NUR 324 (Med/Surg) Midterm Exam Study Guide with Practice Questions and Definitions

A nurse is caring for a client with a cast on the left arm after sustaining a fracture. Which assessment finding is most significant for this client?

A. Fingers on the left hand are swollen and cool

B. Presence of a normal popliteal pulse

C. Minimal pain in the left arm

D. Cast edges are rough, with skin irritation present

A. Fingers on the left hand are swollen and cool

To reduce the incidence of complications in a client in traction, which intervention should be included in the care plan?

A. Remove the weights during linen changes.

B. Increase fiber intake.

C. Reduce fluid intake.

D. Increase calorie intake.

B. Increase fiber intake.

Which is a benefit of a continuous passive motion (CPM) device when applied after knee surgery?

A. It prevents infection and controls edema and bleeding.

B. It promotes healing by increasing circulation and movement of the knee joint.

C. It provides active range of motion.

D. It promotes healing by immobilizing the knee joint.

B. It promotes healing by increasing circulation and movement of the knee joint.

Which nursing action would help prevent deep vein thrombosis in a client who has had an orthopedic surgery?

A. Instruct about exercise, as prescribed

B. Apply cold packs

C. Apply antiembolism stockings

D. Instruct about using client-controlled analgesia, if prescribed

C. Apply antiembolism stockings

Which is an inaccurate principle of traction?

A. The weights are not removed unless intermittent treatment is prescribed.

B. Skeletal traction is interrupted to turn and reposition the client.

C. The client must be in good alignment in the center of the bed.

D. The weights must hang freely.

B. Skeletal traction is interrupted to turn and reposition the client.

The client displays manifestations of compartment syndrome. What treatment will the nurse expect the client to be scheduled for?

A. A fasciotomy

B. A total hip replacement

C. A total knee replacement

D. An open reduction

A. A fasciotomy

Following a total knee replacement, the surgeon orders a continuous passive motion (CPM) device. The client asks about the purpose of this treatment. What is the best response by the nurse?

A. "CPM increases range of motion of the joint."

B. "CPM prevents injury by limiting flexion of the knee."

C. "CPM delivers analgesic agents directly into the joint."

D. "CPM strengthens the muscles of the leg."

A. "CPM increases range of motion of the joint."

The nurse is checking the traction apparatus for a client in skin traction. Which finding would require the nurse to intervene?

A. Ropes freely moving over pulleys

B. Body aligned opposite to line of traction pull

C. Weights hanging and touching the floor

D. Pulleys without evidence of the obstruction

C. Weights hanging and touching the floor

The nurse is providing instructions to the client who is being prepared for skeletal traction. Which statement by the client indicates teaching was effective?

A. "Metal pins will go through my skin to the bone."

B. "The traction can be removed once a day so I can shower."

C. "I will wear a boot with weights attached."

D. "A belt will go around my pelvis and weights will be attached."

A. "Metal pins will go through my skin to the bone."

A client with a right leg fracture is returning to the orthopedist to have the cast removed. What would the physician prescribe as further treatment?

A. discontinue use of crutches

B. cold compresses to leg for swelling

C. physical therapy

D. no options are correct.

C. physical therapy

A client is reporting pain following orthopedic surgery. Which intervention will help relieve pain?

A. Elevate the affected extremity and use cold applications.

B. Breathe deeply and cough every 2 hours until ambulation is possible.

C. Do ROM exercises as indicated.

D. Apply antiembolism stockings as indicated.

A. Elevate the affected extremity and use cold applications.

Which is not a guideline for avoiding hip dislocation after replacement surgery?

A. Put a pillow between the legs when sleeping.

B. Keep the knees apart at all times.

C. Never cross the legs when seated.

D. The hip may be flexed to put on clothing such as pants, stockings, socks, or shoes.

D. The hip may be flexed to put on clothing such as pants, stockings, socks, or shoes.

A client has severe osteoarthritis in the left hip and is having surgery to replace both articular surfaces of the hip. What type of surgical procedure will the nurse prepare the client for?

