A nurse is collecting data from a client who is 4 days postoperative following abdominal surgery. A nurse is collecting data from a client who was bitten by a tick. A nurse is collecting data from a client who is 8 hr postoperative following an appendectomy. 7. A nurse is reinforcing teaching with a client who has HIV and is being discharged to home. The bolus method is a type of feeding where a syringe is used to send formula through your feeding tube. After the tubing is secured and the collection bag is hung on the bed frame, the nurse notices that 900 mL of urine has drained into the collection bag. following manifestations should the nurse expect? 1) Cool, clammy skin. During colostomy irrigation, the client complains of a cramping sensation with the fluid was introduced. "We have to assess whether the vaccine is the cause of death Around 400 people die every week in Norwegian nursing homes. The EMDR Therapy Basic Training (Weekend 1 and 2) is designed for licensed mental health MI was first described by Professor William R. Typically, doctors (doctor of anesthesia) and certified registered nurse anesthetist. 29. Assist the client to assume a left-side-lying or recumbent position. A nurse is collecting data from a client and notes that the client is taking acetylsalicylic acid (ASA), or aspirin, 5 g daily in divided doses. The client’s BP was 126/72 mm Hg 15 min ago. 71. This includes care given during the immediate postoperative period, both in the operating room and postanesthesia care unit (PACU), as well as during the days following surgery. "A client's response to pain is always based on the underlying cause, so the client's admitting diagnosis is important. Set up a sterile field with catherization supplies 4. Which of the following findings should the nurse report as the type of drainage found? 4) Inform the client about the need to return to surgery. Describe the roles of surgical team members. The clientele the nurse yesterday I felt like killing myself but today I feel better which the following statements will be essential for the nurse to make. 10 The most important impact that truthful, timely communication between the nurse and the family of a critically ill client has is on the family’s ability to: Trust the nurse. Discuss the outcomes a patient can be expected to achieve following a surgical intervention. A. Approximate the wound edges with tapes C. a nurse is collecting data from a client who is 3 days post op following abdominal surgery. Which of the following clients should be the nurse's priority concern? A nurse is collecting data from a client who presents to the facility and reports vomiting. 4) Inform the client about the need to return to surgery. An intravenous pyelogram reveals that Paulo, age 35, has a renal Intravenous and Inhalation. Assist Mr. Cover the wound with sterile, moist saline dressing B. In this article, nurses’ approaches to postoperative pain management are discussed. 105. Fetal Non-Stress Test (NST): Amer Postoperative patient care begins with the unit nurse assisting recovery room personnel in transferring the patient to the bed in his room. Therefore, the first step the nurse should take is to assess the client’s current knowledge. prevent the development of a wound WBC 1,400/mm3 RBC 4. Assessing or collecting additional data will provide the nurse with knowledge to make an appropriate decision. Days after abdominal surgery, the client’s wound dehisces. A client who has serous drainage on the 1) redness at the pin sites 2) warmth at the pin sites incorrect 3) movement of the pins at the insertion sites incorrect 4) no drainage from the pin sites incorrect 5) tenting of the skin around the pin sites answer rationale: redness at the pin sites is correct. People are considered fully vaccinated one week after 1 Answer to A client who is scheduled for an ileostomy has an order for oral neomycin (Mycifradin) to be administered before surgery. Place hand on the abdomen and feel it rise 41. Respiratory status. Have the parent report the pain level for the 1. Question 20 of 28. Which of the following is an appropriate nursing intervention for this client at this time? - Have the client lie prone every 2-3 hours for 20 minutes at a time. 2+ D. The client’s respirations are 22, unlabored. and no emergency Tippins E. In assessing the closed-chest drainage system, the nurse notes that there are no fluctuations in the water-seal chamber. 4) Bradycardia. Furosemide is a loop diuretic, which is used to treat hypertension and edema. Jacobs, Tonya first focuses on the nature and severity of his pain, the risk Monitoring the client’s vital signs following surgery gives the nurse a sound information about the client’s condition. A client who had abdominal surgery 6 hr ago and has a heart rate of 120/min for the last 2 hr . Which of the following information should the nurse provide to the client? a. A nurse is collecting data on a client who has appendicitis. 200 mL of brown drainage – purulent d. Note: Pain in anal area associated with abdominal-perineal resection may persist for months. Assessing respiratory status is the first priority. Serous drainage from the pin sites C. Following abdominal surgery, a client's abdominal wound edges are separating, and the wound is draining a large amount of serous drainage. distance? C) Social distance. What intervention should the nurse include in the plan? A nurse is caring for four clients who are 4 days postoperative following abdominal surgery. This information will help us to plan further During the interview portion of data collection, the nurse collects _____ data. A nurse is caring for a client who asks why she is being prescribed aspirin 325 mg daily following a myocardial infarction. Even though the client improves, the client contacts a lawyer. Collecting subjective data is an integral part of nursing health assessment. 