RNSG Exam 1, 2, 3, 4, 5 Fall 2025 REVIEW

The nurse is providing care to a patient who has a tracheostomy. The loss of which protective mechanism does the nurse plan to monitor this patient for during the respiratory assessment process?

1) The ability to cough

2) The filtration and humidification of inspired air

3) A decrease in the oxygen-carrying capacity of the trachea

4) The sneeze reflex initiated by irritants in the nasal passages

2) The filtration and humidification of inspired air

When conducting a respiratory assessment, the nurse notes a low-pitched sound that is continuous throughout inspiration. Which does this lung sound indicate to the nurse?

1) Narrow bronchi

2) Narrow trachea passages

3) Inflamed pleural surfaces

4) Blocked large airway passages

4) Blocked large airway passages

The nurse is providing care to a patient admitted with a respiratory disorder. Which laboratory finding would be most significant?

1) Blood pH 7.32

2) Oxygen saturation 96%

3) Serum sodium 140 mg/dL

4) Hemoglobin level 12 mg/dL

1) Blood pH 7.32

The nurse is providing care to a patient diagnosed with chronic obstructive pulmonary disease (COPD) who is prescribed 24% oxygen at 2 L/min. Which is the best method for the nurse to use in order to administer oxygen to this patient?

1) Face mask

2) Venturi mask

3) Nasal cannula

4) Nonrebreather mask

3) Nasal cannula

The nurse is providing care for a patient admitted with smoke inhalation injury who is developing acute respiratory distress syndrome (ARDS). Which course of action regarding oxygen therapy does the nurse anticipate for this patient?

1) Oxygen via a facial mask

2) Oxygen via a Venturi mask

3) Oxygen via a nasal cannula

4) Oxygen via mechanical ventilation

4) Oxygen via mechanical ventilation

The nurse is providing care to a patient, diagnosed with asthma, with a respiratory rate of 28 at rest who is experiencing audible wheezing during inspiration. Which nursing diagnosis should the nurse use when planning care for this patient?

1) Activity Intolerance

2) Impaired Tissue Perfusion

3) Ineffective Airway Clearance

4) Ineffective Breathing Pattern

4) Ineffective Breathing Pattern

The nurse is providing care to a patient who is diagnosed with chronic obstructive pulmonary disease (COPD). The nurse assesses the patient's breathing rate at 32 breaths per minute. The patient is also experiencing hypertension and fatigue. Which nursing diagnosis is a priority when planning care for this patient?

1) Anxiety

2) Ineffective Coping

3) Ineffective Breathing Pattern

4) Ineffective Airway Clearance

3) Ineffective Breathing Pattern

The nurse is providing care to a patient who is diagnosed with chronic obstructive pulmonary disease (COPD). The patient's pulse oximetry is 93% on room air with a current respiratory rate of 35 breaths per minute. The most recent chest x-ray indicates a flattened diaphragm with infiltrates. The patient is currently febrile with an increased number of white blood cells (WBCs) noted on the latest complete blood count (CBC). Which prescription does the nurse question for this patient based on the current data?

1) Antibiotic therapy

2) Nonsteroidal anti-inflammatory therapy

3) Oxygen therapy via nasal cannula at 3-4 L/min

4) Bronchodilators therapy with adrenergic stimulating drugs

3) Oxygen therapy via nasal cannula at 3-4 L/min

The nurse is providing care to an infant diagnosed with respiratory syncytial virus (RSV). The infant is grunting with expiration. Which action by the nurse is appropriate?

1) Limit fluid intake

2) Place the infant in a supine position

3) Perform chest physiotherapy to clear the nasal passages

4) Suction the airway to relieve the current obstruction that is noted

4) Suction the airway to relieve the current obstruction that is noted

Which nursing action determines the accuracy of the detected waveform when monitoring a patient's oxygen saturation via oximetry? 1) Using a site with adequate perfusion

2) Ensuring the any nail polish is removed

3) Leaving the sensor in place for a minimum of ten seconds

4) Assessing the heart rate and comparing it with the displayed pulse

4) Assessing the heart rate and comparing it with the displayed pulse

Which did the nurse auscultate when conducting a patient's respiratory assessment if wheezing is documented?

1) Snoring sounds

2) Gurgling sounds

3) Low-pitched bubbling

4) High-pitched squeaking

4) High-pitched squeaking

Which did the nurse auscultate when conducting a patient's respiratory assessment if rhonchi is documented?