A. Arthrodesis

B. Hemiarthroplasty

C. Total arthroplasty

D. Osteotomy

C. Total arthroplasty

A client is brought to the emergency department by a softball team member who states the client and another player ran into each other, and the client is having severe pain in the right shoulder. What symptoms of a fractured clavicle does the nurse recognize?

A. Right shoulder is elevated above the left.

B. Right shoulder slopes downward and droops inward.

C. Client complains of tingling and numbness in the right shoulder.

D. Client complains of pain in the unaffected shoulder.

B. Right shoulder slopes downward and droops inward.

Rationale:

The client with a fractured clavicle has restricted motion, and the affected shoulder appears to slope downward and droop inward. The client will have pain, not typically tingling and numbness in the right shoulder. Pain is not felt in the unaffected shoulder.

The nurse is caring for a client with an external fixator that requires pin care twice a day. The nurse observes that there is a new purulent drainage around one of the pins. What intervention should the nurse anticipate doing?

A. Obtaining a culture

B. Scrubbing the drainage from around the pin site

C. Applying iodine-based solution

D. Apply ointment to the pin site.

A. Obtaining a culture

Rationale:

A culture should be obtained if purulent drainage is present. Drainage should be gently removed, not scrubbed. Iodine-based products interfere with tissue healing and are not recommended for cleaning pin sites. Ointment should not be applied to the pin site unless specifically ordered.

Which principle applies to the client in traction?

A. Knots in the ropes should touch the pulley.

B. Weights are removed routinely.

C. Weights should rest on the bed.

D. Skeletal traction is never interrupted.

D. Skeletal traction is never interrupted.

*Rationale:

Skeletal traction is applied directly to the bone and is never interrupted. To be effective, the weights must hang freely and not rest on the bed or floor. Knots in the rope or the footplate must not touch the pulley or the foot of the bed. Traction must be continuous to be effective in reducing and immobilizing fractures.

A client with a long arm cast continues to complain of unrelieved throbbing pain even after receiving opioid pain medication. Which is the priority action by the nurse?

A. Teach relaxation techniques.

B. Assess for previous opioid drug use.

C. Reposition the client for comfort.

D. Assess for complications.

D. Assess for complications.

A client with an arm cast reports pain. What nursing interventions should the nurse provide in order to reduce the incidence of complications? (Select all that apply.)

A. Cut the cast with a cast saw

B. Assess for a pressure sore

C. Administer a prescribed analgesic to promote comfort and allay anxiety.

D. Determine the exact site of the pain.

E. Assess the fingers for color and temperature.

B. Assess for a pressure sore

D. Determine the exact site of the pain.

E. Assess the fingers for color and temperature.

**The reason C is not correct is because administering an analgesic would help with pain, but it would not reduce the incidence of complications.

A patient in pelvic traction needs circulatory status assessed. How should the nurse assess for a positive Homans' sign?

A. Have the patient extend both hands while the nurse compares the volume of both radial pulses.

B. Have the patient plantar flex both feet while the nurse performs the blanch test on all of the patient's toes.

C. Have the patient extend each leg and dorsiflex each foot to determine if pain or tenderness is present in the lower leg.

D. Have the patient squeeze the nurse's hands with his or her hands to evaluate any difference in strength.

C. Have the patient extend each leg and dorsiflex each foot to determine if pain or tenderness is present in the lower leg.

Rationale:

Homans' sign is a test for presence of DVT. The nurse should assess for pain on passive flexion of each foot, which could indicate deep vein thrombosis.

Which device is designed specifically to support and immobilize a body part in a desired position?

A. Trapeze

B. Splint

C. Continuous passive motion (CPM) device

D. Brace

B. Splint

Which statement is accurate regarding care of a plaster cast?

A. The cast will dry in about 12 hours.

B. The cast can be dented while it is damp.

C. The cast must be covered with a blanket to keep it moist during the first 24 hours.

D. A dry plaster cast is dull and gray.

B. The cast can be dented while it is damp.

Rationale:

The cast can be dented while it is damp. A dry plaster case is white and shiny. The cast will dry in 24 to 72 hours. A freshly applied cast should be exposed to circulating air to dry and should not be covered with clothing or bed linens or placed on plastic-coated mats or bedding.