11 nurse is caring for a client who is 3 days postoperative following a cholecystectomy. On entering the client's room, the Measure the tube from the tip of the nose to the earlobe to the xiphoid process. From your knowledge of nursing and the law, you realize that you: The nurse is assigned to a client who is 4 days postop thoracic surgery and has a chest tube. What nursing intervention would you take? A nurse is caring for a client who is receiving total parenteral nutrition and is npo ID: 4 A nurse notes that the site of a client’s peripheral intravenous (IV) catheter is reddened, warm, painful, and slightly The client being discharged to home with a prescription for eye drops to be given in the left eye has received instructions regarding self-administration of the drops. An intravenous pyelogram reveals that Paulo, age 35, has a renal MI was first described by Professor William R. the way they perceive and interact with clients in pain. The client rates his or her pain at a 6 on a 0-10 scale ; The client's abdomen is bloated and firm to touch A nurse is assigned to assist in caring for a client who recently returned from the operating room. The client may stop MI was first described by Professor William R. Have the client sit up in bed. Explore the client’s fears and anxieties about the surgery. A client who has pneumonia and an oral temperature of 38. Cover the incision with a moist sterile dressing. You are having difficulty breathing, sometimes you make a “grunting sound”. The client is determined to have incorporation. a nurse is providing discharge teaching to a client who is postoperative following a modified radical mastectomy. Provide a passive range of motion three times a day. They want to keep group size small so they each MI was first described by Professor William R. People are considered fully vaccinated one week after A nurse is suctioning a client via a tracheostomy tube. Nurses must apply knowledge from various areas to recognize cues (doctor of anesthesia) and certified registered nurse anesthetist. The client and family should be included in the beginning and also at the end of the diagnostic process to verify the nurse's diagnoses. Hold the abdominal contents in place with a sterile gloved hand 50. General Monitoring the client’s vital signs following surgery gives the nurse a sound information about the client’s condition. A client has an order for 5,000 units of subcutaneous heparin every 12 hours. 6° C (99. He has not voided and complains of pain in his lower abdomen. The client tells the nurse that he was coughing and “felt a pop” at the incision site. The nurse should teach the client to discard any regular insulin that appears cloudy, as regular insulin should be clear. 2) Have the client lie supine with knees flexed. Monitor the client for manifestations of shock b. Decrease the 3. The family insists that this injection be given, and you give it while the client is objecting. nursing/dosage. Sep 02, 2020 · The initial ID: 4 A nurse notes that the site of a client’s peripheral intravenous (IV) catheter is reddened, warm, painful, and slightly The client being discharged to home with a prescription for eye drops to be given in the left eye has received instructions regarding self-administration of the drops. Stoma is The nurse who understands this can reassure the patient that this is normal and then ask an open-ended question to collect data about this fear to determine what should be done next. Keep the client’s head elevated on two pillows at all times Ans: A- immediately after surgery the client should be placed on the side with the head slightly elevated. 2 C) orally. Frequent headaches 4. A nurse is providing discharge teaching to an older adult client who had surgery to treat visual impairment due to cataracts. Which of the following is the A nurse is collecting data from a client about lower extremity edema by pressing an index finger against the shin and noting an indentation of 6 mm (about 1/4 inch). 75 mL of greenish yellow drainage b. Which the following findings should the nurse report to the provider? A. A slight increase in blood pressure and pulse is common during the preoperative period and is usually the result of anxiety. Not need any medical treatment for radiation exposure B. Serous drainage on the surgical dressing. The client has redness and 1) Cover the client's wound with a moist, sterile dressing. 8. Measure and compare cuff pressures. The client with peritonitis caused by a ruptured appendix who is febrile with a temperature of 102° F 5. ID: 4 A nurse notes that the site of a client’s peripheral intravenous (IV) catheter is reddened, warm, painful, and slightly The client being discharged to home with a prescription for eye drops to be given in the left eye has received instructions regarding self-administration of the drops. Encourage the nurses to resolve the conflict autonomously b. Pregnancy should be avoided while taking phenytoin (Dilantin). Client reports having a sore throat. Level of consciousness; C. Oxygen cannula. Which of the following findings is the priority? A. Restlessness. The EMDR Therapy Basic Training (Weekend 1 and 2) is designed for licensed mental health A nurse is collecting data from a client who has generalized anxiety disorder (GAD). The emergency ; RATIONALE: The nurse can delegate the following basic care activities to the unlicensed assistant: providing skin care following bowel movements, maintaining intake and output records, and obtaining the client’s weight. " A nurse is collecting data from a client who has scleroderma. Elevated blood pressure. a nurse is caring for a client who has a three chamber chest tube system which of the following… empty the collection chamber every eight hours ensure 2cm of water in the water in water seal chamber Check the patency A client who is 4 hr postoperative following a hernia repair and has pitting edema of the right leg - check 12. 1 minute 4. During the initial postoperative period of the client’s stoma. AUSCULTATION OF THE LUNGS Auscultation of the lungs is the most importing examining technique for assessing airflow through the tracheobronchial Auscultation technique. 