1) Snoring sounds

2) Gurgling sounds

3) Low-pitched bubbling

4) High-pitched squeaking

1) Snoring sounds

Which position should the nurse place a patient prior to performing in-line suctioning?

1) Prone

2) Supine

3) Fowler's

4) Semi-Fowler's

4) Semi-Fowler's

When conducting in-line suctioning, which is the maximum amount of time for each suctioning event?

1) 10 seconds

2) 30 seconds

3) 45 seconds

4) 60 seconds

1) 10 seconds

When conducting in-line suctioning on a patient, which amount of time should the nurse allow as a rest period between suction procedures?

1) 5 to 15 seconds

2) 10 to 20 seconds

3) 15 to 25 seconds

4) 20 to 30 seconds

2) 10 to 20 seconds

The nurse is performing in-line suctioning when the patient experiences a drop in oxygen saturation and bradycardia. Which nursing action is appropriate?

1) Continue suctioning and administer 50% oxygen

2) Discontinue suctioning and prepare for resuscitation

3) Discontinue suctioning and administer 100% oxygen

4) Continue suctioning and administer prescribed epinephrine

3) Discontinue suctioning and administer 100% oxygen

The nurse is providing care to a patient who is mechanically ventilated. The high-pressure alarm beeps and the nurse notes a mucous plug in the endotracheal (ET) tube. Which action by the nurse is appropriate?

1) Suction, as needed

2) Insert an oral airway

3) Assess for asymmetric chest rise

4) Empty water from the ventilator tubing

1) Suction, as needed

The nurse is providing care to a patient who is mechanically ventilated. The high-pressure alarm beeps and the nurse notes the patient is biting down on the endotracheal (ET) tube. Which action by the nurse is appropriate?

1) Suction, as needed

2) Insert an oral airway

3) Assess for asymmetric chest rise

4) Empty water from the ventilator tubing

2) Insert an oral airway

The nurse is providing care to a patient who is mechanically ventilated. The high-pressure alarm beeps and the nurse notes a collection of moisture in the ventilator tubing. Which action by the nurse is appropriate?

1) Empty the water

2) Suction, as needed

3) Insert an oral airway

4) Assess for asymmetric chest rise

1) Empty the water

The nurse is providing education to a patient who is prescribed oxygen in the home environment. Which statement made by the patient indicates the need for further education?

1) "I will ensure that the oxygen is kept six feet away from the stove."

2) "I placed a no smoking sign on the door and several places within the house."

3) "I will store the oxygen on its side, per the instructions provided by the agency."

4) "I will keep a fire extinguisher in the house and keep it close to where the oxygen is stored."

3) "I will store the oxygen on its side, per the instructions provided by the agency."

The nurse is providing education to a patient regarding the use of an incentive spirometer. Which patient statement indicates the need for further education?

1) "I should be in a sitting position when using this device."

2) "I will use this device 20 times per hour while I am awake each day."

3) "I will exhale completely prior to placing my lips around the mouthpiece."

4) "I will hold my breath for 3 seconds after I feel like I cannot inhale any more breath."

2) "I will use this device 20 times per hour while I am awake each day."

The nurse is providing care to a patient who is mechanically ventilated. In order to decrease the risk for aspiration, which action by the nurse is appropriate?

1) Elevate the head of the bed between 30 to 45 degrees

2) Limit each suctioning event to no more than 10 seconds

3) Perform chest physiotherapy as prescribed by the practitioner

4) Ensure an NPO status is maintained for the length of the prescribed treatment

1) Elevate the head of the bed between 30 to 45 degrees

The nurse is providing care to a patient who is being weaned from mechanical ventilation. Which finding would necessitate the continuation of mechanical ventilation if noted during the assessment process?

1) An FIO2 less than or equal to 0.4-0.5

2) A PEEP less than or equal to 5-8 cm H2O

3) A pH greater than 7.25 during spontaneous ventilation

4) A drop in blood pressure indicating a hypotensive state

4) A drop in blood pressure indicating a hypotensive state

The nurse is providing care to a patient who is recovering from facial trauma who requires high-flow oxygen therapy. Which method of oxygen delivery should the nurse plan for when providing care?

1) Face tent

2) Nasal cannula

3) Venturi mask

4) Nonrebreather mask

1) Face tent

The nurse is providing care to a patient diagnosed with chronic obstructive pulmonary disease (COPD) who requires supplemental oxygen. Which is the anticipated flow rate range by nasal cannula (NC) when providing care for this patient?