Which would be contraindicated as a component of self-care activities for the client with a cast?

A. Do not attempt to scratch the skin under a cast

B. Elevate the casted extremity to heart level frequently

C. Cushioning rough edges of the cast with tape

D. Cover the cast with plastic to insulate it

D. Cover the cast with plastic to insulate it

Rationale:

The cast should be kept dry, but do not cover it with plastic or rubber because this causes condensation, which dampens the cast and skin. The other activities are consistent with cast care.

Which action would be most important postoperatively for a client who has had a knee or hip replacement?

A. Assisting in early ambulation.

B. Encouraging expressions of anxiety.

C. Providing crutches to the client.

D. Using a continuous passive motion (CPM) machine.

A. Assisting in early ambulation.

A group of students is studying for a test on traction. The students demonstrate understanding of the types of traction when they identify which of the following as an example of skin traction?

A. Crutchfield tongs

B. Thomas splint

C. Buck's

D. Balanced suspension

C. Buck's

A variety of complications can occur after a leg amputation. Which is not a possibility in the immediate postoperative period?

A. hematoma

B. osteomyelitis

C. hemorrhage

D. infection

B. osteomyelitis

*Rationale:

Chronic osteomyelitis may occur after persistent infection in the late postoperative period. Hematoma, hemorrhage, and infection are potential complications in the immediate postoperative period.

A group of students is reviewing information about cast composition in preparation for a discussion on the advantages and disadvantages of each. The students demonstrate understanding of the topic when they cite which of the following as an advantage of a plaster cast?

A. Quicker drying

B. Better molding to the client

C. Longer lasting

D. More breathable

B. Better molding to the client

*Rationale:

Plaster casts require a longer time for drying but mold better to the client and are initially used until the swelling subsides. Fiberglass casts dry more quickly, are lighter in weight, longer lasting, and breathable.

A client is having a cast applied for a fractured leg that extends from below the knee to the base of the toes. The foot is flexed at a right angle in a neutral position. What type of cast is the client having applied?

A. Walking cast

B. Short leg cast

C. Long leg cast

D. Hip spica cast

B. Short leg cast

A client in the emergency department is being treated for a wrist fracture. The client asks why a splint is being applied instead of a cast. What is the best response by the nurse?

A. “Not all fractures require a cast.”

B. “It is best if an orthopedic doctor applies the cast.”

C. “A splint is applied when more swelling is expected at the site of injury.”

D. “You would have to stay here much longer because it takes a cast longer to dry.”

C. "A splint is applied when more swelling is expected at the site of injury."

A patient arrives in the emergency department with a suspected bone fracture of the right arm. How does the nurse expect the patient to describe the pain?

A. Sharp and piercing

B. Sore and aching

C. A dull, deep, boring ache

D. Similar to "muscle cramps"

A. Sharp and piercing

A physician calls the nurse for an update on his client who underwent abdominal surgery 5 hours ago. The physician asks the nurse for the total amount of drainage collected in the Hemovac since surgery. The nurse reports that according to documentation, no drainage has been recorded. When the nurse finishes on the telephone, she goes to assess the client. Which assessment finding explains the absence of drainage?

A. The client has been lying on his side for 2 hours with the drain positioned upward.

B. There is a moderate amount of dry drainage on the outside of the dressing.

C. The Hemovac drain isn't compressed; instead it's fully expanded.

D. The client has a nasogastric (NG) tube in place that drained 400 ml.

C. The Hemovac drain isn't compressed; instead it's fully expanded.

In preparing the client for transfer to the operating room, which of the following actions by the nurse is inappropriate?

