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RN Nursing School · Med-Surg · 374 questions

Perioperative Care practice questions

Every question below is free to read with its full rationale. For timed sets, the rest of the bank and progress tracking on Perioperative Care, practise in the app.

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  1. 1A nurse is caring for a client who is 1 day postoperative following coronary artery bypass graft (CABG) surgery. The nurse notes the following assessment data: temperature 38.1° C (100.6° F), chest tube drainage of 150 mL in 1 hour, blood glucose of 252 mg/dL, and a pain rating of 5 on a 0 to 10 scale. Which finding should the nurse report to the provider immediately?Answer →
  2. 2A nurse is preparing to administer 1.3 mg of morphine sulfate to a client experiencing pain. The medication solution on the unit is 5 mg in 10 mL. How many mL should the nurse administer? ___ mL (If needed, round the answer to the nearest tenth.)Answer →
  3. 3What type of nonpharmacologic pain relief measure uses electrical stimulation to inhibit transmission of painful impulses?Answer →
  4. 4A nurse is caring for a client in the recovery room who has just undergone thoracic surgery. Which of the following actions by the client indicates that additional education is required on how to properly perform deep breathing exercises?Answer →
  5. 5A nurse is assisting with the care for a client who is scheduled for surgery. The nurse is reviewing the client's medical record. Which of the following findings places the client at risk for delayed wound healing? Select all that apply.Answer →
  6. 6A nurse is providing teaching to a client who has been diagnosed with a complete molar pregnancy. Which of the following statements by the client indicates understanding?Answer →
  7. 7The nurse pauses preparations and notifies the surgeon, who returns to the bedside and re-explains the procedure, long-term management, and expected outcomes. Ms. Davis verbalizes understanding, agrees to lifelong follow-up, and states she is comfortable continuing with surgery. Ms. Davis is transported to the OR. The surgical time-out is performed, anesthesia is started, and the team prepares to begin the procedure. What is the nurse's action after the patient is taken to PACU?Answer →
  8. 8A nurse is collecting data on a client who has a surgical wound healing by secondary intention. Which of the following findings should the nurse report to the charge nurse?Answer →
  9. 9What is a TURP?Answer →
  10. 10The nurse administers oxycodone 5 mg with acetaminophen 500 mg (Percocet) to a patient for postoperative pain. Which patient teaching about the analgesic agent is the nurse's priority before the nurse leaves the patient's room?Answer →
  11. 11A nurse on a labor and delivery unit is monitoring the fetal heart rate (FHR) pattern of a client in labor. Which of the following findings should the nurse classify as nonreassuring fetal heart rate patterns? (Select All that Apply.)Answer →
  12. 12A nurse is calculating the intake of a client during the past 9 hr. The client's intake includes lactated Ringer's IV at 150 mL/hr, cefazolin 2 g IV intermittent bolus in 100 mL of 0.9% sodium chloride, two units of packed RBCs of 275 mL and 250 mL, two IV bolus infusions of 250 mL of 0.9% sodium chloride, famotidine 20 mg IV intermittent bolus in 50 mL of 0.9% sodium chloride. How many mL of intake should the nurse record?Answer →
  13. 13The nurse is providing preoperative teaching to a client scheduled for lung resection surgery. The nurse instructs the client about prevention of postoperative complications. Which statement by the nurse is most appropriate?Answer →
  14. 14A nurse is preparing to initiate PCA morphine for a 59-year-old postoperative client following abdominal surgery. The client's spouse says, 'I'll make sure to press the button if my husband falls asleep so he doesn't wake up in pain.' The nurse reviews the client's orders: PCA morphine Demand dose: 1 mg Lockout interval: 8 minutes Continuous pulse oximetry ordered Sedation scale assessments q2 hours Which nursing precautions must the nurse implement? Select all that apply.Answer →
  15. 15The intraoperative nurse is transferring an older adult client from the operating room to the PACU after right knee replacement. Which action should the nurse prioritize?Answer →
  16. 16Which of the following is true regarding the nurse's responsibility with informed consent?Answer →
  17. 17A patient is day 1 post-operative after a bowel resection for a colon tumor. The patient begins to complain of sudden, sharp abdominal pain. The most appropriate initial response by the nurse is to:Answer →
  18. 18A client receiving Total Parenteral Nutrition (TPN) via a central venous catheter reports chills, nausea, and a feeling of fullness in the chest. The nurse notes that the TPN solution is behind schedule, and the infusion pump has alarmed for occlusion twice. Which action should the nurse take first?Answer →
  19. 19A nurse is discharging a client who is postpartum, providing the client and their support system with education on vaccinations. Which of the following people has the highest priority to be vaccinated against tetanus-diphtheria-acellular pertussis at the time of discharge?Answer →
  20. 20The nurse reviews the client data. Which increases the client's chance for positive outcomes after the completion of the bariatric surgery? Select all that apply.Answer →
  21. 21A postoperative patient with a Jackson-Pratt (JP) drain reports persistent discomfort around the insertion site and the nurse notes the drainage amount has decreased significantly over the past 12 hours. The drain bulb is fully compressed but has not reinflated. Which nursing action is most appropriate to address this situation?Answer →
  22. 22A nurse is caring for a client who is scheduled for heart surgery. Prior to surgery the client states, "I'm not sure I want to go through with this procedure after all." Which of the following actions should the nurse take?Answer →
  23. 23A nurse is caring for a client who is post op appendectomy. (Vitals: BP 162/76, HR 100, RR 24, T 37.1, O2 89% on room air). The client is at risk for developing ______ evidenced by ______.Answer →
  24. 24A nurse is researching data about best practice for reducing medication errors on a surgical unit. Which of the following steps of evidence-based practice (EBP) is the nurse taking?Answer →
  25. 25Nursing interventions for the person undergoing a radical neck dissection include: Select all that applyAnswer →
  26. 26A nurse is caring for a client who has placenta previa. Which of the following reportable client findings should the nurse expect?Answer →
  27. 27A nurse is preparing a client to be transferred to the operating room. The nurse informs the client that there is a delay and they will not be transferred for another 15 min. Which of the following actions should the nurse take during this delay?Answer →
  28. 28A nurse on a postpartum unit is caring for a client. Which of the following statements should the nurse include when teaching the client? (Select All that Apply.)Answer →
  29. 29An adult client has just been admitted to the PACU following abdominal surgery. As the client begins to awaken, the client is unusually restless. The nurse notes the skin is cold, moist, and pale. The nurse should suspect which surgical complication?Answer →