1) 1-2 L/min

2) 2-3 L/min

3) 3-4 L/min

4) 4-5 L/min

1) 1-2 L/min

Which independent nursing actions are appropriate to include in the plan of care for a patient who is experiencing an alteration in oxygenation? Select all that apply.

1) Providing suctioning

2) Assisting with positioning

3) Prescribing bronchodilators

4) Monitoring activity tolerance

5) Encouraging deep breathing exercises

1) Providing suctioning

2) Assisting with positioning

4) Monitoring activity tolerance

5) Encouraging deep breathing exercises

Which should the nurse include in the plan of care for a mechanically ventilated patient who is receiving care based on a ventilator bundle? Select all that apply.

1) Elevating the head of the bed

2) Ensuring a sedation vacation each day

3) Conducting a readiness to wean assessment

4) Administering a prescribed peptic ulcer prophylactic regimen

5) Avoiding the use of compression stockings during immobility

1) Elevating the head of the bed

2) Ensuring a sedation vacation each day

3) Conducting a readiness to wean assessment

4) Administering a prescribed peptic ulcer prophylactic regimen

Which information should the nurse document when monitoring a patient's oxygen saturation via oximetry? Select all that apply.

1) The SpO2 result

2) The current vital signs

3) The presence of family or visitors at the patient's bedside

4) The type and amount of oxygen therapy in use

5) The education provided to the patient and family

1) The SpO2 result

2) The current vital signs

4) The type and amount of oxygen therapy in use

5) The education provided to the patient and family

The nurse suctions a mechanically ventilated patient using in-line suctioning. Which information should the nurse document in the medical record after the procedure is completed? Select all that apply. 1) The amount of secretions

2) The color of the secretions

3) The consistency of the secretions

4) The patient's response to the procedure

5) The amount of oxygen the patient received during the procedure

1) The amount of secretions

2) The color of the secretions

3) The consistency of the secretions

4) The patient's response to the procedure

Which actions by the nurse are considered best practice when providing tracheostomy care? Select all that apply.

1) Asking the family to leave the bedside

2) Suctioning at the start and finish of the procedure

3) Applying appropriate personal protective equipment

4) Inspecting the site of infection, irritation, and skin breakdown

5) Rinsing a disposable inner cannula with sterile water and drying

3) Applying appropriate personal protective equipment

4) Inspecting the site of infection, irritation, and skin breakdown

The nurse is providing care for an adult patient who is admitted to the emergency department (ED) after passing out. The patient has been fasting and currently has ketones in the urine. Which acid-based imbalance should the nurse monitor the patient for based on the current data?

1) Metabolic acidosis

2) Metabolic alkalosis

3) Respiratory acidosis

4) Respiratory alkalosis

1) Metabolic acidosis

The nurse is providing care to patient with the following laboratory values: pH - 7.31; PaCO2 - 48 mmHg; and a normal HCO3. Which condition should the nurse plan care for based on the current data?

1) Metabolic acidosis

2) Metabolic alkalosis

3) Respiratory acidosis

4) Respiratory alkalosis

3) Respiratory acidosis

The nurse is reviewing the latest arterial blood gas results for a patient with metabolic alkalosis. Which result indicates that the metabolic alkalosis is compensated?

1) pH 7.32

2) HCO3 8 mEq/L

3) PaCO2 48 mmHg

4) PaCO2 18 mmHg

3) PaCO2 48 mmHg

Which diagnostic test should the nurse anticipate when providing care to a patient diagnosed with chronic obstructive pulmonary disease (COPD) to monitor acid-base balance?

1) Pulse oximetry

2) Bronchoscopy

3) Sputum studies

4) Arterial blood gases

4) Arterial blood gases

Which patient statement indicates the need for additional education regarding the use of sodium bicarbonate to treat acidosis?

1) "I need to purchase antacids without salt."

2) "I should use the antacid for at least 2 months."

3) "I should contact the doctor if I have any gastric discomfort with chest pain."

4) "I should call the doctor if I get short of breath or start to sweat with this medication."

2) "I should use the antacid for at least 2 months."

The patient is receiving sodium bicarbonate intravenously (IV) for correction of acidosis secondary to diabetic coma. The nurse assesses the patient to be lethargic, confused, and breathing rapidly. Which is the nurse's priority response to the current situation?

