Nokea
A preoperative nurse is reviewing morning laboratory values on four clients waiting for surgery. Which result warrants immediate communication with the surgical team?
- A. Creatinine 2 mg/dL
- B. Potassium 3.8 mEq/L
- C. Hemoglobin 12 g/dL
- D. Platelet count 150,000/mm³
Correct Answer: A
Rationale: A creatinine level of 2 mg/dL is elevated, indicating potential renal impairment, which can affect anesthesia and surgical outcomes. This warrants immediate communication with the surgical team. The other values are within normal ranges and do not require urgent reporting.
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A client who collapsed during dinner in a restaurant arrives in the emergency department. The client is going to surgery to repair an abdominal aortic aneurysm. What medication does the nurse prepare to administer as a priority with this client?
- A. Hydrocodone (Vicodin)
- B. Lorazepam (Ativan)
- C. Metoclopramide (Reglan)
- D. Morphine sulfate (Morphine)
Correct Answer: C
Rationale: Metoclopramide (Reglan) increases gastric emptying, an important issue for this client who was eating just prior to the operation to reduce the risk of aspiration. The other drugs are appropriate for pain or anxiety management but are not the priority in this scenario.
A postoperative client has an abdominal drain. What assessment by the nurse indicates that goals for the client are being met?
- A. Drain output is clear and minimal
- B. Drain site is red and swollen
- C. Drain is clogged and not draining
- D. Client reports severe pain at drain site
Correct Answer: A
Rationale: A clear and minimal drain output indicates that the surgical site is healing appropriately and there is no significant infection or fluid accumulation. Redness and swelling, a clogged drain, or severe pain could indicate complications such as infection or obstruction, which would require further intervention.
A nursing instructor is teaching students about different surgical procedures and their classifications. Which procedures are correctly classified?
- A. Hemicolectomy: diagnostic
- B. Liver biopsy: diagnostic
- C. Spinal cord decompression: palliative
- D. Total shoulder replacement: restorative
- E. Mastectomy: restorative
Correct Answer: B,E
Rationale: A diagnostic procedure is used to determine cell type of cancer and to determine the cause of a problem, such as a liver biopsy. A restorative procedure aims to improve functional ability, such as a total shoulder replacement. A curative procedure either removes or repairs the causative problem, such as a mastectomy or hemicolectomy, which are not diagnostic or palliative.
A nurse assesses a client in the preoperative holding area and finds brittle nails and hair, dry skin, and muscle wasting. What action by the nurse is best?
- A. Consult the surgeon about a postoperative dietitian referral
- B. Document the findings thoroughly in the client's chart
- C. Encourage the client to eat more after recovering from surgery
- D. Refer the client to Meals on Wheels after discharge
Correct Answer: A
Rationale: This client has signs of malnutrition, which can impact recovery from surgery. The nurse should consult the surgeon about prescribing a consultation with a dietitian in the preoperative period to optimize the client's nutritional status. Documenting findings is important but not sufficient alone. Encouraging the client to eat more may be helpful, but a professional nutritional assessment is needed. Meals on Wheels may not address immediate preoperative needs.
A nurse works on the postoperative floor and has four clients who are being discharged tomorrow. Which one has the greatest need for the nurse to consult other members of the health care team for post-discharge care?
- A. Married young adult who is the primary caregiver for children
- B. Middle-aged client who is post long time replacement, needs physical therapy
- C. Older adult who lives at home despite some memory loss
- D. Young client who lives alone, has family and friends nearby
Correct Answer: C
Rationale: The older adult has the most potentially complex discharge needs. With memory loss, the client may not be able to follow the prescribed home regimen. The client's physical abilities may be limited by chronic illness. This client has several safety needs that should be assessed. The other clients all have evidence of a support system and no known potential for serious safety issues.