A. Remove all jewelry.

B. Have client wear hospital gown.

C. Have the client void.

D. Allow the client to wear dentures.

D. Allow the client to wear dentures.

The anesthesiologist will use moderate (conscious) sedation during the client's surgical procedure. The circulating nurse will expect the client to:

A. Respond verbally during the procedure

B. Be anxious throughout the procedure

C. Need pain control throughout the procedure

D. Need an endotracheal tube

A. Respond verbally during the procedure

The OR personnel responsible for maintaining the safety of the client and the surgical environment is the:

A. Surgeon

B. Circulating nurse

C. Anesthesiologist

D. Scrub nurse

B. Circulating nurse

The nurse understands that the purpose of the "time out" is to:

A. verify all necessary supplies are available.

B. identify the client's allergies.

C. clarify the roles of the OR personnel.

D. maintain the safety of the client.

D. maintain the safety of the client.

At what point does the preoperative period end?

A. When the client is admitted to the PACU

B. When the client signs the consent form

C. When the decision is made to proceed with surgery

D. When the client is transferred onto the operating table

D. When the client is transferred onto the operating table

A patient is in the operating room for surgery. Which individual would be responsible for ensuring that procedure and site verification occurs and is documented?

A. Circulating nurse

B. Surgeon

C. Registered nurse first assistant

D. Scrub nurse

A. Circulating nurse

A gunshot wound would be classified under which category of surgery based on urgency?

A. Elective

B. Emergent

C. Urgent

D. Required

B. Emergent

In which zone of the surgical area are street clothes allowed?

A. Restricted

B. Limited

C. Unrestricted

D. Semi-restricted

C. Unrestricted

The nurse is caring for a client during an intra operative procedure. When assessing vital signs, which result indicates a need to alert the anesthesiologist immediately?

A. Temperature of 102.5°F (39°C)

B. Respiratory rate of 18 breaths/min

C. Blood pressure of 104/62 mm Hg

D. Pulse rate of 110 beats/min

A. Temperature of 102.5°F (39°C)

The nurse is planning care for a client following abdominal surgery. Which outcome demonstrates a return of functioning to the gastrointestinal tract?

A. The client is tolerating sips of water.

B. The client is passing flatus.

C. The client states being hungry.

D. The client reports a small bowel movement.

D. The client reports a small bowel movement.

What is the highest priority nursing intervention for a client in the immediate postoperative phase?

A. Assessing urinary output every hour

B. Monitoring vital signs at least every 15 minutes

C. Assessing for hemorrhage

D. Maintaining a patent airway

D. Maintaining a patent airway

A client receiving moderate sedation for a minor surgical procedure begins to vomit. What should the nurse do first?

A. Provide a basin.

B. Suction the mouth.

C. Administer an antiemetic medication.

D. Roll the client onto his or her side.

D. Roll the client onto his or her side.

A client has been transported to the operating room for emergent surgery. Which statement by the nurse best supports the need for emergent surgery?

A. "The client was unresponsive, had a distended abdomen, and had unstable vital signs after a motor vehicle accident."

B. “The client had severe pain and a laceration to the face with minimal bleeding after being attacked by a dog 1 hour ago.”

C. “The client was tachycardic, had progressive weight loss, and experienced bouts of insomnia as a result of hyperthyroidism.”

D. “The client had epigastric abdominal pain, an elevated white blood count, and vomiting for 1 day.”

A. "The client was unresponsive, had a distended abdomen, and had unstable vital signs after a motor vehicle accident."

The nurse is educating a community group about types of surgery. A member of the group asks the nurse to describe a type of surgery that is curative. What response by the nurse is true?

A. A biopsy

B. Tumor excision

C. A face-lift

D. Placement of gastrostomy tube

B. Tumor excision

A client refuses to remove her wedding band when preparing for surgery. What is the best action for the nurse to take?

A. Allow the client to wear the ring and cover it with tape.

B. Notify the surgeon to cancel surgery.

C. Remove the ring once the client is sedated.

D. Discuss the risk for infection caused by wearing the ring.

A. Allow the client to wear the ring and cover it with tape.

A client having a surgical procedure takes aspirin 325 mg daily for prevention of platelet aggregation. When should the client stop taking the aspirin before the surgery?