  30. 30A nurse is transcribing medication prescriptions for a group of clients. Which of the following is the appropriate way for the nurse to record medications that require the use of a decimal point?Answer →
  31. 31A nurse is preparing to administer amoxicillin 320 mg PO every 12 hr to an infant. The amount available is amoxicillin suspension 400 mg/5 ml. How many mL should the nurse administer per dose? (Round the answer to the nearest tenth. Use a leading zero if it applies. Do not use a trailing zero.)Answer →
  32. 32The nurse plans care for a client receiving total parenteral nutrition (TPN) through a central venous catheter. What action(s) should the nurse plan to include in the care of this client? Select all that apply.Answer →
  33. 33A nurse is educating new parents on preventing sudden infant death syndrome (SIDS). Which of the following instructions should the nurse prioritize to effectively reduce the infant's risk?Answer →
  34. 34A nurse is caring for a client who is at risk for shoulder dystocia. Which of the following manifestations indicate that shoulder dystocia is occurring?Answer →
  35. 35A nurse is working with a client who is 6 hr postpartum following a vaginal birth with first-degree laceration. Which of the following actions is an example of the nurse providing a stepwise approach to manage the client's pain?Answer →
  36. 36The nurse in the preoperative unit is teaching the client about incentive spirometry. Which statement regarding incentive spirometry should the nurse include with preoperative teaching?Answer →
  37. 37A postoperative patient with a Jackson-Pratt (JP) drain reports persistent discomfort around the insertion site and the nurse notes the drainage amount has decreased significantly over the past 12 hours. The drain bulb is fully compressed but has not reinflated. Which nursing action is most appropriate to address this situation?Answer →
  38. 38The nurse in the post anesthesia care unit (PACU) notes that a patient has a respiratory rate of 8 breaths/min 30 minutes after surgery. Which action should the nurse implement next?Answer →
  39. 39A nurse is caring for a client who is prescribed tetracycline 2 grams daily PO in four divided doses every 6 hr. Available is tetracycline 250 mg capsules. How many capsules should the nurse administer per dose?Answer →
  40. 40A nurse from the recovery area is caring for a client who is beginning to wake up from anesthesia following a foot amputation. Which of the following priority postoperative complications should the nurse expect the patient to experience first?Answer →
  41. 41In the preoperative area, a nurse reports that surgeons frequently skip marking the surgical site before procedures. Which response by the nurse manager best reflects a culture of safety?Answer →
  42. 42Which professional organization publishes the Scopes and Standards of Practice for Nurses?Answer →
  43. 43A nurse is preparing to administer morphine sulfate 2 mg IV bolus. Available is morphine sulfate 10 mg/mL. How many ml should the nurse administer per dose? (Round the answer to the nearest tenth. Use a leading zero if it applies. Do not use a trailing zero.) mLAnswer →
  44. 44While observing his surgical incision, a male client asks the nurse why all the hair was removed during surgery. The nurse should explain that the most important reason for shaving the incisional area is to?Answer →
  45. 45A nurse is explaining to a patient the anticipated effect of the application of cold to an injured area. What response indicates that the patient understands the explanation?Answer →
  46. 46The nurse is about to make first rounds after receiving report. Which client should the nurse assess first?Answer →
  47. 47A nurse is assessing a client's abdominal surgical wound and notes redness, warmth, swelling, and purulent drainage. What action should the nurse take?Answer →
  48. 48The nurse is caring for a 79-year-old client who returned to the postsurgical unit following abdominal surgery. The client is unable to ambulate and refuses to wear external pneumatic compression stockings. The nurse should explain that refusing to wear them increases the risk of which postsurgical complication?Answer →
  49. 49Drag the words from the choices below to fill in each blank in the following sentence Effective nonpharmacological pain management approaches often include [blank1], [blank2] and [blank3]Answer →
  50. 50When reviewing the admitting prescriptions for a client, the nurse notes that the dose of one medication is three times the usual dose of this medication. The nurse calls the provider but he is unavailable for several days. Which Of the following actions should the nurse take?Answer →
  51. 51A nurse is conducting a home visit on a client who is 5 weeks postpartum. The client says they are still experiencing a "yellow-ish white vaginal discharge." What should the nurse include in the teaching to the client about this type of discharge?Answer →
  52. 52A client returns from surgery following a hiatal hernia repair via Nissen fundoplication. In which position should the nurse place this client?Answer →
  53. 53Correct continuum of care sequence after major surgery?Answer →
  54. 54A nurse is administering an IM injection using a passive needle-safety device. After injection, which of the following actions should the nurse take?Answer →
  55. 55A nurse is caring for a patient who is postoperative day one following a rhinoplasty. Which nursing intervention takes priority in identifying a potential complication?Answer →
  56. 56A nurse is preparing to administer a prescribed medication to a hospitalized client. The client says, "That pill looks different from the one I took yesterday." Which action by the nurse is most appropriate?Answer →
  57. 57A nurse is caring for a client who is about to undergo an elective surgical procedure. The nurse should take which of the following actions regarding informed consent? (Select all that apply)Answer →
  58. 58A client receives a prescription for 500 mL of normal saline to be infused over 5 hours. The IV infusion drop chamber delivers 15 gtt/mL. The nurse should regulate the drop chamber to deliver how many gtt/min? (Enter numeric value only.)Answer →
  59. 59A nurse is caring for a client who has a dehisced abdominal wound. Which of the following actions should the nurse take first?Answer →
  60. 60A perioperative nurse is caring for a postoperative patient. The patient has a shallow respiratory pattern and is reluctant to cough or to begin mobilizing. The nurse should prioritize the patient's increased risk for what complication?Answer →
  61. 61A client is exploring treatment options after being diagnosed with age-related cataracts that affect her vision. What treatment is most likely to be used in this client's care?Answer →
  62. 62A client is brought by friends to the ED after being involved in a motor vehicle accident. The client sustained blunt trauma to the abdomen. What nursing action would be most appropriate for this client?Answer →
  63. 63A nurse is reviewing providers' prescriptions for four clients. Which of the following prescriptions should the nurse verify with the provider?Answer →
  64. 64Which properties are held by the medication ibuprofen? Select all that apply.Answer →
