A.)Administer naloxone (Narcan) IV.
B.) Administer morphine IV
C.) Adminiter 0.9% sodium chloride IV bolus
D.) Administer atropine IV
An IV fluid bolus should increase the client’s hypotension and tachycardia to promote
adequate cardiac output and tissue perfusion.
A.) Assess oxygen saturation
B.) Obtain blood pressure
C.) Palpate heart rate
D.) Check Temperature
The greatest risk for the client is injury from hypoxia. The first action is to assess the
client’s oxygen saturations.
hyperthermia. Which of the following should the nurse include in the information?
A.)Infuse iced IV fluids.
B.)Provide 100% oxygen.
C.)Place on a cooling blanket.
D.)Treat the condition while continuing surgery.
E.)Administer IV dantrolene (Dantrium).
Infusing iced IV fluids should help lower the client’s rapidly rising temperature.
Providing 100% oxygen will help to prevent hypoxia due to muscle tremors and
rigidity from increased lactic acid.
Placing the client on a cooling blanket will help lower the rapidly rising temperature
Dantrolene IV is a muscle relaxant used to treat malignant hyperthermia.
the following actions by the nurse is appropriate?
A.)Monitor serum creatinine levels.
B.)Prepare to administer IV thiopental (Pentothal).
C.)Turn client to the right side.
D.)Administration 0.9% sodium chloride 500 mL IV bolus.
Thiopental is a fast-acting barbiturate administered by an anesthesiologist for treatment
of systemic toxic reaction to a spinal block.
of the following is an appropriate nursing action?
A.)Decrease the client’s fluid intake.
B.)Apply pressure to the puncture site.
C.)Place the client’s head of bed flat.
D.)Instruct the client to lie prone.
Placing the client’s head of bed flat will decrease the intensity of the headache and
decrease cerebral spinal fluid leakage.
Propofol (Diprivan) – anesthetic
Midazolam (Versed) – benzodiazepine
felt, yet the client is able to respond to verbal stimuli, retains reflexes (gag reflex), and is
-Instruct the client to be NPO for 6 hr before the procedure.
-Attach monitor equipment.
-Start IV access.
-Verify informed consent.
-Assess the level of consciousness.
-Monitor cardiac and respiratory status.
-Have emergency cart and equipment available in the room.
-Have oxygen and suction equipment ready and available if needed.
-Continue to monitor vital signs and consciousness.
-Determine ability to cough, deep breathe, and swallow.
-Assess for nausea, vomiting, shortness of breath, or dizziness before discharge
following should the nurse report to the provider? (Select all that apply.)
A. Potassium 3.9 mEq/L
B. Sodium chloride 145 mEq/L
C. Creatinine 2.8 mg/dL
D. Blood glucose 235 mg/dL
E. WBC 17,850/uL
The nurse should report an elevated creatinine level, which may indicate kidney failure,
to the provider before surgery.
The nurse should report an elevated blood glucose, which needs treatment prior to surgery.
The nurse should report an elevated WBC count, which indicates a need for antibiotic
therapy before surgery
. The client’s temperature is
39° C (102.2° F) orally. Which of the following is an appropriate action by the nurse?
A. Inform the surgeon of the elevated temperature.
B. Transfer the client to the preoperative unit.
C. Apply ice packs to the client’s groin.
D. Encourage the client to increase intake of clear liquids
An appropriate action by the nurse is immediately notifying the surgeon of the elevated
temperature to determine if cancelling the surgery is necessary due to an underlying infection
are appropriate nursing actions? (Select all that apply.)
A. Explain to the client the purpose of having the procedure.
B. Inform the client of risks to having the procedure.
C. Ensure the client understood the information about the procedure.
D. Witness the client signing the informed consent form.
E. Determine if the client is mentally capable of understanding the reason for the procedure.
Ensuring the client understood the information about the procedure is an appropriate
Witnessing the client signing the informed consent is an appropriate nursing action.
Determining if the client is mentally capable to sign the informed consent is an
appropriate nursing action.
. Which of the following
statements by the nurse are appropriate? (Select all that apply.)
A. “Take your blood pressure medication with a sip of water before surgery.”
B.”Splint the abdominal incision with a pillow when coughing and deep breathing.”
C.”Bedrest is recommended for the first 48 hr.”
D. “Antiembolism stocking are applied before surgery.”
E. “You may eat solid foods up to 4 hr before surgery.
The nurse should teach the client to take certain antihypertensive and other
medications as prescribed with a sip of water before surgery.
The nurse should teach the client how to splint with a pillow to support the incision
when coughing and deep breathing postoperatively.
The nurse should inform the client of the application of antiembolism stockings to
prevent deep-vein thrombosis.
appropriate nursing action?
A.Encourage the client to void after medication administration.
B.Administer antibiotics 30 min prior to surgical incision.
C.Remove hair using a manual razor.
D.Remove nail polish on fingers and toes
The nurse should ensure the nail beds are visible for color and circulation by removing
nail polish before surgery
identify risk factors that can lead to postoperative complications. Which of the following clients are at risk
for complications? (Select all that apply.)
A. A client who has a WBC of 22,500/uL
B. A client who uses an insulin pump
C. A client taking warfarin (Coumadin) daily
D. A client who had a bowel prep
E. A client who has a BMI of 26
An increased WBC indicates an underlying infection and places the client at risk for
An insulin pump indicates the client has type 1 diabetes mellitus and places the client
at risk of postoperative complications.