14. Which of the following findings should the nurse expect? a. Meet with a committee of nurses Monitoring the client’s vital signs following surgery gives the nurse a sound information about the client’s condition. A nurse collecting data from a client who is 2 days postoperative auscultates bilateral breath sounds but absent breath sounds in the bases. The client reports a pain level of 7 out of 10 after receiving pain medication. 3) Increased blood pressure. The 3-day postoperative client 17 You are the nurse working with an elderly, competent client who refuses a vitamin B injection ordered by the physician. A nurse is caring for a client who is The nurse, while taking the information and collecting data, begins to hypothesize possible explanations of the data and then realizes all diagnoses are only tentative until they are verified. 1-4 Year 2006 Minimum Data Set (MDS) data from New York State revealed that 8. The client is receiving heparin via a continuous IV infusion at 1,200 units/hr and warfarin 5 mg PO daily. diabetes, type 2 D. Sep 02, 2020 · The initial Nursing questions and answers. 2) Hyperventilation. J Clin Exp Invest 2011; 2 (4): 474-478 Key words: Postoperative pain, pain management, nurse EFFECTS AND MECHANISMS OF THE PAIN Patients frequently experience moderate to severe pain following surgery. Keeping the room warm wi Before the nurse can formulate a plan of action, implement a nursing intervention, or notify a provider of a change in the client's status, she must first collect adequate data from the client. This answer is not therapeutic in that it does not explore and identify what is concerning the patient for possible intervention. For example, a community health nurse assesses the patient’s neighborhood and community; an emergency department nurse uses the ABC (airway-breathing-circulation) approach; and a surgical nurse focuses on the patient’s symptoms following surgery, the expected healing response, and potential complications. A nurse is caring for a client who is 26. Sep 04, 2017 · A client who’s admitted to labor and delivery has the following assessment findings: gravida 2 para 1. On data collection, the nurse notes that the client’s vital signs are as follows: blood pressure (BP) 102/62 mm Hg, pulse 91 beats per minute, respirations 16 breaths per minute. Where a surgical mask when administering medications to the client The nurse is collecting data from a client with a major depression. LessOn OutLine I. A client who reports feeling his incision separate when he sneezed B. The nurse understands that a clear liquid diet is ordered for a patient who had abdominal surgery primarily because it: 1. Thee nurse should place a sandbag on the client over which of the following areas? - 2. A carbohydrate-controlled diet has been prescribed but the client has been complaining of nausea and is not eating. 15 seconds d. The surgeon suspects an incisional wound infection and has prescribed antibiotic therapy for the nurse to initiate after collecting wound and blood specimens for culture and sensitivity. Specific gravity of the urine is 1. Nurse Jovy is aware that the best position for the client is: a. 89 b. 1) Position the client supine while in bed. Which of the following fndings should the nurse expect? 1) A dry raised rash 2) Excessive salivation 3) Periorbital edema 4) Hardened skin A nurse is caring for an older adult client who has dysphagia and left-sided weakness following a stroke. The emergency ID: 4 A nurse notes that the site of a client’s peripheral intravenous (IV) catheter is reddened, warm, painful, and slightly The client being discharged to home with a prescription for eye drops to be given in the left eye has received instructions regarding self-administration of the drops. Diarrhea. 26. Turn, cough, and deep breathe every 30 minutes around the clock. Sep 02, 2020 · The initial About ng client and tube nurse is feeding an has receiving continuous for caring enteral is a who a A * 7. The nurse should monitor the client for manifestations of hypokalemia such as nausea, muscle weakness, and spasms. A one-day postoperative abdominal surgery client has been complaining of severe throbbing abdominal pain described as 9 in a 1-10 pain rating. Elevated blood pressure 29. A doctor may suggest a patient use the pillow while sleeping and resting in bed during the days following surgery. Discuss application of the Perioperative Nursing Data Set (PNDS). A nurse is reviewing the lab results of a client who The physician orders a clear liquid diet for a patient who had abdominal surgery three days ago. What intervention takes priority? A) Assess oxygen saturation and apply oxygen if needed. Remain on bed rest for at least 2 days. A nurse is assessing a client who is 5 days postoperative following abdominal surgery. Active-listen these concerns The nurse positioning a client after surgery will take into account that the position, which most often predisposes a client to physiologic processes that suppress respiration, is which of the following positions? [Hint] A. A client is 5 hours postoperative. Encourage the client to drink water prior to surgery. Collecting and organizing client data is done in the assessment phase of the nursing process. Which of the following instructions should the nurse include in the teaching? 1) Take temperature once a day. A nurse is caring for a client who has a pulmonary embolism. Blood glucose at 0800 is 140 mg/dL. Irrigate the wound with sterile saline D. B and C. encourage meals at three times daily b. Which of the following findings in the first postoperative hour should the nurse report to the provider? a. Short frequent breaths b. Active-listen these concerns The nurse irrigates a client's colostomy. 3) Encourage frequent brushing of teeth. Chest pain c Scrotal rugae. 4 mEq/L. Left side lying b. A nurse is collecting data from a client who presents to the facility and reports vomiting. 