  65. 65A nurse is caring for a client who reports feeling nauseous immediately following a procedure using moderate (conscious) sedation. Which of the following should be the nurse's priority action?Answer →
  66. 66At 0330, a nurse is caring for a client who is postoperative. The client's IV fluids are infusing at 120 mL/hr. How many mL of IV fluid should infuse by 0600? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.) mLAnswer →
  67. 67A nurse is caring for a client who is 4 days postoperative following bariatric surgery. Which of the following actions should the nurse plan to take? Select all that apply.Answer →
  68. 68A nurse is planning care for a client who requires insertion of a peripherally inserted central catheter (PICC) line. Which of the following actions should the nurse plan to take?Answer →
  69. 69A client is scheduled for an abdominal surgery. The client received an opioid analgesic for pain and is now drowsy. The client's legal next of kin is not present. What is the nurse's most appropriate action?Answer →
  70. 70The nurse is caring for a patient 48 hours after surgery and suspects the surgical wound is infected. Which nurse assessment finding would confirm a localized infection? (Select all that apply)Answer →
  71. 71The nurse is providing nutritional education for a client being discharged after bariatric surgery. Which statement by the client demonstrates understanding of the teaching?Answer →
  72. 72A nurse is reviewing surgical screening lab work with a client who has arrived for an elective procedure. During which of the following phases is this task performed?Answer →
  73. 73A nurse is preparing to change the linens on a client's bed. Which of the following actions should the nurse take?Answer →
  74. 74The client has just returned to the surgical floor after undergoing a retinal detachment repair. The postoperative orders specify that the client should be kept in a prone position until otherwise ordered. What should the nurse do?Answer →
  75. 75Drag from the choices below to specify what condition the client is most likely experiencing [blank1], 2 actions the nurse should take to address that condition [blank2] and [blank3], and 2 parameters the nurse should monitor to assess the client's progress [blank4] and [blank5].Answer →
  76. 76A patient undergoes surgery, and post-operative assessment shows a surgical wound with evisceration. What is the immediate nursing priority?Answer →
  77. 77A patient recovering from thoracotomy is at risk for postoperative pulmonary complications. Which intervention best prevents atelectasis?Answer →
  78. 78A nurse cares for a client 4 hours after a total laryngectomy. Which concern should the nurse prioritize?Answer →
  79. 79A nurse is assigned a group of postoperative clients. Which of the following client findings should the nurse identify as the priority?Answer →
  80. 80A nurse is caring for a patient who reports severe pain rated 9/10 and has not yet received their scheduled analgesic, due in 30 minutes. The patient is visibly distressed and requests pain relief. What is the nurse's best action to adhere to the principle of beneficence in this situation?Answer →
  81. 81A nurse is replacing a surgical dressing on a client who had abdominal surgery. Which of the following actions should the nurse take?Answer →
  82. 82Complete the following sentence by using the list of options. The client is at risk for developing [blank1] as evidenced by the client's [blank2].Answer →
  83. 83A nurse is admitting a client who is at 36 weeks of gestation, has placenta previa, and has moderate vaginal bleeding. Which of the following actions should the nurse take? (Select All that Apply.)Answer →
  84. 84The nurse is working in the perioperative setting. Which action best reflects the Quality Improvement (QI) competency from the Quality and Safety Education for Nurses (QSEN) initiative?Answer →
  85. 85The physician has ordered doxycycline 200 mg PO BID. The available dose is doxycycline 100 mg per tab. How many tablets will the patient receive per day?Answer →
  86. 86A client is 24 hours postoperative following a Roux-en-Y gastric bypass. Which assessment finding requires immediate nursing action?Answer →
  87. 87The provider has ordered IV fluids to infuse at a rate of 125 mL/hr. Using a drop factor of 15 gtt/mL, how many gtts/min will the nurse regulate the IV to infuse? (Provide answer as a number only, round answer to the nearest whole number)Answer →
  88. 88Which antibiotic is reserved for use in patients who have infections of the eyes, ears, or skin and is used to suppress the bowel flora before bowel surgery?Answer →
  89. 89A nurse is assessing a client's readiness for discharge from the PACU. The client can be roused by name, can move all extremities, has a blood pressure of 134/82 mm Hg, and has a baseline preoperative blood pressure of 128/78 mm Hg. The pulse oximetry reading is 94% on room air, and respirations are deep and easy at 12 breaths/min. What is the calculated Aldrete score?Answer →
  90. 90A nurse is caring for a postoperative patient who just returned from abdominal surgery. The physician prescribes a clear liquid diet. Which of the following items should the nurse include on the patient's meal tray? (Select all that apply.)Answer →
  91. 91The physician order is: Amoxicillin 500 mg PO every 8 hours for 10 days. Medication label: 125 mg/5 mL. How many mL per dose should the nurse administer?Answer →
  92. 92A nurse is field-triaging clients after an industrial accident. Which client condition would the nurse triage with a red tag?Answer →
  93. 93A nurse is assessing IV sites and needs to determine which complication is present based on clinical findings. Match each symptom to the most likely IV complication.Answer →
  94. 94A client who has had abdominal surgery under general anesthesia is transferred to the postanesthesia care unit (PACU). While planning nursing care for the first 24 hour postoperative period, which are the greatest dangers this client may experience?Answer →
  95. 95A nurse is caring for a client who is 2 hr postoperative following orthopedic surgery and reports pain as 10 on a scale of 0 to 10. Which of the following prescriptions should the nurse expect to administer?Answer →
  96. 96A nurse's sibling had a diagnostic test at the nurse's facility. The sibling asks the nurse to look up the result in the computer. The nurse should identify which of the following as the reason for her decision about her sibling's request?Answer →
  97. 97When the nurse observes that a postoperative client demonstrates a constant low level of oxygen saturation via the O2 saturation monitor despite the client's breathing appearing normal, What action should the nurse take first?Answer →
  98. 98A nurse is caring for a client who is postoperative following an appendectomy and is prescribed D5 lactated Ringer's at 150 mL/hr by continuous IV infusion for 12 hr. The drop factor of the manual IV tubing is 10 gtt/mL. The nurse should set the manual IV infusion to deliver how many gtt/min? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)Answer →
  99. 99The nurse is assessing the abdomen of a client who has been NPO for three days following abdominal surgery. After auscultating the abdomen for 120 seconds, the nurse hears bowel sounds in all four quadrants. Which action should the nurse implement first?Answer →