1) Stop the infusion and notify the provider because the patient is in alkalosis.

2) Increase the rate of the infusion and continue to assess the patient for symptoms of acidosis.

3) Decrease the rate of the infusion and continue to assess the patient for symptoms of alkalosis.

4) Continue the infusion, because the patient is still in acidosis, and notify the provider.

4) Continue the infusion, because the patient is still in acidosis, and notify the provider.

The nurse is planning care for an older adult patient with respiratory acidosis. Which intervention should the nurse include in this patient's plan of care?

1) Maintain adequate hydration.

2) Reduce environmental stimuli.

3) Administer intravenous sodium bicarbonate

4) Administer prescribed intravenous fluids carefully

1) Maintain adequate hydration.

The results of a patient's arterial blood gas sample indicate an oxygen level of 72 mmHg. Which should the nurse closely assess when providing care to this patient?

1) Perfusion

2) Cognition

3) Communication

4) Fluid and electrolytes

2) Cognition

The nurse is caring for a comatose patient with respiratory acidosis. For which intervention will the nurse need to collaborate when caring for this patient?

1) Monitoring vital signs

2) Measuring intake and output

3) Determining recent eating behaviors

4) Identifying current oxygen saturation level

3) Determining recent eating behaviors

The nurse is analyzing the patient's arterial blood gas report, which reveals a pH of 7.15. The patient has just suffered a cardiac arrest. Which consequences of this pH value does the nurse consider for this patient?

1) Decreased cardiac output

2) Decreased potassium levels

3) Increased magnesium levels

4) Decreased free calcium in the ECF

1) Decreased cardiac output

The nurse is caring for a patient admitted with renal failure and metabolic acidosis. Which clinical manifestation would indicate to the nurse that planned interventions to relieve the metabolic acidosis have been effective?

1) Tachypnea

2) Palpitations

3) Increased deep tendon reflexes

4) Decreased depth of respirations

4) Decreased depth of respirations

A patient with metabolic acidosis has been admitted to the unit from the emergency department (ED). The patient is experiencing confusion and weakness. Which independent nursing intervention is the priority?

1) Protecting the patient from injury

2) Placing the patient in a high-Fowler's position

3) Administering sodium bicarbonate to the patient

4) Providing the patient with appropriate skin care

1) Protecting the patient from injury

The nurse is reviewing new orders provided by the health-care provider for a critical care patient with metabolic acidosis. Which prescription should the nurse question?

1) Draw serum potassium levels every two hours.

2) Draw arterial blood gas samples every two hours.

3) Administer one ampule of sodium bicarbonate now.

4) Begin intravenous infusion of 0.9% normal saline.

3) Administer one ampule of sodium bicarbonate now.

The nurse is providing care to a patient who has been vomiting for several days. The nurse knows that the patient is at risk for metabolic alkalosis because gastric secretions have which characteristic?

1) Gastric secretions are acidic.

2) Gastric secretions are alkaline.

3) Gastric secretions have a foul smell.

4) Gastric secretions are green in color.

1) Gastric secretions are acidic.

Which is the priority nursing action when providing care to a patient who is admitted with metabolic alkalosis?

1) Monitoring oxygen saturation

2) Setting goals for the plan of care

3) Administering prescribed medications

4) Teaching the family about risk factors

1) Monitoring oxygen saturation

The nurse is providing care to a patient who is admitted after a morphine overdose. Which acid-base imbalance should the nurse plan this patient's care to reflect?

1) Metabolic acidosis

2) Metabolic alkalosis

3) Respiratory acidosis

4) Respiratory alkalosis

3) Respiratory acidosis

The nurse is providing care for a patient admitted to the unit with respiratory failure and respiratory acidosis. Which data from the nursing history is the probable cause for the patient's current diagnoses?

1) Aspiration pneumonia

2) A recent trip to South America

3) Recent recovery from a cold virus

4) Use of ibuprofen for the control of pain

1) Aspiration pneumonia

Which chronic lung condition noted in the patient's health history supports the current diagnosis of respiratory acidosis?

1) Aspiration

2) Pneumonia

3) Cystic fibrosis

4) Hyperthyroidism

3) Cystic fibrosis

A patient is admitted to the emergency department for the treatment of a drug overdose causing acute respiratory acidosis. Which substance noted on the toxicology report is the most likely cause for the current diagnosis?