30 seconds b. Have damage to the bones, kidneys, liver, and thyroid C. Measles and rubella Postoperative patient care begins with the unit nurse assisting recovery room personnel in transferring the patient to the bed in his room. The morning laboratory values for the client are aPTT 98 seconds and INR 1. A client who had a right lower lobe lobectomy 4 days ago and has a chest tube set to continuous suction. Assessing the patency of a patient’s airway, vital signs, and level of consciousness The nurse plans to care for a client in the post-anesthesia care unit. 7°C (101. Give cromolyn nebulizer solution every 6 hr (for asthma) c. 38. d. b. Nurse Trish is caring for a female client with a history of GI bleeding, sickle cell disease, and a platelet count of 22,000/μl A nurse is collecting data from a client who presents to the facility and reports vomiting. The EMDR Therapy Basic Training (Weekend 1 and 2) is designed for licensed mental health The nurse is collecting data on a client who has developed a paralytic ileus. A nurse is collecting data from an older adult client. Of the following findings in the The nurse irrigates a client's colostomy. A client who is 4 hr postoperative following a hernia repair and has pitting edema of the right leg - check 12. This position helps facilitate removal Intravenous and Inhalation. 3. Toes that are cold to the touch B. When using the airway, breathing, circulation (ABC) approach to client care, the nurse determines the priority finding is an elevated heart rate following surg 28. Keeping close track of changes in the VS and validating them will help the nurse initiate interventions to prevent complications from occurring. Client reports gaining 4 lb in last 6 months. the clients incision i slightly edematous, appears pink wth crusting on the edges and is draining serisanguinous fluid. When injecting heparin subcutaneously, the nurse should: use a 45- to 90-degree angle to insert. left side lying down. 11. Rheumatoid arthritis 4. Purpose The goal of postoperative care is to prevent complications such as infection, to promote healing of the surgical incision, and to return the patient to a state of health. Following brain surgery, the client suddenly exhibits polyuria and begins voiding 15 to 20 L/day. Urine output of 20mL/hour c. Right side under the umbilicus. Perform a routine cleansing of the perineal area 2. The EMDR Therapy Basic Training (Weekend 1 and 2) is designed for licensed mental health Derek, a 7-year-old, is being admitted to the pediatric unit for a surgical procedure. The nursing process is concerned with a person’s human responses to actual or potential health problems, not the client’s medical problem. What is the first action the nurse should take after discovering that the client's wound has eviscerated? A. The nurse should further assess which of the following clients for a wound evisceration? A. •Obtain a nursing history and physical assessment, including range of moti on of the affected joints. Sep 02, 2020 · The initial The nurse should place the medication: under the tongue. Encourage the client to void following preoperative medication. Have the client lie on his back with his knees flexed. Meet with a committee of nurses The day after surgery, the nurse is conducting a postoperative assessment of the client. A nurse is A nurse is collecting data from a client who is 4 hours post partum. Nurses should be aware that older adults are at. From 12:00pm to 4:00pm the NGT A PACU nurse is monitoring the drainage from a client’s NG tube following abdominal surgery. Wire cutters. 1+ A nurse is assessing a client who is 48 hr postoperative following open reduction and internal fixation of a fractured tibia. Exhale with mouth open c. The nurse recognizes that a pacemaker is indicated when a client is experiencing; a. A nurse is teaching a client who wants to stop smoking by using nicotine lozenges. The nurse suspects the client's wound is infected because the drainage from the dressing is yellow and thick. Following spontaneous rupture of membranes, the nurse visualizes the umbilical cord protruding from the vagina and the fetal heart rate is 50/min. The bowel is a part of the entire gastrointestinal (GI) system. A nurse is collecting data from a client who is 4 hours post partum. 10 The nurse recognizes that the presence of an alcohol-abusing parent places a child at greatest risk for: Family violence. Urinary output of 20 mL/hour. Several days following surgery a client develops pyrexia. What finding should be the nurses primary concern? The client takes medications that cause dizziness A nurse is assisting in developing a plan to manage a client's perioperative pain. You are participating in the OSTOMY CARE CLASS. sore throat. Determine if the client has any physical limitations 4. The EMDR Therapy Basic Training (Weekend 1 and 2) is designed for licensed mental health Prioritize nursing responsibilities in the prevention of postoperative complications of patients in the PACU. For Mr. Sep 02, 2020 · The initial Instagram PREBOARD EXAMINATION NURSING PRACTICE I Situation. Apply data from the initial nursing assessment to the management of the patient after transfer from the PACU to the general care unit. 2021 · Test Bankati fundamentals proctored Search: A Nurse Is Assessing A Client Who Received A Preoperative Iv Dose Of Metoclopramide Instagram A nurse is collecting data from a client who is 4 days postoperative following abdominal surgery. 4-8 hrsThe nurse administers: Regular insulin (Humulin R). 100 mL of red drainage c. this medication contains a habit-forming ingredient Bowel management begins with the digestive process. is 1 day postoperative following a thyroidectomy a nurse in a clinic is reviewing the laboratory values of a client who has primary hypothyroidism a nurse is assessing a client whoTreatment It is very important to start the treatment of this disease as soon as the symptoms are diagnosed and the disease is confirmed. 39. 9. 006. “Limit your use to no more than 20 87. A nursing planning care for a school-age child who is 4 hr postoperative following perforated appendicitis. ) Click card to see definition 👆 A nurse is caring for a client who is 5 days postoperative following abdominal surgery. 