  100. 100A nurse is documenting an incident where a patient fell and sustained an injury. The primary purpose of the nurse completing this incident report is to:Answer →
  101. 101A nurse is caring for a client who is scheduled for abdominal surgery. Which of the following nursing interventions should the nurse include in the preoperative education?Answer →
  102. 102A nurse is caring for a client who is 3 days postoperative following a cholecystectomy. The nurse suspects the client's wound is infected because the drainage from the dressing is yellow and thick. Which of the following findings should the nurse report as the type of drainage found?Answer →
  103. 103During shift assessment of a postsurgical client, the nurse finds the client's mental status, level of consciousness, speech, and orientation are intact and at baseline, but the client appears unusually restless. What should the nurse do next?Answer →
  104. 104A nurse is caring for a client in the immediate postoperative period who becomes acutely confused, disoriented to time and place, and demonstrates fluctuating levels of consciousness with periods of agitation. Which of the following nursing interventions should the nurse implement to help prevent worsening of the client's condition?Answer →
  105. 105A nurse is providing teaching to a client who is about to begin using a PCA pump to deliver morphine for postoperative pain management. Which of the following statements by the client indicates an understanding of the teaching?Answer →
  106. 106Which action is most important for the nurse to implement to reduce the risk for deep vein thrombosis (DVT) in a postoperative client?Answer →
  107. 107A nurse obtained a telephone order from a pain management provider for a patient in pain. Which documentation shows that the nurse follows documentation guidelines?Answer →
  108. 108A nurse is assessing a client's response to receiving morphine for postoperative pain management. Which of the following findings is the nurse's priority?Answer →
  109. 109A nurse is reinforcing postoperative education to a client who has just had a procedure 2 days ago. Which of the following postoperative education topics should be included?Answer →
  110. 110A nurse is caring for a client who understands a prescribed surgical procedure, but cannot read or write. Which of the following actions should the nurse take?Answer →
  111. 111A nurse is educating a postoperative (post-surgery) client on essential nutrition for healing. What statement by the client would indicate a need for more information?Answer →
  112. 112Following surgery for an obstruction of the small intestines, a client's incision separates exposing abdominal organs. The nurse calls for help and notifies the rapid response team. Which intervention should the nurse implement next?Answer →
  113. 113A nurse is caring for a child who is 2 hr postoperative following a tonsillectomy. Which of the following fluid items should the nurse offer the child at this time?Answer →
  114. 114Which type of wound is caused by a blunt instrument that causes injury to underlying soft tissue with the overlying skin remaining intact?Answer →
  115. 115A nurse is assisting in preparing an in-service program about preventing medication errors when transcribing a prescription. The nurse is using a dosage example of two tenths of a milligram. Which of the following transcription examples should the nurse use?Answer →
  116. 116A client tells the nurse that he is "very nervous" about the surgery he is scheduled to have in the morning. Which action should the nurse implement first?Answer →
  117. 117A nurse is preparing to administer eardrops to a 2-year-old child. The nurse should pull the auricle in which of the following directions when instilling the medication?Answer →
  118. 118A nurse witnesses a colleague discussing details about a patient's medical condition and care plan in the hospital cafeteria, mentioning the patient by name where other employees and visitors could hear. What is the most appropriate immediate action for the witnessing nurse to take to maintain professional standards and legal compliance?Answer →
  119. 119A nurse is caring for a client in the second stage of labor whose provider has recommended an assisted vaginal birth via vacuum extraction due to nonreassuring fetal status. The client asks the nurse "Why can't I just have a cesarean birth?" Which of the following responses should the nurse make?Answer →
  120. 120A postoperative client rapidly presents with hypotension; rapid, thready pulse; oliguria; and cold, pale skin. The nurse suspects that the client is experiencing a hemorrhage. What should be the nurse's first action?Answer →
  121. 121The nurse receives a postoperative client from the PACU to the medical-surgical unit after left hip replacement. Which concern should the nurse prioritize during the first few hours on the unit?Answer →
  122. 122A nurse is preparing to administer 0.9% sodium chloride 1,200 mL IV to infuse over 24 hr. The drop factor of the manual IV tubing is 15 gtt/mL. The nurse should set the manual IV infusion to deliver how many gtt/min? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)Answer →
  123. 123A nurse is planning to assign obtaining the vital signs of postoperative clients to an assistive personnel (AP). Which of the following clients should the nurse assign to the AP?Answer →
  124. 124A nurse in a clinic is caring for a client who requires a hysterectomy and states, "I've decided to delay having this surgery for several months." Which of the following statements should the nurse make?Answer →
  125. 125An adult client has been hospitalized for the past three weeks due to complications experienced following elective surgery. When the client's condition first began to deteriorate, the client's spouse reminded the healthcare provider (HCP) that the client has a living will explaining the desire for a natural death. The HCP does not agree with the client's living will and refuses to honor it. Which action should the nurse take?Answer →
  126. 126A preoperative client is being instructed in the use of patient-controlled analgesia (PCA) after surgery. Which response by the client indicates the best understanding of this equipment?Answer →
  127. 127A nurse is caring for a client who is in the immediate postoperative period following a partial laryngectomy. Which of the following parameters should the nurse assess first?Answer →
  128. 128A nurse is caring for a client who has a large surgical wound healing by secondary intention. The nurse should recommend a diet high in protein and which of the following nutrients?Answer →
  129. 129A child weighing 22 pounds is prescribed amoxicillin at a dose of 20 mg/kg/day, divided into two doses. The available suspension is 250 mg/5 mL. How many milliliters should the nurse administer per dose?Answer →
  130. 130A nurse administers IV lorazepam for procedural sedation prior to a bedside closed reduction for a dislocated shoulder following a motor vehicle accident. Ten minutes later, the patient becomes difficult to arouse. Vital signs are: BP 104/62 mmHg, HR 58/min, RR 6/min, SpO₂ 86% on 4 L nasal cannula. What is the nurse's priority action?Answer →
  131. 131A patient in surgery receives a neuromuscular blocking agent as an adjunct to general anesthesia. While in the post anesthesia care unit (PACU), which assessment finding is most important for the nurse to report?Answer →