1) PCP

2) Cocaine

3) Marijuana

4) Oxycodone

4) Oxycodone

Which clinical manifestation supports the nurse's plan of care focusing on chronic respiratory acidosis?

1) Irritability

2) Blurred vision

3) Daytime sleepiness

4) Warm, flushed skin

3) Daytime sleepiness

The nurse is providing care to a patient who is admitted to the hospital with sudden, severe abdominal pain. Which arterial blood gas supports the patient's current diagnosis of respiratory alkalosis?

1) pH is 7.35 and PaO2 is 88.

2) pH is 7.30 and HCO3 is 30.

3) pH is 7.47 and PaCO2 is 25.

4) pH is 7.33 and PaCO2 is 36.

3) pH is 7.47 and PaCO2 is 25.

The client is admitted to the emergency department (ED) with symptoms of a panic attack. Based on this data, the nurse plans care for which health problem?

1) Emesis

2) Memory loss

3) Hypoventilation

4) Respiratory alkalosis

4) Respiratory alkalosis

The nurse completes discharge teaching for a patient with an anxiety disorder. Which patient statement indicates correct understanding of information related to respiratory alkalosis?

1) "I will eat more bananas at breakfast."

2) "I will see my counselor on a regular basis."

3) "I will not take antacids when I have heartburn."

4) "I will breathe faster when I am feeling anxious."

2) "I will see my counselor on a regular basis."

The nurse is reviewing the health-care provider orders for a patient who is diagnosed with respiratory alkalosis. Which prescription is appropriate for this patient's care needs?

1) Draw arterial blood gas analysis.

2) Administer oxygen via face mask.

3) Restrict fluids to two liters per day.

4) Infuse one ampule of sodium bicarbonate.

1) Draw arterial blood gas analysis.

The nurse is providing care to a patient who is intubated and receiving mechanical ventilation after a motor vehicle crash. The patient is fighting the ventilator and attempting to remove the endotracheal tube. Which nursing action decreases the patient's risk for developing respiratory alkalosis?

1) Apply wrist restraints.

2) Administer a prescribed sedative.

3) Teach the patient to take slow, deep breaths.

4) Discuss removing the endotracheal tube with the health-care provider.

2) Administer a prescribed sedative.

Which risk factors exhibited by the patient presenting in the emergency department (ED) would place the patient at risk for metabolic acidosis? Select all that apply.

1) Pneumonia

2) Abdominal fistulas

3) Acute renal failure

4) Hypovolemic shock

5) Chronic obstructive pulmonary disease

2) Abdominal fistulas

3) Acute renal failure

4) Hypovolemic shock

A patient recently diagnosed with diabetes mellitus (DM) is hospitalized in diabetic ketoacidosis (DKA) after a religious fast. The patient tells the nurse, "I have fasted during this season every year since I became an adult. I am not going to stop now." The nurse is not knowledgeable about this particular religion. Which nursing actions would be appropriate? Select all that apply.

1) Request a consult from a diabetes educator.

2) Assess the meaning and context of fasting for this religion.

3) Tell the patient that things are different now because of the new diagnosis.

4) Ask family members of the same religion to discuss fasting with the patient.

5) Encourage the patient to seek medical care if signs of ketoacidosis occur in the future

1) Request a consult from a diabetes educator.

2) Assess the meaning and context of fasting for this religion.

5) Encourage the patient to seek medical care if signs of ketoacidosis occur in the future

The nurse is caring for the patient experiencing hypovolemic shock and metabolic acidosis. Which nursing actions are appropriate for this patient? Select all that apply.

1) Limit the intake of fluids.

2) Administer sodium bicarbonate

3) Monitor ECG for conduction problems.

4) Keep the bed in the locked and low position.

5) Monitor weight on admission and discharge.

2) Administer sodium bicarbonate

3) Monitor ECG for conduction problems.

4) Keep the bed in the locked and low position.

The nurse is providing care to a patient who is admitted with manifestations of metabolic alkalosis. Which diagnostic test findings support the admitting diagnosis? Select all that apply.

1) Serum glucose level 142 mg/dL

2) Blood pH 7.47 and bicarbonate 34 mEq/L

3) Intravenous pyelogram shows kidney stones

4) Bilateral lower lobe infiltrates noted on chest x-ray

5) Electrocardiogram changes consistent with hypokalemia

2) Blood pH 7.47 and bicarbonate 34 mEq/L

5) Electrocardiogram changes consistent with hypokalemia

Which nursing actions are appropriate when conducting an Allen test? Select all that apply.