A. 2 to 3 days

B. 2 weeks

C. 7 to 10 days

D. 4 weeks

C. 7 to 10 days

What measurement should the nurse report to the physician in the immediate postoperative period?

A. A temperature reading between 97°F and 98°F

B. A hemoglobin of 13.6

C. Respirations between 20 and 25 breaths/min

D. A systolic blood pressure lower than 90 mm Hg

D. A systolic blood pressure lower than 90 mm Hg

Clients who have received corticosteroids preoperatively are at risk for which type of insufficiency?

A. Thyroid

B. Adrenal

C. Parathyroid

D. Pituitary

B. Adrenal

Which position is used for perineal surgical procedures?

A. Lithotomy

B. Sims

C. Trendelenburg

D. Dorsal recumbent

A. Lithotomy

The nurse observes that a postsurgical client has hemorrhaged and is in hypovolemic shock. Which nursing intervention will manage and minimize hemorrhage and shock?

A. Rubbing the back

B. Reinforcing dressings or applying pressure if bleeding is frank

C. Encouraging the client to breathe deeply

D. Elevating the head of the bed

B. Reinforcing dressings or applying pressure if bleeding is frank

Informed consent from the surgical client is essential in all of the following categories of surgery except:

A. Required surgery

B. Urgent surgery

C. Emergent surgery

D. Elective surgery

C. Emergent surgery

The nurse recognizes that the client who takes hydrochlorothiazide to manage hypertension is predisposed for which interaction with anesthesia?

A. Seizures

B. Hypotension

C. Increased risk of bleeding

D. Respiratory depression

D. Respiratory depression

Which question is most important for the nurse to ask the client when obtaining the preoperative admission history?

A. "Did you bring a copy of your healthcare power of attorney?"

B. "Who is here with you?"

C. "When is the last time you ate or drank?"

D. "Did you bring any valuables with you?"

C. "When is the last time you ate or drank?"

Which intervention should the nurse plan to implement to decrease the client's risk for injury during the intraoperative period?

A. Allow the client to verbalize fears.

B. Keep the family informed of the client's status.

C. Assess the client for allergies.

D. Verify the client's preoperative vital signs.

C. Assess the client for allergies.

The client is experiencing nausea and vomiting following surgery. What will the nurse expect the surgeon to order?

A. ondansetron

B. chlorpromazine

C. ranitidine

D. omeprazole

A. ondansetron

A client is scheduled for a surgical procedure. When planning the client's care, the nurse should consider that which of the following conditions will increase the client's risk of complications after surgery?

A. A history of osteoarthritis

B. A history of sensitivity to aspirin

C. A history of chronic low back pain

D. A history of diabetes

D. A history of diabetes

After teaching a patient scheduled for ambulatory surgery using moderate sedation, the nurse determines that the patient has understood the teaching based on which of the following statements?

A. "I'll be sleepy but able to respond to your questions."

B. "Only the surgical area will be numb."

C. "I'm so glad that I will be unconscious during the surgery."

D. "I won't feel it, but I'll have a tube to help me breathe."

A. "I'll be sleepy but able to respond to your questions."

A physically fit 86-year-old is scheduled for right knee replacement. Which factor puts the client at increased risk for complications during or after surgery?

A. Ability to metabolize medication

B. Nutritional status

C. Age

D. Type of surgery

C. Age

A nurse assesses a postoperative client as having abdominal organs protruding through the surgical incision. Which term best describes this assessment finding?

A. Erythema

B. Dehiscence

C. Hernia

D. Evisceration

D. Evisceration

A client is postoperative day 3 after surgical repair of an open abdominal wound and traumatic amputation of the right lower leg following a motorcycle crash. What is the highest priority nursing intervention?

A. Obtaining dietary consultation for improved wound healing

B. Assessing WBC count, temperature, and wound appearance

C. Administering pain medications within 1 hour of the client’s request

D. Educating the client on safe bed-to-chair transfer procedures

B. Assessing WBC count, temperature, and wound appearance

The nurse is attempting to ambulate a client who underwent shoulder surgery earlier in the day, but the client is refusing to do so. What action by the nurse is most appropriate?