  132. 132A nurse is caring for two patients who both need immediate attention: a wealthy businessman who donated money to the hospital and an uninsured homeless individual. Both patients have similar severity of symptoms. According to the principle of justice in nursing ethics, the nurse should:Answer →
  133. 133eplacement patient is at risk for deep vein thrombosis (DVT). Which intervention is most effective in preventing pulmonary embolism?Answer →
  134. 134The nurse is concerned that the client's abdominal wound is at risk for dehiscence. Which of the following is the best intervention to prevent this complication?Answer →
  135. 135A nurse is caring for an oncological client who just returned from the OR after having a hemicolectomy. The report from the operative nurse notes "significant blood loss of 750 mLs" during the procedure. Which action should the nurse take first?Answer →
  136. 136Magnesium hydroxide 1.5 ounces PO is prescribed for a client troubled with heartburn. After taking the prescribed dose 3 times today, how many mL of magnesium hydroxide has the client ingested? (Enter numeric value only.)Answer →
  137. 137A nurse is providing teaching to a client who is about to begin using a PCA pump to deliver morphine for postoperative pain management. Which of the following statements by the client indicates an understanding of the teaching?Answer →
  138. 138The order is to administer 1000 mL of D5W over 10 hours. The tubing has a drop factor of 10 gtt/mL. Determine the flow rate in gtt/min. Round to the nearest whole number. gtt/minAnswer →
  139. 139Which intervention is critical to prevent falls for a hospitalized client identified as high-risk for falls?Answer →
  140. 140The nurse is caring for a client who has just returned to the postsurgical unit following renal surgery. When assessing the client's output surgical drains, the nurse should physically assess what parameter(s)? Select all that apply.Answer →
  141. 141A nurse is caring for an adult client who is competent and has refused an analgesic injection. The nurse administers the injection despite the client's objections. Which of the following types of tort has the nurse committed?Answer →
  142. 142A nurse is assessing a patient receiving a continuous opioid infusion. For which outcome of treatment would the nurse immediately notify the primary care provider?Answer →
  143. 143A nurse is preparing to infuse dextrose 5% in 0.45% sodium chloride 500 mL IV bolus over 4 hr. The drop factor of the manual IV tubing is 60 gtt/mL. The nurse should set the IV infusion to deliver how many gtt/min? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)Answer →
  144. 144A nurse is preparing an injection using a single dose glass ampule. Which of the following actions should the nurse take?Answer →
  145. 145A nurse is assisting with teaching a class about converting household measurements into metric measurements. Which of the following information should the nurse include?Answer →
  146. 146A patient scheduled for surgery has the following preoperative lab results: Hemoglobin 8.5 g/dL, Hematocrit 25%, Platelets 200,000/μL, and INR 1.0. Which action should the nurse prioritize based on these findings?Answer →
  147. 147A nurse is preparing to use the Z-track technique to administer a medication to a client. Which of the following actions should the nurse plan to take?Answer →
  148. 148The home health nurse is visiting an older adult client who was discharged from the hospital 3 days ago following hip pinning surgery. The client lives with her daughter, who prepares the family meals. In discussing nutrition for postoperative healing, which food choices should the nurse suggest for this client's diet? Select all that apply.Answer →
  149. 149A nurse is preparing to administer dextrose 5% in water (D5W) 1,200 mL IV to infuse over 24 hr. The drop factor of the manual IV tubing is 15 gtt/mL. The nurse should set the manual IV infusion to deliver how many gtt/min? (Round to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)Answer →
  150. 150A nurse is educating a preoperative client on how to effectively deep breathe. Which instruction would be included?Answer →
  151. 151There is an order to infuse 1 liter of NSS over 6 hours. At what rate in mL/hr should the nurse infuse the solution? Round to the nearest tenth if indicated.Answer →
  152. 152Under Emergency Medical Treatment and Labor Act (EMTALA) guidelines, which action should emergency department staff take first when a client arrives with an acute medical condition?Answer →
  153. 153A patient is 24 hours postoperative bilateral mastectomy, the nurse notes bright red drainage in the Jackson Pratt (JP) drain. Which term would the nurse use to describe this drainage in the documentation?Answer →
  154. 154A nurse is assessing a client who is 8 hr postpartum. Where should the nurse expect to find the fundus?Answer →
  155. 155While planning nursing care in the immediate postoperative period, which factor has the highest priority in determining the frequency of vital sign assessment?Answer →
  156. 156A home care nurse makes the following assessments of a wound: increased drainage and pain, increased body temperature, red and swollen wound, and purulent wound drainage. What wound complication do these assessments indicate?Answer →
  157. 157When a central venous catheter dressing becomes moist or loose, what should a nurse do first?Answer →
  158. 158Which of the following is a primary function of the Nurse Practice Act in each state?Answer →
  159. 159The nurse is caring for a client, on postoperative day 5 and evaluates the client for infection during each assessment. Which finding is most indicative of infection?Answer →
  160. 160What is the meaning of QID?Answer →
  161. 161Which property of a drug is most likely to reduce the risk of medication errors?Answer →
  162. 162A client is scheduled for coronary artery bypass graft (CABG) surgery. Which assessment finding would indicate the most urgent need for intervention before the procedure?Answer →
  163. 163At the beginning of a shift, a client's IV bag has 900 mL remaining. The IV is infusing at 75 mL/hour. In 8 hours, how many mL should remain in the IV bag? (Enter numerical value only. If rounding is required, round to the nearest whole number.)Answer →
  164. 164The nurse is caring for an older adult client in the post anesthesia care unit. The client begins to awaken and responds to name but is confused, restless, and agitated. Which principle should guide the nurse's assessment?Answer →
  165. 165A nurse is caring for a client who is 12 hours postoperative and has a chest tube to a disposable water-seal drainage system with suction. The nurse should intervene for which of the following observations?Answer →
  166. 166A client who is 1 day postoperative is using a morphine (opioid) client-controlled analgesia (PCA) pump. The client is confused and disoriented. What is the priority intervention(s) by the nurse?Answer →
  167. 167A nurse is reviewing providers' prescriptions for four clients. Which of the following prescriptions should the nurse verify with the provider?Answer →
  168. 168A nurse is preparing to transfer a client who has left-sided weakness from a sitting position in bed to a chair. Which of the following actions should the nurse take?Answer →