1) Rest the patient's arm on the mattress.

2) Support the patient's wrist with a rolled towel.

3) Tell the patient to relax the hand and then clench a fist.

4) Ensure that a second nurse is available to assist with the procedure.

5) Press the patient's radial and ulnar arteries using the index and middle fingers.

1) Rest the patient's arm on the mattress.

2) Support the patient's wrist with a rolled towel.

5) Press the patient's radial and ulnar arteries using the index and middle fingers.

The nurse administers the preoperative medication to the patient one hour before elective surgery, and then discovers the preoperative consent is not signed. Which action by the nurse is the most appropriate?

1) Have the patient sign the consent quickly, before the medication begins taking effect.

2) Have a family member or medical power of attorney sign the consent.

3) Send the patient to the holding area without a signed consent.

4) Notify the health-care provider that surgery will need to be canceled.

4) Notify the health-care provider that surgery will need to be canceled.

The nurse is completing the preoperative checklist on the night shift in preparation for the patient's surgery, scheduled for 0800. Which tasks could the nurse complete at this time?

1) Documenting the time of last voiding

2) Checking the medical record for the history, physical, and signed informed consent

3) Administering preoperative medication

4) Removing the prosthesis

2) Checking the medical record for the history, physical, and signed informed consent

The nurse is conducting a medication assessment for a preoperative patient. Which action by the nurse is appropriate for the patient who is prescribed amiodarone?

1) Obtaining a baseline ECG

2) Monitoring blood pressure

3) Assessing for hyperglycemia

4) Tapering the drug two days prior to surgery

1) Obtaining a baseline ECG

The nurse is conducting a medication assessment for a preoperative patient. Which action by the nurse is appropriate for the patient who is prescribed warfarin?

1) Obtaining a baseline ECG

2) Monitoring blood pressure

3) Assessing for hyperglycemia

4) Tapering the drug two days prior to surgery

4) Tapering the drug two days prior to surgery

The nurse is conducting a medication assessment for a preoperative patient. Which action by the nurse is appropriate for the patient who is prescribed metoprolol?

1) Obtaining a baseline ECG

2) Monitoring blood pressure

3) Assessing for hyperglycemia

4) Tapering the drug two days prior to surgery

2) Monitoring blood pressure

The nurse is conducting a medication assessment for a preoperative patient. Which action by the nurse is appropriate for the patient who is prescribed dexamethoasone?

1) Obtaining a baseline ECG

2) Monitoring blood pressure

3) Assessing for hyperglycemia

4) Tapering the drug two days prior to surgery

3) Assessing for hyperglycemia

The nurse is conducting a medication assessment for a preoperative patient. Which action by the nurse is appropriate for the patient who is prescribed phenobarbital?

1) Obtaining a baseline ECG

2) Monitoring blood pressure

3) Maintaining the drug during the perioperative period

4) Assessing blood glucose levels closely during the perioperative period

3) Maintaining the drug during the perioperative period

The nurse is conducting a medication assessment for a preoperative patient. Which action by the nurse is appropriate for the patient who is prescribed insulin?

1) Obtaining a baseline ECG

2) Monitoring blood pressure

3) Holding the drug during the perioperative period

4) Assessing blood glucose levels closely during the perioperative period

4) Assessing blood glucose levels closely during the perioperative period

Which should the nurse teach the patient regarding NPO status prior to a surgical procedure?

1) Nothing by mouth for 12 hours prior to surgery

2) Nothing solid by mouth for six hours prior to surgery

3) No clear liquids by mouth for four hours prior to the surgery

4) No clear liquids by mouth for two hours prior to the surgery

4) No clear liquids by mouth for two hours prior to the surgery

Which is the priority nursing action when providing patient care during the preoperative phase of care?

1) Ensuring NPO status

2) Monitoring vital signs

3) Obtaining informed consent

4) Completing a preoperative checklist

4) Completing a preoperative checklist

The nurse is reviewing the medical records for patients who are scheduled for surgery the next day. Which patient may not provide consent to receive blood products?

1) A Hispanic Catholic patient.

2) An African-American Baptist patient.

3) A Caucasian Jehovah's Witness patient.

4) A Native American patient with no religious affiliation.

3) A Caucasian Jehovah's Witness patient.

