurse complains to the nurse manager that an unlicensed assistive personnel (UAP) consistently leaves the work area untidy and does not restock supplies. The best initial response by the nurse manager is which of these statements? o A. "I will arrange for a conference with you and the UAP within the next week" o B. "I can assure you that I will look into the matter" o C. "I would like for you to approach the UAP about the problem the next time it occurs" o D. "I will add this concern to the agenda for the next unit meeting" C The home care nurse has been managing a client for 6 weeks. What is the best method to determine the quality of care provided by a home health care aide assigned to assist with the care of this client? o A. Ask the client and family if they are satisfied with the care given o B. Determine if the home health aide's care is consistent with the plan of care o C. Investigate if the home health aide is prompt and stays an appropriate length of time for care o D. Check the documentation of the aide for appropriateness and comprehensiveness B Which one of these tasks can be safely delegated to a licensed practical nurse (LPN)? Discuss o A. Assess the function of a newly created ileostomy

o B. Care for a client with a recent complicated double barrel colostomy o C. Provide stoma care for a client with a well functioning ostomy o D. Teach ostomy care to a client and their family members C Which tasks should the registered nurse delegate to the unlicensed assistive personnel (UAP)? Select all that apply. A Empty foley bag B Refill water pitcher C Assess vital signs D Ask the patient if the pain med helped E Ambulate the patient to the bathroom A, B, E The RN is working with an UAP and LPN. Which assignment is most appropriate to assign to the LPN? A Emptying a urine catheter bag on a immobile patient B Assessing the lungs on a patient with leg cellulitis C Taking vital signs on the post-op patient D Teaching a newly diagnosed patient about diabetes B The charge nurse is working with a licensed practice nurse (LPN), unlicensed assistive personnel (UAP) and another registered nurse (RN). Which patient assignment is appropriate to delegate to the other RN? A Patient A with an arm fracture needs assisting with feeding and bathing B Patient B with diabetes and a wound infection needs the daily insulin injection C Patient C needs his chest pain re-assessed before giving a second dose of medication