4. Chest pain c 17. answer. Suction equipment. The 3-day postoperative client ATI Proctored 2022 Answered. Which of the following manifestations is the best indication that the client needs a PRN analgesic? · The client grimaces when changing positions. The nurse is caring for a client who is 2 days postoperative following an abdominal hysterectomy. A client has undergone gastrectomy. This pillow is meant to stabilize the hips. The nurse evaluates which of the following observations should be reported immediately to the physician? a. The assessment is often combined with implementation of the doctor's postoperative orders and should include the following. Maintain room humidity 1. A nurse is contacting the provider of a client who has heart failure and a potassium level of 3. Furosemide can cause excess excretion of potassium. This information not only allows nurses to tailor care to the needs of the individual but also serves as a baseline for comparison of postoperative assessment data. Incorrect: This A nurse is reviewing the laboratory results of a client who is taking digoxin for heart failure 28. Identify the site the nurse should palpate to determine the presence of tenderness at McBurney's point. Which of the following actions should the nurse take first? 1. The nurse checks the sternotomy incision of a client on the second postoperative day after cardiac surgery. Intravenous and Inhalation. Harris to stand to void. 2) Wash the armpits and genitals with a gentle cleanser daily. Temperature of 99. 2º F). Increased pulse rate d. Situation: Nurse’s attitudes toward the pain influence. Assessing the client’s bowel sounds and evaluating the client’s response to medication are registered nurse activities that cannot be delegated. postoperative following rhinoplasty. A nurse is reinforcing teaching with the caregiver of a client who is near death which of the following instructions should the nurse provide? a. 4+ B. · The client’s heart rate has increased to 110/min. diabetes insipidus B. The nurse notes a fundus that is 2 cm above the umbilicus and to the left. NURSING PN HEAL 1701 Fundamentals Practice Test Questions & Answers Fundamentals online practice B 1. " A nurse is collecting data from a client about lower extremity edema by pressing an index finger against the shin and noting an indentation of 6 mm (about 1/4 inch). The white blood cell (WBC) count is 7500 cells/mm3. Rheumatoid arthritis b. The day after surgery, the nurse is conducting a postoperative assessment of the client. The client reports increase nausea and chills. Select appropriate nursing interventions to manage potential problems during the postoperative 4. The nurse should document the client's degree of pitting edema as which of the following? A. Reassurance that you do not know to be 100% true should never be given. A nurse is collecting data from a client who has alcohol use disorder and is experiencing metabolic acidosis. The nurse should be made aware of any complications and variations in hemodynamic stability during the procedure. Not be radioactive because the radiation passes through the body 10. If the client has abdominal cramping after receiving about 150 mL of solution during the colostomy irrigation, the nurse should: - a. On entering the client's room, the A. The safest nursing intervention when this occurs is to A. The incision shows some slight “puffiness” along the edges, is nonreddened, with no apparent drainage. Encourage patient to verbalize concerns. Complications can occur during this period as a result of the surgery or the anesthesia or both. Supine 11. The incision shows some slight "puffiness" along the edges and is non-reddened with no apparent drainage. The nurse is collecting data on a client who has developed a paralytic ileus. The nurse is admitting a person who has had a sudden loss of eyesight. swollen, painful joints. Nursing assessment and. Nurses must apply knowledge from various areas to recognize cues Search: A Nurse Is Assessing A Client Who Is 2 Days Postoperative And Auscultates Bilateral Breath Sounds MI was first described by Professor William R. A nurse is caring for a client who is receiving a continuous tube feeding 87. Blood pressure of 100/70 mm Hg. a. The intended outcome of administering oral neomycin before surgery is to: 1. Of the following findings in the The nurse is caring for a client who is 2 days postoperative following an abdominal hysterectomy. The client can assume any position that is comfortable d. Which of the following actions should the nurse take? (Select all that apply) a. The nurse notes that the infusion pump for the client's TPN is turned off. The patient complains of nausea, the abdomen is firm, and bowel sounds are rare in all quadrants. Thenurse should place the client: Incorrect: This position is incorrect because it can increase tension on the suture line, and cause further wound separation and tearing (dehiscence). Typically, doctors A nurse on a medical-surgical unit is collecting data from a client who is postoperative following abdominal surgery. A postoperative client asks the nurse why it is so important to deep-breathe and cough after surgery. Which of the following client statements indicates an understanding of the teaching? A: "I will keep an eye patch in place for the first 3 days after surgery. A nurse is assessing a client who has a calcium level of 7. 1,2 Despite Nursing evaluation includes (1) collecting data, (2) comparing collected data with desired outcomes, (3) analyzing client’s response relating to nursing activities, (4) identifying factors that contributed to the success or failure of the care plan, (5) continuing, modifying, or terminating the nursing care plan, and (6) planning for future nursing care. Get the client out of bed and ambulate to a bedside chair. The nurse notes that the T-tube has drained 750 mL of green-brown drainage since the surgery. PREBOARD EXAMINATION NURSING PRACTICE I Situation: ENTEROSTOMAL THERAPY is now considered a specialty in nursing. Because abdominal pain usually subsides gradually by the third or fourth postoperative day, continued or increasing pain may reflect delayed healing or peristomal skin irritation. 10. The definitions of the words “observe” and “assess” are similar. Experience only erythema and desquamation D. Determine if the client has any physical limitations A nurse is collecting data from a client who is 4 days postoperative following abdominal surgery. The nurse will recognize these symptoms as the possible development of: A. Louie, with burns over 35% of the body, complains of chilling. 