Which identifier should the nurse use during the initial time-out to determine the right patient?

1) Date of birth

2) Maiden name

3) Medical record number

4) Photo placed in the medical record

1) Date of birth

Which information should the nurse collect during the health history that is conducted during the preoperative period?

1) Caretaker after discharge

2) Oral intake over the last day

3) Date of last sexual encounter

4) Previous response to anesthesia

4) Previous response to anesthesia

The nurse is preparing a patient, diagnosed with asthma, for surgery. Which should the nurse include in the plan of care for this patient?

1) Monitoring blood pressure every hour

2) Assessing bowel sounds twice per shift

3) Monitoring pulse oximetry continuously

4) Assessing deep tendon reflexes every hour

3) Monitoring pulse oximetry continuously

Which is the priority action by the nurse when a patient discloses a medication allergy during the health history prior to a surgical procedure?

1) Asking the patient to describe the reaction that occurs

2) Documenting the information on the patient's medical record

3) Placing an alert bracelet on the patient prior to leaving the unit

4) Verifying the information with the patient's family members at the bedside

3) Placing an alert bracelet on the patient prior to leaving the unit

Which parameter for NPO status is appropriate when providing care to a pediatric patient in the preoperative period?

1) Ensuring nothing by mouth for six hours prior to the surgical procedure

2) Ensuring no solid foods by mouth for six hours prior to the surgical procedure

3) Allowing formula to be included in the child's intake for up to six hours prior to the surgical procedure

4) Allowing breast milk to be included in the child's intake for up to six hours prior to the surgical procedure

3) Allowing formula to be included in the child's intake for up to six hours prior to the surgical procedure

Which risk factor should the nurse include in the preoperative plan of care for a patient who smokes?

1) Angina pain

2) Gastrointestinal upset

3) Cognitive impairment

4) Respiratory depression

4) Respiratory depression

Which laboratory test should the nurse include in the plan of care for a patient who may require a blood transfusion during the surgical procedure?

1) Urinalysis

2) Type and crossmatch

3) Basic metabolic panel

4) Arterial blood gas analysis

2) Type and crossmatch

Which gauge catheter should the nurse use when initiating intravenous (IV) access for a preoperative patient?

1) 18

2) 20

3) 22

4) 24

1) 18

Which should the nurse ask the patient to verify during the initial time-out, the "pause for cause"?

1) "What is the name of your surgeon?"

2) "Which procedure are you having done today?"

3) "Is the information on your identification band correct?"

4) "Which side of the body is your procedure going to be completed on?"

5) "Have you signed your informed consent for the scheduled procedure?"

1) "What is the name of your surgeon?"

2) "Which procedure are you having done today?"

3) "Is the information on your identification band correct?"

4) "Which side of the body is your procedure going to be completed on?"

A patient is informed that a surgical procedure is to be scheduled in two weeks. Which teaching points should the nurse focus to prepare the patient for the surgery? Select all that apply.

1) Maintaining a patent airway

2) Deep breathing and coughing

3) Caring for the surgical incision

4) Managing constipation

5) Managing pain

2) Deep breathing and coughing

3) Caring for the surgical incision

4) Managing constipation

5) Managing pain

The nurse is preparing a patient for emergency surgery to repair liver and colon lacerations caused by a motor vehicle crash. Which information about this type of surgery will the nurse use to guide the patient's care? Select all that apply.

1) An organ is going to be removed.

2) This is an emergency surgery.

3) The patient will be hospitalized longer.

4) The patient is at risk for blood loss.

5) The patient is at risk for hypothermia.

2) This is an emergency surgery.

3) The patient will be hospitalized longer.

4) The patient is at risk for blood loss.

5) The patient is at risk for hypothermia.

The nurse is preparing an older adult patient for surgery. Which topics should the nurse focus on when preparing this patient's preoperative teaching? Select all that apply.

1) Level of hearing

2) Transportation needs of the patient after discharge

3) Teaching on deep breathing and coughing

4) Plans for discharge care

5) Actions to prevent pressure ulcers

1) Level of hearing

3) Teaching on deep breathing and coughing

4) Plans for discharge care

5) Actions to prevent pressure ulcers

When providing preoperative teaching for the patient who is scheduled for coronary artery bypass surgery in the morning, the nurse would include which topics? Select all that apply.