A. Use multiple staff members to remove the client from the bed.

B. Document the client’s refusal.

C. Reinforce the importance of early mobility in preventing complications.

D. Delegate the task to the unlicensed assistive personnel.

C. Reinforce the importance of early mobility in preventing complications.

The anesthesiologist administered a transsacral conduction block. Which documentation by the nurse is consistent with the anesthesia being administered?

A. Yelling and pulling at equipment

B. Unresponsive to verbal or tactile stimuli

C. No movement in right lower leg

D. Denies sensation to perineum and lower abdomen

D. Denies sensation to perineum and lower abdomen

The circulating nurse is unsure whether proper technique was followed when an object was placed in the sterile field during a surgical procedure. What is the best action by the nurse?

A. Remove the entire sterile field from use.

B. Remove the item from the sterile field.

C. Ask another nurse to review the technique used.

D. Mark the client’s chart for future review of infections.

A. Remove the entire sterile field from use.

An anxious client being prepared for surgery is encouraged to concentrate on a pleasant experience or restful scene. What cognitive coping strategy would the nurse document as being used?

A. Distraction

B. Optimistic self-recitation

C. Imagery

D. Progressive muscular relaxation

C. Imagery

How would the operating room nurse place a patient in the Trendelenburg position?

A. On his side with his uppermost leg adducted and flexed at the knee

B. Flat on his back with his arms next to his sides

C. On his back with his legs and thighs flexed at right angles

D. On his back with his head lowered so that the plane of his body meets the horizontal on an angle

D. On his back with his head lowered so that the plane of his body meets the horizontal on an angle

A fractured skull would be classified under which category of surgery based on urgency?

A. Urgent

B. Elective

C. Required

D. Emergent

D. Emergent

Which health care profession has the ultimate responsibility to provide appropriate information regarding a nonemergent surgery?

A. Certified nurse's aide

B. Nurse

C. Case manager

D. Physician

D. Physician

Which would be considered to require an urgent surgical procedure?

A. Cataract

B. Acute gallbladder infection

C. Severe bleeding

B. Loose facial skin

B. Acute gallbladder infection

The primary objective in the immediate postoperative period is:

A. controlling nausea and vomiting.

B. monitoring for hypotension.

C. maintaining pulmonary ventilation.

D. relieving pain.

C. maintaining pulmonary ventilation.

An inappropriate nursing action implemented to keep the client safe includes:

A. Accurately identifying the client

B. Protecting bony prominences

C. Screening for latex allergy

D. Moving the client swiftly

D. Moving the client swiftly

Which statement by the client indicates further teaching about epidural anesthesia is necessary?

A. "I will lose the ability to move my legs."

B. "A needle will deliver the anesthetic into the area around my spinal cord."

C. "I will become unconscious."

D. "I will be able to hear the surgeon during the surgery."

C. "I will become unconscious."

The nurse is teaching the client about usual side effects associated with spinal anesthesia. Which of the following should the nurse include when teaching?

A. Seizures

B. Headache

C. Sore throat

D. Itching

B. Headache

Which type of healing occurs when granulation tissue is not visible and scar formation is minimal?

A. Third intention

B. First intention

C. Fourth intention

D. Second intention

B. First intention

A patient who has undergone surgery and received spinal anesthesia is reporting a headache. Which of the following would be most appropriate?

A. Encourage increased fluid intake.

B. Notify the anesthesiologist immediately.

C. Turn on the television for distraction.

D. Position the patient on the side.

A. Encourage increased fluid intake.

A client is undergoing preoperative assessment. During admission paperwork, the client reports having enjoyed a hearty breakfast this morning to be ready for the procedure. What is the nurse's next action?

A. Document what foods the client ate.

B. Give the client plenty of water to aid digestion.

C. Cancel the surgery.

D. Notify the surgeon.

D. Notify the surgeon.

During a procedure, a client's temperature begins to rise rapidly. This is likely the result of which complication?