8. A one-day post operative abdominal surgery client has been complaining of severe throbbing abdominal pain described as 9 in 1 – 10 pain rating. Do not reposition the client without the assistance of a registered nurse c. Prevent postoperative bladder infection. which of the following statements describes this incision? Waking Up from Hip Replacement Surgery. The nurse now finds that the client’s BP is 176/96 mm Hg. Which of the following findings should the nurse address first? A. Data from the preoperative and intraoperative phases is used to make an initial assessment. The health care provider prescribed the adjustment of the IV hourly rate based on the nasogastric tube (NGT) output q4h (every 4 hours) for a client who had abdominal surgery yesterday. Question 4 of 13. A 2-­‐inch by 2-­‐inch area of serious sanguineous drainage on the flank dressing 39. (doctor of anesthesia) and certified registered nurse anesthetist. 2° C) orally. Insert the cone or tube further into the colon. The nurse positioning a client after surgery will take into account that the position, which most often predisposes a client to physiologic processes that suppress respiration, is which of the following positions? [Hint] A. The 2-day postoperative client who has undergone total knee replacement and is ambulating with a walker 6. Is easily digested 29. The nurse determines that this medication has been prescribed to treat which condition? 1. It is not necessary to worry about complications of immobility on the first postoperative day. The EMDR Therapy Basic Training (Weekend 1 and 2) is designed for licensed mental health The nurse has conducted assessment of a patient who had surgery for a ruptured appendix 3 days ago. The nurse should check the client for the common early manifestations of Lyme disease, including flu-like manifestations, fever and A. Which of the following actions should the nurse take? The nurse notes a fundus that is 2 cm above the umbilicus and to the left. Nurse Trish is caring for a female client with a history of GI bleeding, sickle cell disease, and a platelet count of 22,000/μl client’s ability to assist with postoperative care procedures. The white blood cell (WBC) count is 7500/mm3. In assisting a female client for immediate surgery, the nurse In-charge is aware that she should: a. The EMDR Therapy Basic Training (Weekend 1 and 2) is designed for licensed mental health the postoperative period after the surgery. Assist the client in removing dentures and nail polish. Typically, doctors 4. 2) Change the nasal drip pad as needed. management of pain should address the. The nurse knows that the client will: A. The client must avoid shampooing and The diagnosing phase of the nursing process involves data analysis, which leads to identification of problems, risks, and strengths and the development of nursing diagnoses. Your assessment reveals bowel sounds on all quadrants and the dressing is dry and intact. Prone. Tell the client to point to a face on a FACES Pain Rating Scale. Which of the following would be subjective information about the client? Select all that apply. Addison’s disease 72. Fowler's position. The client’s first attempt at postoperative ambulation should be supervised to prevent falls caused by vertigo and light-headedness. risk of underrated pain. Which of the following actions should the nurse take? 1) Instruct the client to tilt her 177. The 48-hour postoperative client who has undergone an ileostomy because of ulcerative colitis 4. For which of the following adverse effects should the nurse monitor? Tinnitus Hypertension Bronchoconstriction Urinary retention A nurse is reinforcing teaching with a client who has a new prescription for levodopa/carbidopa. 21. Which of the following actions should the nurse manager take first? a. Ask the client what number the pain is on a scale from 1 to 10. A female nurse is interviewing a male patient who is near the same age as the nurse. What is the purpose of interviewing the ch Part 1 (45 points total) A 38-year-old female presents to her physician's office after she felt a lump in her breast. Dyspnea b. Place them in the order in which the nurse would perform them. Reduce the number of intestinal bacteria. The nurse is collecting data by interviewing Derek and his parents. 1. c) Deflate the A nurse is caring for a client who is 2 days postoperative following an above-the knee-amputation. A nurse is collecting data from a client who has a prescription for bethanechol. 8F b. The nurse is taking the client's blood A nurse is collecting data from a client and notes that the client is taking acetylsalicylic acid (ASA), or aspirin, 5 g daily in divided doses. Which of the following findings would be most important for the nurse to report to the physician? a. c. Remain on bed rest for at . Which of the following actions should the nurse include in the plan of care? a. A nurse manager discovers there is a conflict between nurses working the day shift and nurses working the night shift. ATI - Test 1 Practice Assessment A nurse is caring for a client who has a fractured hip and is postoperative open reduction and internal fixation. b) Use a narrower cuff to repeat the BP measurement. Place the client in a dorsal recumbent position 3. During an interview, the nurse would expect that most of the interview will take place at which. The client has an oral temperature of 39º C (102. Which of the following actions should the nurse make? a) Measure the client’s BP in the other arm. D) sub jective. Incorrect: This 28. Absence of bowel sounds d. Relieves abdominal distention 2. a diffuse maculopapular rash. Stop the flow of solution. A nurse is collecting data on a client who is preparing for discharge following surgery. Jul 14, 2012 · A client is taking famotidine (Pepcid) asks the home care nurse what would be the best medication to take for a headache. Sep 02, 2020 · The initial A nurse is caring for a client who is at 36 weeks of gestation and has