1) Location of incisions

2) Discharge information

3) Postoperative drains to expect

4) Postoperative pain management

5) Coughing and deep breathing exercises

1) Location of incisions

3) Postoperative drains to expect

4) Postoperative pain management

5) Coughing and deep breathing exercises

The nurse performs preoperative teaching for a patient requiring a surgical intervention. Which actions by the patient indicate appropriate understanding of the information provided? Select all that apply.

1) Demonstrating how to turn and get out of bed

2) Having no anxiety about the impending surgery

3) Demonstrating proper performance of leg exercises

4) Demonstrating proper coughing and deep breathing

5) Asking questions about and voicing understanding of information provided

1) Demonstrating how to turn and get out of bed

3) Demonstrating proper performance of leg exercises

4) Demonstrating proper coughing and deep breathing

5) Asking questions about and voicing understanding of information provided

The patient is transferred to the operating table. Which dimension of the operative period is the patient currently experiencing?

1) Postoperative period

2) Preoperative period

3) Perioperative period

4) Intraoperative period

4) Intraoperative period

The nurse is performing a surgical hand scrub, and holds the hands in which position when rinsing?

1) Straight out from the elbows

2) Lower than the elbows

3) Higher than the elbows

4) Irrelevant as long as the hands are well scrubbed

3) Higher than the elbows

Which personal protective equipment should the scrub nurse don to decrease the likelihood of a splash injury during a surgical procedure?

1) Gloves

2) Gown

3) Mask

4) Eyewear

4) Eyewear

Which classification should the nurse document, according to the American Society of Anesthesiologists, for a patient who is diagnosed with a mild systemic disease?

1) 2

2) 3

3) 4

4) 5

1) 2

Which classification should the nurse document, according to the American Society of Anesthesiologists, for a patient who is diagnosed with a severe systemic disease?

1) 2

2) 3

3) 4

4) 5

2) 3

Which classification should the nurse document, according to the American Society of Anesthesiologists, for a patient who is diagnosed with a severe systemic disease that is a threat to life?

1) 2

2) 3

3) 4

4) 5

3) 4

Which classification should the nurse document, according to the American Society of Anesthesiologists, for a patient who is not expected to survive without the planned surgical procedure?

1) 2

2) 3

3) 4

4) 5

4) 5

Which American Society of Anesthesiologists' classification should the circulating nurse document for a patient who is brain-dead and having organs procured for donation?

1) 3

2) 4

3) 5

4) 6

4) 6

Which term should the nurse document for a patient who is having surgery for the removal of female reproductive organs?

1) Episiotomy

2) Hysterectomy

3) Amniocentesis

4) Cholecystectomy

2) Hysterectomy

Which term should the nurse document for a patient who is having surgery for the removal of the gallbladder?

1) Episiotomy

2) Hysterectomy

3) Amniocentesis

4) Cholecystectomy

4) Cholecystectomy

The circulating nurse is assisting the anesthesiologist with patient monitoring during a surgical procedure. When documenting the administration of propofol, which terminology should the nurse use?

1) A narcotic analgesic

2) An intravenous anesthetic

3) A depolarizing muscle relaxant

4) A nondepolarizing muscle relaxant

2) An intravenous anesthetic

The circulating nurse is assisting the anesthesiologist with patient monitoring during a surgical procedure. When documenting the administration of morphine sulfate, which terminology should the nurse use?

1) A narcotic analgesic

2) An intravenous anesthetic

3) A depolarizing muscle relaxant

4) A nondepolarizing muscle relaxant

1) A narcotic analgesic

The circulating nurse is assisting the anesthesiologist with patient monitoring during a surgical procedure. When documenting the administration of cisatracurium, which terminology should the nurse use?

1) A narcotic analgesic

2) An intravenous anesthetic

3) A depolarizing muscle relaxant

4) A nondepolarizing muscle relaxant

4) A nondepolarizing muscle relaxant

The circulating nurse is assisting the anesthesiologist with patient monitoring during a surgical procedure. When documenting the administration of succinylcholine, which terminology should the nurse use?

1) A narcotic analgesic

2) An intravenous anesthetic

3) A depolarizing muscle relaxant

4) A nondepolarizing muscle relaxant

3) A depolarizing muscle relaxant

Which drug should the nurse prepare for the anesthesiologist to reverse the effects of cisatracurium during a surgical procedure?

1) Fentanyl

2) Atropine

3) Neostigmine

4) Glycopyrrolate

3) Neostigmine