A client who takes warfarin daily is at risk for bleeding and postoperative complications.
Receiving a bowel prep to cleanse the colon can cause dehydration and places the client
at risk for complications
Which of the following findings requires action by the nurse? (Select all that apply
A. Urine output less than 25 mL/hr
B. Hematocrit 48%
C. BUN 24 mg/dL
D. Tenting of skin over the sternum
E. Apical pulse rate 62/min
Urine output less than 25 mL/hr is a manifestation of hypovolemia and requires
intervention by IV fluid therapy.
Hematocrit of 48% indicates concentrated blood volume and is a manifestation of
hypovolemia, requiring intervention by IV fluid therapy.
BUN of 24 mg/dL indicates decreased kidney function and can be a manifestation of
hypovolemia, requiring intervention with IV fluid therapy.
Tenting of skin indicates decreased or absent skin turgor due to dehydration, requiring
intervention with IV fluid therapy
. The client is not
responding to verbal stimuli. Which of the following actions should the nurse perform first?
A. Compare and contrast the peripheral pulses.
B. Apply a warm blanket.
C. Assess the client’s dressings.
D. Place the client in a lateral position
The greatest risk to the client is injury from aspiration. The first action is to position the
interventions should the nurse include in the plan of care? (Select all that apply.)
A. Encourage the use of the incentive spirometer every 2 hr
B. Instruct to splint incision when coughing and deep breathing.
C. Reposition the client every 2 hr
D. Administer antibiotic therapy.
E. Assist with early ambulation.
The use of the incentive spirometer every 2 hr expands the lungs and prevents atelectasis.
Incisional splinting with a pillow or blanket supports the incision during coughing and
deep breathing which prevents atelectasis.
Repositioning the client every 2 hr will cause the client to deep breathe and expand the
lungs to prevent atelectasis
Early ambulation expands the lungs through deep breathing and prevents atelectasis.
Which of the following actions should the nurse perform first?
A. Assess bowel sounds.
B. Administer antiemetic medication.
C. Restart prescribed IV fluids.
D. Insert a prescribed nasogastric tube
Using the nursing process, the first step is to assess the client. Assessing bowel sounds is
the correct action by the nurse.
peripheral vision. For which of the following is the client at risk?
The nurse should anticipate that the client is experiencing open-angle glaucoma. Loss
of peripheral vision is a clinical manifestation associated with this diagnosis.
A.”You may resume playing golf.”
B.”You need to tilt your head back when washing your hair”
C.”You may continue driving to and from work.”
D.”You need to limit your housekeeping activities.”
The nurse should instruct the client to limit housekeeping activities following cataract
surgery. This activity could elevate the client’s intraocular pressure (IOP) or result in injury to
following should the nurse recognize as risk factors associated with this disease? (Select all that apply.)
Genetic predisposition is a risk factor associated with glaucoma.
Hypertension is a risk factor associated with glaucoma.
Age is a risk factor associated with glaucoma.
Diabetes mellitus is a risk factor associated with glaucoma.
manifestations should the nurse expect to find? (Select all that apply.)
E.Bilateral red reflexes
Blurred vision is a clinical manifestation associated with cataracts.
White pupils are a clinical manifestation associated with cataracts
y. The client reports nausea and severe eye pain.
Which of the following actions should the nurse take?
A.Notify the provider.
B.Administer an analgesic.
C.Administer an antiemetic.
D.Turn the client onto the operative side
Following cataract surgery, the provider should be notified if the client is experiencing
nausea and severe pain
A.Pearly, gray tympanic membrane (TM)
B.Malleus visible behind the TM
C.Flaky skin in the external canal near the TM
D.Black cerumen partially occluding the TM
Cerumen varies from light to dark yellowish-brown in color. Black cerumen may
indicate the presence of blood and is an unexpected finding during an otoscopic examination
benign paroxysmal vertigo for several weeks. Which of the following actions should the nurse recommend
to help control the vertigo? (Select all that apply.)
A.Reduce exposure to bright lighting.
B.Move head slowly when changing positions.
C.Avoid fruits high in potassium.
D.Plan evenly spaced daily fluid intake.
Remaining in a darkened, quiet environment can reduce vertigo, particularly when
it is severe.
Moving slowly when standing or changing positions can reduce vertigo
Fluid intake should be planned so that it is evenly spaced throughout the day to
prevent excess fluid accumulation in the semicircular canals.
s disease. Which of the following is an
A.Presence of a purulent lesion in the external ear canal
B.Recent history of plane travel
C.Bulging, red bilateral tympanic membranes
D.Unilateral hearing loss
Unilateral sensorineural hearing loss is a clinical finding in Ménière’s disease
are expected findings? (Select all that apply.)
B.Report of recent colds
C.Discontinued prescription for furosemide 6 months ago
D.Light reflexes visible on otoscopic exam at 5 and 7 o’clock
E.Report of frequent ingestion of ibuprofen
Enlarged tonsils are a clinical finding associated with a middle ear infection.
Frequent colds and otitis media are clinical findings associated with a middle ear disorder.
Ibuprofen is an ototoxic medication and can cause a middle ear disorder.
statements by the client indicates understanding of the teaching?
A.”I am glad I’ll be able to return to my position as an airplane pilot right away.”
B.”I will cover my ear when washing my hair.”
C.”I will remove the dressing behind my ear in 7 days.”
D.”I can expect my hearing to return in 24 hours.”
Water should be prevented from entering the ear canal until the incision is healed
following a stapedectomy