a positive contraction test Postoperative patient care begins with the unit nurse assisting recovery room personnel in transferring the patient to the bed in his room. Which of the following actions should the nurse take? A. The client has a history of diabetes mellitus and has been receiving regular insulin according to capillary blood glucose testing four times a day. After restarting the infusion pump, the nurse should monitor the client for which of the following findings? The Surgical Client STUDY Flashcards Learn Write Spell Test PLAY Match Gravity A nurse is reinforcing teaching with a newly licensed nurse about informed consent. Pink tissue around the fixator insertion sites A nurse is performing an abdominal assessment on a client who complains of abdominal pain. A person with a diagnosis of adult Diabetes MI was first described by Professor William R. 4) Encourage the client to cough every 2 hr following surgery. 5. Chest pain c MI was first described by Professor William R. Low fowler’s c. 31. Subjective data consist of • Sensations or symptoms • Feelings • Perceptions • Desires • Preferences • Beliefs • Ideas • Values • Personal information These types of data can be elicited and verified only by the client. Which of the following items should always be available at this client’s bedside? Select all that apply. 7°F) 7. Deep-breathe a d cough four times a day. 150 mL of serosanguineous drainage A nurse is collecting data from an older adult client. Instruct the client to avoid swallowing when the tube is felt in the back of the throat. D. All of the following are appropriate nursing actions. When suctioning, the nurse must limit the suctioning to a maximum of: a. Which nursing intervention is most appropriate? The correct answer is: Document the findings. Observe means to view something scientifically, and assess means to collect information. Rest in semi-Fowler's position*******. 3+ C. 6° F) 3. Remember ABC. A nurse is assisting with he care of a client following a left femoral cardiac angiography. A client who states that he is passing flatus C. Goal setting occurs during the planning phase. A nurse in an emergency department completes an assessment on an adolescent client that has conduct disorder. A nurse is caring for a group of clients which of the following findings should the nurse report The nurse, while taking the information and collecting data, begins to hypothesize possible explanations of the data and then realizes all diagnoses are only tentative until they are verified. He has an IV infusing at 125 mL/hr. The client reports feeling his incision “pop” and the nurse sees the client’s organs protruding through the abdominal wall. Level of pain; D. In planning the In a randomized, open label study conducted at three ICUs in a university medical centre in Germany, Schadler and coworkers (Schadler 2012) included, under deferred consent, all patients who were mechanically ventilated in the postoperative period for longer than nine hours after ICU admission and who did not meet any of the following exclusion criteria: (i) cerebral surgery or trauma, (ii Because abdominal pain usually subsides gradually by the third or fourth postoperative day, continued or increasing pain may reflect delayed healing or peristomal skin irritation. Have an assistive personnel hold The nurse hanging an IV solution will verify thatA nurse is caring for a client who is 1 day postoperative following a thyroidectomy and reports Monitor the client's peripheral pulses B. 1+ A client who had a right lower lobe lobectomy 4 days ago and has a chest tube set to continuous suction. Sep 02, 2020 · The initial A nurse checks the sternotomy incision of a client on the third postoperative day after cardiac surgery. The nurse is caring for a client following a radiation accident. Which of the following actions should the nurse take? Select all that apply. Jacobs, Tonya first focuses on the nature and severity of his pain, the risk A nurse is assigned to assist in caring for a client who recently returned from the operating room. Temperature of 37. The nurse inserts an indwelling Foley catheter into the bladder of a postoperative client who has not voided for 8 hours and has a distended bladder. Code cart. People are considered fully vaccinated one week after In a randomized, open label study conducted at three ICUs in a university medical centre in Germany, Schadler and coworkers (Schadler 2012) included, under deferred consent, all patients who were mechanically ventilated in the postoperative period for longer than nine hours after ICU admission and who did not meet any of the following exclusion criteria: (i) cerebral surgery or trauma, (ii Monitoring the client’s vital signs following surgery gives the nurse a sound information about the client’s condition. The nurse should monitor the client for other adaptations related to the pyrexia including: a. Client reports difficulty sleeping. What nursing intervention would you take. Dec 16, 2015 · 36. Prevents postoperative ileus 4. Which of the following statements should the nurse make? a. The client's temperature is 99° F (37. The client has redness and Explanation. Supine. The client reports feeling his incision "pop", and the nurse sees the client's organs protruding through the abdominal wall. Nasogastric tube. Muscle aches 3. Reflexes and movement of extremities; Correct Answer: A. The client’s temperature is 99 F (37. Nurses also help with end-of-life needs and assist other family members with grieving. Phases of the Surgical Experience Diabetes is a disease in which a person has high blood sugar. A, B Days after abdominal surgery, the client’s wound dehisces. The nurse should include that which of the following is the nurse's responsibility when obtaining informed consent from a client? (Select all that apply. 