A. fluid volume excess

B. hypothermia

C. malignant hyperthermia

D. infection

C. malignant hyperthermia

A client is placed on the operating room table for the surgical procedure. Which surgical team member is responsible for handing sterile instruments to the surgeon and assistants?

A. First assistant

B. Scrub nurse

C. Certified registered nurse anesthetist

D. Circulating nurse

B. Scrub nurse

A client is at postoperative hour 8 after an appendectomy and is anxious, stating, “Something is not right. My pain is worse than ever and my stomach is swollen.” Blood pressure is 88/50, pulse is 115, and respirations are 24 and labored. The abdomen is soft and distended. No obvious bleeding is noted. What action by the nurse is most appropriate?

A. Notify the physician.

B. Inform the client this is the normal progression after abdominal surgery.

C. Ambulate the client to reduce abdominal distention.

D. Administer morphine per orders.

A. Notify the physician.

A client asks why a drain is in place to pull fluid from the surgical wound. What is the best response by the nurse?

A. “It assists in preventing infection.”

B. “Most surgeons use wound drains now.”

C. “The drain will remove necrotic tissue.”

D. “It will cut down on the number of dressing changes needed.”

A. "It assists in preventing infection."

A patient with uncontrolled diabetes is scheduled for a surgical procedure. What chief life-threatening hazard should the nurse monitor for?

A. Glucosuria

B. Hypoglycemia

C. Dehydration

D. Hypertension

B. Hypoglycemia

Why is assessment of dentition important in the patient preparing to have a surgical procedure with general anesthesia?

A. The patient may require referral to the dentist.

B. The patient can sue if a tooth falls out during surgery.

C. Oral hygiene is important for all patients.

D. Decayed teeth or dental prosthesis can become dislodged during intubation.

D. Decayed teeth or dental prosthesis can become dislodged during intubation.

The nurse is completing a postoperative assessment for a patient who has received a depolarizing neuromuscular blocking agent. The nursing assessment includes careful monitoring of which body system?

A. Endocrine system

B. Gastrointestinal system

C. Cardiovascular system

D. Genitourinary system

C. Cardiovascular system

The nurse is responsible for monitoring cardiovascular function in a postoperative patient. What method can the nurse use to measure cardiovascular function?

A. Central venous pressure

B. Complete blood count

C. Upper endoscopy

D. Chest x-ray

A. Central venous pressure

After a tonsillectomy, a client is being prepared for discharge. The nurse should instruct the client to report which sign or symptom immediately?

A Bleeding

B. Difficulty swallowing

C. Difficulty talking

D. Throat pain

A. Bleeding

A client undergoes a total laryngectomy and tracheostomy formation. On discharge, the nurse should give which instruction to the client and family?

A. "Limit the amount of protein in the diet."

B. "Clean the tracheostomy tube with alcohol and water."

C. "Family members should continue to talk to the client."

D. "Oral intake of fluids should be limited for 1 week only."

C. "Family members should continue to talk to the client."

A client is prescribed two sprays of a nasal medication twice a day. The nurse is teaching the client how to self-administer the medication and instructs the client to:

A. Wait 10 seconds before administering the second spray.

B. Blow the nose before applying medication into the nares.

C. Tilt the head back when activating the spray of the medication.

D. Clean the medication container once each day.

B. Blow the nose before applying medication into the nares.

A client is experiencing acute viral rhinosinusitis. The nurse is providing instructions about self-care activities and includes information about:

A. Saline lavages to the nares

B. Use of a dehumidifier

C. Cold compresses to the sinus cavities

D. Administration of oral antibiotics

A. Saline lavages to the nares

A nurse is providing instructions for the client with chronic rhinosinusitis. The nurse accurately tells the client:

A. Do not perform saline irrigations to the nares.

B. You may drink 1 glass of alcohol daily.

C. Sleep with the head of bed elevated.

D. Caffeinated beverages are allowed.

C. Sleep with the head of bed elevated.

A nurse has pharyngitis and will be providing self care at home. It is most important for the nurse to:

A. Properly dispose of used tissues

B. Seek medical help if he experiences inability to swallow

C. Place an ice collar on the throat to relieve soreness

D. Stay in bed when experiencing a fever

B. Seek medical help if he experiences inability to swallow

The nurse is caring for a client diagnosed with enlarged adenoids. What condition is produced by enlarged adenoids?