  169. 169The operating room (OR) nurse acts in the circulating role during a client's scheduled surgical procedure. For what task is this nurse responsible?Answer →
  170. 170A patient complains of severe pain following major surgery. Which medication would be a good choice for this patient?Answer →
  171. 171A client who was admitted to the post-anesthesia unit 30 minutes ago begins to report being cold, rates pain at 7 out of 10 on a 0 to 10 pain scale, and asks for the spouse. The nurse determines that the abdominal dressing is dry and the postanesthesia score (Aldrete score) is 9. Which client need should be addressed first?Answer →
  172. 172After a client has undergone coronary artery bypass graft surgery (CABG), which nursing intervention should be prioritized to minimize the risk of complications?Answer →
  173. 173A nurse is preparing to administer preoperative medications to a client who is alert and oriented x2 and scheduled for an organ transplant. What nursing action is the most appropriate?Answer →
  174. 174The nurse is conducting a presurgical interview for a client with liver cancer. The client states, "that he drinks approximately 20 ounces (600 mL) of vodka per day". It is imperative that the nurse inform the surgical team so the client can be assessed for what post operatively?Answer →
  175. 175A nurse is caring for a client who is postoperative and requesting something to drink. The nurse reads the client's postoperative prescriptions, which include, "Clear liquids, advance diet as tolerated." Which of the following actions should the nurse take first?Answer →
  176. 176A nurse is caring for a client in the postoperative period. Which nursing intervention should the nurse prioritize to help reduce the client's risk of thrombus (blood clot) development?Answer →
  177. 177A client receives the wrong medication in error. The nurse who made the medication error should do which of the following first?Answer →
  178. 178A nurse is educating a postoperative client about strategies to prevent deep vein thrombosis (DVT). Which of the following recommendations should the nurse include? (Select All that Apply.)Answer →
  179. 179The nurse is caring for a patient with inner maxillary fixation (IMF) following a jaw fracture repair. Which teaching point is most essential to prevent a life-threatening complication?Answer →
  180. 180Review the electronic health record. Drag from the choices below to specify what stage of wound healing the client is most likely experiencing [blank1], two actions the nurse should take to address that condition [blank2] and [blank3], and two parameters the nurse should monitor to assess the client's progress [blank4] and [blank5].Answer →
  181. 181A nurse is reinforcing teaching about diaphragmatic breathing with a client as part of preparing them for postoperative care. Which of the following instructions should the nurse include?Answer →
  182. 182What must the nurse do first when making a medication error and why?Answer →
  183. 183A patient recovering from thoracotomy is at risk for postoperative pulmonary complications. Which intervention best prevents atelectasis?Answer →
  184. 184The nurse would recognize which of these devices as an open drainage system?Answer →
  185. 185Order: Infuse 1000 mL NSS in 12 hours. Tubing: Drop factor is 15 gtt/mL. What is the flow rate (gtts/min)?Answer →
  186. 186A preoperative client is being instructed in the use of patient-controlled analgesia (PCA) after surgery. Which response by the client indicates the best understanding of this equipment?Answer →
  187. 187A healthcare provider orders 250 mg of cefuroxime to be administered orally twice a day. The pharmacy supplies cefuroxime suspension with a concentration of 125 mg/5 mL. How many milliliters will you administer per dose? (Answer as number only, round to the nearest whole number)Answer →
  188. 188A nurse is caring for a client who has just undergone a laparoscopic appendectomy for a non-ruptured appendicitis. Which nursing intervention should the nurse prioritize to promote safe recovery in the immediate postoperative period?Answer →
  189. 189A nurse is caring for a client who is 12 hours post-abdominal surgery and reports a pain level of 9 out of 10. The client is receiving intravenous morphine via a PCA pump. The nurse notes that the client appears drowsy with a respiratory rate of 10 breaths per minute. Which action should the nurse take first?Answer →
  190. 190The client has an order for 0.9% sodium chloride 1 L to infuse over 12 hours. At what rate will the nurse set the infusion? (If needed, round to the nearest whole number)Answer →
  191. 191A client has an order for vancomycin 500 mg in 250 mL NS to infuse over 90 minutes. At what rate will the nurse set the infusion? ___ mL/hour (If needed, round the answer to the nearest whole number)Answer →
  192. 192The nurse recognizes that the most common serious complication after having gastric bypass surgery is ______ as evidenced by increased back, shoulder, or abdominal pain, restlessness, and tachycardia.Answer →
  193. 193Before administering client medications. the nurse must identify the client. Which of the following methods of identification should the nurse use?Answer →
  194. 194Which medication information helps the nurse maintain a serum drug level within the therapeutic index? (Select all that apply.)Answer →
  195. 195A nurse is preparing to administer 0.9% sodium chloride 1,200 mL IV to infuse over 24 hr. The drop factor of the manual IV tubing is 15 gtt/mL. The nurse should set the manual IV infusion to deliver how many gtt/min? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)Answer →
  196. 196A patient is day 1 post-operative after a bowel resection for a colon tumor. The patient begins to complain of sudden, sharp abdominal pain. The most appropriate initial response by the nurse is to:Answer →
  197. 197The nurse is caring for a postoperative client with a history of congestive heart failure and peptic ulcer disease. The client is reluctant to ambulate and drinks only hot tea with meals. Vital signs are slightly elevated, the client has a nonproductive cough, and crackles are heard at the lung bases. Which complication should the nurse suspect first?Answer →
  198. 198A client is brought to the renal unit from the PACU status postresection of a renal tumor. Which of the following nursing actions should the nurse prioritize in the care of this client?Answer →
  199. 199A nurse is delegating care for a client. Which task is appropriate for the nurse to assign to the NA II?Answer →
  200. 200A nurse is providing teaching to a client who is exclusively breastfeeding and has mastitis. Which of the following information should the nurse include?Answer →
  201. 201A nurse is assisting with teaching a newly licensed nurse about preventing puncture injuries. Which of the following instructions should the nurse include?Answer →
  202. 202A nurse is caring for a client who is postoperative following a right-sided mastectomy and has a drain connected to a portable drainage evacuator. Which of the following actions should the nurse take?Answer →