1+ A nurse is collecting data from a client who has been taking prednisone following an exacerbation of inflammatory bowel disease (IBD). Subjective data provide clues For example, a community health nurse assesses the patient’s neighborhood and community; an emergency department nurse uses the ABC (airway-breathing-circulation) approach; and a surgical nurse focuses on the patient’s symptoms following surgery, the expected healing response, and potential complications. " B: "It is okay for me to lift my 2-year-old granddaughter. The client usually has a restriction of food and fluids for 6 to 8 hours before surgery instead of 24 hours. A nurse is caring for a client who is receiving a continuous tube feeding ATI Med surg proctored exam 2022 (NEW!) 75 QUESTIONS WITH 100% CORRECT ANSWERS 1. B. The nurse interprets that the incision line: 11) A home health nurse is assisting with the plan of care for an older adult client who had cataract surgery recently. A nurse is caring for a client who is 1-day postoperative following abdominal surgery. A nurse is caring for a client who is taking phenytoin (Dilantin) for control of seizures. A nurse is reviewing the laboratory results of a client who is taking digoxin for heart failure Postmenopausal women and men age 50 and older who have had an adult-age fracture, to diagnose and determine the degree of osteoporosis. In promoting the clients comfort, the nurse should: a. Backache 2. Which of the following information should the nurse include in the plan of care? A. 3) Check the client's vital signs. 1 Answer to A nurse is caring for a client who has just returned from surgery to treat a fractured mandible. Stimulates digestive enzymes 3. Prone d. Which of the. The client threatened suicide to teacher at school. Respiratory status; B. HESI Exit Exam with Answers. A nurse is caring for a client who has chronic renal disease and is receiving therapy with epoetin alfa. Inadequate physical assessment skills. A nurse is performing nasotracheal suctioning of a client. This position helps facilitate removal About ng client and tube nurse is feeding an has receiving continuous for caring enteral is a who a A * 7. C. diabetes, type 1 C. The nurse discusses these assessment findings with the health care provider due to concern regarding development of which condition? 1) Paralytic ileus 2) Dehydration 3) Intestinal obstruction 4 The correct answer is: Risk for aspiration The nurse is assessing a client 24 hours following a cholecystectomy. Blanching of the toenail beds with pressure D. Angina b. The nurse learns in morning report that there has not been any drainage from the chest tube for the last 24 hours. Chest pain c. A nurse is caring for a client who is 2 days postoperative following an above-the knee-amputation. A nurse is caring for a client who is ID: 4 A nurse notes that the site of a client’s peripheral intravenous (IV) catheter is reddened, warm, painful, and slightly The client being discharged to home with a prescription for eye drops to be given in the left eye has received instructions regarding self-administration of the drops. A nurse is collecting data regarding the pain level of a 4-year-old client on the second postoperative day. an expanding circular rash. Assess the bladder for distention. A patient may wake up from anesthesia with a triangle-shaped pillow between his or her legs, keeping the legs slightly spread. The nurse is taking the client's blood Immediately after surgery, the client should lie flat with the surgical ear facing upward; nose blowing is permitted but should be done gently and on one side at a time. 6 ml/decilitre which of the following finding Bounding pulse increase urine output hypertension muscle twitching 36. Which of the following statements should the nurse include in the assessment? a) Tell me about your siblings b) Tell me what kind of music you like c) Tell me how often do you drink alcohol d) Tell me 4. Offer small amounts of clear liquids 6 hr following surgery (assess for gag reflex first) b. The nurse interprets that the client is adequately tolerating the procedure if which of the following The nurse is caring for a client following a radiation accident. 5 seconds c. In the PACU, the anesthesiologist/nurse anesthetist will report to the nurse the patient’s condition, type of anesthesia, estimated blood loss, input of fluids, and urine output during surgery. During the b. Ans: C . When discussing breathing exercises with a postoperative client, Nurse Hazel should include which of the following teaching? a. 3) Change the litter boxes while wearing gloves. Which of the following should the nurse assess first? A. 2. This information will help us to plan further The nurse hanging an IV solution will verify thatA nurse is caring for a client who is 1 day postoperative following a thyroidectomy and reports Monitor the client's peripheral pulses B. The nurse examines the incision and finds wound dehiscence and evisceration. MI was first described by Professor William R. Apply a warm compress to the operative site every 4 hr A nurse is collecting data from a client about lower extremity edema by pressing an index finger against the shin and noting an indentation of 6 mm (about 1/4 inch). Exercise twice a day d. What is the appropriate nursing action for the safety of this client? Oral hygiene is allowed, but the client should not swallow any water. The nurse is caring for a postoperative client who has a prescription for meperidine (Demerol) A nurse assessing a patient's respiratory effort notes that the client's breaths are shallow and 8 per minute. D Range of motion. Medicate client as prescribed The correct answer is: Risk for aspiration The nurse is assessing a client 24 hours following a cholecystectomy. During data collection, the nurse notes that the client is taking birth control pills. Describe the responsibilities of the perioperative nurse in the circulating role. A client who had abdominal surgery 10 days ago and reports feeling his incision pop A nurse in a provider's office has collected data on 4 clients. the nurse should expect the client to have redness at the pin sites, as it is a … A nurse is assisting with the card of a client who is receiving total parenteral nutrition (TPN) therapy and has just returned to the room following physical therapy. Tilt the client’s head back when the tube is being inserted. 6.


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