A. Hardened secretions

B. Noisy breathing

C. Erosion of the trachea

D. Incrusted mucous membranes

B. Noisy breathing

A client comes into the Emergency Department with epistaxis. What intervention should you perform when caring for a client with epistaxis?

A. Place the client in a semi-Fowler's position.

B. Apply direct continuous pressure.

C. Apply a moustache dressing.

D. Provide a nasal splint.

B. Apply direct continuous pressure.

You are doing preoperative teaching with a client scheduled for laryngeal surgery. What should you teach this client to help prevent atelectasis?

A. Encourage deep breathing every 2 hours.

B. Provide meticulous mouth care every 4 hours.

C. Monitor for signs of dysphagia.

D. Caution against frequent coughing.

A. Encourage deep breathing every 2 hours.

You are caring for a client who is 42 years old and status post adenoidectomy. You find the client in respiratory distress when you enter their room. You ask another nurse to call the physician and bring an endotracheal tube into the room. What do you suspect?

A. Infection

B. Post-operative bleeding

C. Plugged tracheostomy tube

D. Edema of the upper airway

D. Edema of the upper airway

A client is being seen by the physician because of an unrelenting headache, facial tenderness, low-grade fever, and dark yellow nasal discharge. The client reports seeming to develop sinus infections "all the time." Which factor may predispose the client to sinusitis?

A. increased exposure to the healthcare environment

B. more than 8 hours of sleep per night

C. interference with sinus drainage

D. excessive protein intake

C. interference with sinus drainage

The nurse is caring for a client with allergic rhinitis. The client asks the nurse about measures to help decrease allergic symptoms. Which is the best response by the nurse?

A. “You need to see your ear, nose, and throat specialist monthly.”

B. “You should try to reduce exposure to irritants and allergens.”

C. “Take over-the-counter nasal decongestants when you experience symptoms.”

D. “Be sure to receive your influenza vaccination each year.”

B. "You should try to reduce exposure to irritants and allergens."

The nurse is providing discharge instructions to a client who has nasal packing in place following nasal surgery. Which discharge instructions would be most appropriate for the client?

A. Take aspirin for nasal discomfort.

B. Decrease the amount of daily fluids.

C. Administer normal saline nasal drops as ordered.

D. Avoid sports activities for 6 weeks.

D. Avoid sports activities for 6 weeks.

A nurse is caring for a client who has a history of sleep apnea. The client understands the disease process when he says:

A. "I should become involved in a weight loss program."

B. "I should sleep on my side all night long."

C. "I should eat a high-protein diet."

D. "I need to keep my inhaler at the bedside."

A. "I should become involved in a weight loss program."

The nurse initiates the following intervention upon receiving a client back to the clinical unit after a throat-related procedure, "Elevate the head of the bed 45°." This assists in meeting which nursing goal?

A. The client will have increased tissue perfusion.

B. The client will remain alert and oriented.

C. The client will have decreased edema.

D. The client will have decreased pain.

C. The client will have decreased edema.

The nurse is obtaining a health history from a client with laryngitis. Which causative factor, stated by the client, is least likely?

A. "I used my voice in excess over the weekend."

B. "I have environmental allergies."

C. "I smoke a pack of cigarettes a day."

D. "I was chewing ice chips all day long."

D. "I was chewing ice chips all day long."

A nurse is assisting with a subclavian vein central line insertion when the client's oxygen saturation drops rapidly. He complains of shortness of breath and becomes tachypneic. The nurse suspects the client has developed a pneumothorax. Further assessment findings supporting the presence of a pneumothorax include:

A. diminished or absent breath sounds on the affected side.

B. paradoxical chest wall movement with respirations.

C. muffled or distant heart sounds.

D. tracheal deviation to the unaffected side.

A. diminished or absent breath sounds on the affected side.