  203. 203A nurse is caring for a client using a PCA pump delivering hydromorphone with a basal rate and a demand dose option. The client's respiratory rate is 10 breaths per minute, oxygen saturation is 90% on room air, and the client appears drowsy but arousable. What is the nurse's most appropriate immediate action?Answer →
  204. 204A nurse is preparing to administer penicillin IM to an adult client. Which of the following angles should the nurse use for injection into the client's ventrogluteal muscle?Answer →
  205. 205A nurse is caring for a client who has a Penrose drain. Which of the following actions should the nurse take?Answer →
  206. 206A nurse is preparing to administer a pre-packaged oral medication to a client and complete the final medication check. At which of the following times or places should the nurse perform this final check?Answer →
  207. 207A client who had a laparoscopic cholecystectomy was just admitted to the surgical unit from the post-anesthesia care unit. The nurse caring for this client knows to immediately report which assessment finding to the healthcare provider?Answer →
  208. 208A client is brought to the emergency room (ER) in an unconscious state and emergency surgery is needed. No family members are present, and the client does not have identification. What action by the nurse is the priority regarding consent for treatment?Answer →
  209. 209A nurse is preparing a client for surgery. Which of the following is a priority when completing an assessment preoperatively?Answer →
  210. 210The nurse reviews the 1300 nursing note for the postoperative client. Which findings require follow-up? Select all that apply.Answer →
  211. 211A nurse is transferring a client to the surgical unit postoperatively. During the handoff report, the nurse states that "Dr. Jones performed a bowel resection." Which section of the SBAR communication tool does this statement address?Answer →
  212. 212The nurse is caring for a school-age child who is scheduled for major cardiac surgery the next morning. The nurse enters the room and observes the child crying quietly and avoiding eye contact. Which response by the nurse is most therapeutic?Answer →
  213. 213The healthcare provider inserts a subclavian central venous catheter (CVC) and prescribes total parental nutrition (TPN) for infusion via the CVC line. While waiting for the pharmacy to deliver the TPN, which action should the nurse take?Answer →
  214. 214Review is done of client data. Click to highlight the findings that indicate the client is stable for discharge.Answer →
  215. 215A nurse is preparing to witness informed consent for a client having surgery. Which of the following priority information should the nurse share with the client while witnessing consent?Answer →
  216. 216After a mass casualty event, which client will the nurse triage with a yellow tag?Answer →
  217. 217The surgeon's preoperative assessment identifies a client as high risk for venous thromboembolism. Once the client is admitted to the postsurgical unit, which intervention should the nurse prioritize to reduce this risk?Answer →
  218. 218A nurse is preparing to discharge a client who has complex medication needs and limited mobility. Using the IDEAL discharge planning tool, which action best demonstrates the nurse's application of assessing the effectiveness of education during discharge planning?Answer →
  219. 219Which vital signs require follow-up? (Select All that Apply.)Answer →
  220. 220An older adult client had a right hip replacement 6 hours ago has a prescription for morphine sulfate 1 mg IV PRN every 2 hours for moderate pain, and morphine sulfate 2 mg IV PRN every 2 hours for severe pain. When the client reports that the pain is 8 on a 0 to 10 scale, 30 minutes after the administration of morphine sulfate 1 mg, which action should the nurse take?Answer →
  221. 221A registered nurse is planning care for assigned patients and needs to delegate appropriate tasks to the unlicensed assistive personnel (UAP). Considering the scope of practice for UAPs, which of the following tasks can the nurse delegate to the UAP? (Select all that apply.)Answer →
  222. 222A nurse has administered preoperative medications to a client. Which of the following actions should the nurse implement?Answer →
  223. 223A nurse in the post-anesthesia care unit is caring for a client who is postoperative following a thoracotomy and lobectomy. Which of the following postoperative assessments should the nurse give the highest priority to?Answer →
  224. 224When caring for a client who had general anesthesia, which nursing intervention has the highest priority during the immediate postoperative period?Answer →
  225. 225A nurse is caring for a client who is postoperative following abdominal surgery. The surgeon initially prescribes a clear liquid diet. Which of the following items should the nurse include on the client's lunch tray?Answer →
  226. 226A nurse is preparing to administer an intramuscular injection to a client. Which of the following actions should the nurse plan to take?Answer →
  227. 227Fat emulsion is prescribed for the client receiving total parenteral nutrition. The nurse is preparing to administer the fat emulsion and notes the presence of fat globules in the solution. What would the nurse do?Answer →
  228. 228A nurse is caring for a client who is receiving total parenteral nutrition (TPN). Which of the following nursing actions are appropriate? (Select all that apply.)Answer →
  229. 229During a teaching session about walker safety, a nurse demonstrates proper walker positioning and gait technique to a hospitalized client. Following the demonstration, the nurse observes as the client attempts to replicate the walking technique. What type of learning evaluation method is the nurse employing?Answer →
  230. 230A client has just arrived on the unit after a thyroidectomy. During the nurse's initial interaction, which is the highest priority to be completed?Answer →
  231. 231A nurse is caring for a client who is in labor. Which of the following actions should the nurse take? Select (3) options.Answer →
  232. 232A nurse is caring for a client who is competent, refuses further treatment, and asks to sign out of the hospital against medical advice (AMA). The nurse notifies the charge nurse, who tells the nurse that the provider has recommended restraining the client, if necessary. to keep her from leaving the hospital. The nurse refuses to implement the action based on the knowledge that restraining this client would be committing which of the following torts?Answer →
  233. 233The dressing around a client's Jackson-Pratt drain has scant drainage. The nurse believes the amount may be increasing. How can the nurse best confirm this?Answer →
  234. 234The nurse has just educated a postoperative client on coughing and deep breathing techniques. Which follow-up task should the nurse plan to delegate to the unlicensed assistive personnel (UAP)?Answer →
  235. 235The nurse is caring for a client who has just been transferred to the PACU from the operating room. What is the highest nursing priority?Answer →
  236. 236A surgical client has just been admitted to an inpatient unit from the PACU with client-controlled analgesia (PCA). What is required for safe and effective use of PCA?Answer →
  237. 237Which statement describes the concept of scene safety in trauma situations?Answer →
  238. 238Six hours postoperatively, a client reports feeling out of breath. The nurse makes the following assessment: cyanotic nail beds of the lower extremities, dyspnea, occasional cough, and auscultatory crackles in the lower lung fields bilaterally. Which is the best initial nursing action?Answer →
  239. 239A nurse is caring for a patient who is postoperative day one following a rhinoplasty. Which nursing intervention takes priority in identifying a potential complication?Answer →
  240. 240A nurse is researching data about best practice for reducing medication errors on a surgical unit. Which of the following steps of evidence-based practice (EBP) is the nurse taking?Answer →
  241. 241A nurse in a clinic is caring for a client who requires a hysterectomy and states, "I've decided to delay having this surgery for several months." Which of the following statements should the nurse make?Answer →
  242. 242A client is being asked to choose between an ambulatory surgical center and a hospital-based surgical unit. What guidance should the nurse provide?Answer →
  243. 243A nurse is assisting a client with ambulation several hours after a hip replacement. Which of the following postoperative complications is the nurse trying to prevent?Answer →
  244. 244Upon responding to the client's call bell, the nurse discovers the client's wound has dehisced. Initial nursing management includes calling the physician and:Answer →
  245. 245A nurse is preparing to assist with irrigating a wound for a client. Which of the following actions should the nurse plan to take?Answer →
  246. 246What action should the nurse take to minimize adverse effects associated with morphine Patient Controlled Analgesia (PCA) use in a postoperative client?Answer →
  247. 247Which nursing actions are appropriate for managing a client's pain while caring for a chest tube placed following thoracic surgery?Answer →
  248. 248The nurse is caring for a client who has returned to the postsurgical suite after postanesthetic recovery from a nephrectomy. The nurse's most recent assessment reveals increased sedation, shortness of breath, hypotension, and low urine output over the last 2 hours. What is the nurse's best response?Answer →
  249. 249A nurse in a long-term care facility is caring for a client who is unresponsive. When performing oral hygiene for the client, which of the following actions should the nurse take?Answer →
  250. 250A nurse is caring for a client who is 5 hr postoperative following a transurethral resection of the prostate (TURP). The nurse notes that the client's indwelling urinary catheter has not drained in the past hour. Which of the following actions should the nurse take first?Answer →
  251. 251The nurse is caring for a client on postoperative day 2 following a colon resection. While turning the client, wound dehiscence with evisceration occurs. What should the nurse do first?Answer →
  252. 252The nurse provides care for a client who is postoperative for a nephrectomy. The client reports breathing difficulty related to incisional pain and restricted positioning. Which measure(s) should the nurse include in the updated care plan to relieve this client's distress? Select all that apply.Answer →
  253. 253A nurse is caring for a client in the operating room. Which of the following interventions is the priority to perform prior to surgery in order to prevent mistakes?Answer →
  254. 254Which antibiotic is used for prophylaxis against infection in surgical patients?Answer →
  255. 255The physician orders a rectal suppository for an adult patient. When administering the rectal suppository, the nurse should:Answer →
  256. 256The surgical unit nurse has just interviewed a patient with a history of smoking. Which action is most important before the patient goes into surgery?Answer →
  257. 257A nurse is completing a preoperative assessment for a client scheduled for abdominal surgery. Which of the following allergy findings should the nurse report immediately to the surgical team?Answer →
  258. 258The charge nurse observes a new nurse perform a peripheral intravenous (IV) catheter insertion for a client who is going to surgery for a right radial fracture. What action by the new nurse requires intervention by the charge nurse?Answer →
  259. 259The nurse reviews new data. Which 5 nursing interventions are indicated for this client?Answer →
  260. 260The nurse is planning care for a client after a Roux-en-Y gastric bypass (RYGB) surgery. For each potential action, click to specify if it is anticipated or not anticipated in the care of this client.Answer →
  261. 261A nurse is caring for a client who is 2 hr postoperative following orthopedic surgery and reports pain as 10 on a scale of 0 to 10. Which of the following prescriptions should the nurse expect to administer?Answer →
  262. 262A nurse is caring for a client who has intermittent gastric suction and is postoperative. Which of the following findings should the nurse monitor for while caring for this client?Answer →
  263. 263A nurse is caring for a client who is 1 day postoperative following an open thoracotomy. The client is receiving oxygen mist at 40% by face tent. The client's SpO2 is 89%. ABG results are: pH 7.31, PaO2 93 mm Hg, PCO₂ 50 mm Hg. HCO3 25 mEq/L. Which of the following is an appropriate action by the nurse?Answer →
  264. 264A nurse receives report on four patients. Which patient should be assessed first?Answer →
  265. 265Following three days of nausea, vomiting, and diarrhea, an older adult is admitted with severe dehydration. After two attempts, the nurse secured venous access using a 24 gauge IV catheter and began infusing 0.9% normal saline at 150 mL/hour. Minutes later, the client is reporting pain at the IV site. Which intervention should the nurse implement first?Answer →
  266. 266The nurse is caring for a client recovering on the postsurgical unit after a transurethral resection of the prostate (TURP). The client is reluctant to ambulate and states a need to recover in bed. For which complication is the client most at risk?Answer →
  267. 267When forming a PICOT question to investigate the effectiveness of a new nursing intervention for reducing hospital readmission rates, which component is critical to define the "O" in PICOT?Answer →
  268. 268A nurse prepares to administer gentamicin 800 mg in 100 mL of 5% dextrose in water (D5W) to be infused over 1 hour. The drop factor of the tubing is 20 gtt/mL. At what rate will the nurse set the infusion? ___ gtt/min (If needed, round the answer to the nearest whole number.)Answer →
  269. 269A nurse is assisting with teaching a class about reducing the risk for medication errors. Which of the following information should the nurse include?Answer →
  270. 270The postoperative client is transferred from the PACU to the surgical unit. Which action should the nurse implement first?Answer →
  271. 271A nurse is preparing to administer an Otic medication to a client. Which of the following actions should the nurse take?Answer →
  272. 272A patient had a transurethral prostatectomy (TURP) for benign prostatic hyperplasia. The patient is being treated with continuous bladder irrigation and is complaining of an increase in severity of bladder spasms. Which of the following interventions should be done first?Answer →
  273. 273A nurse is preparing to administer a rectal suppository to a client. The nurse should instruct the client to lie in which of the following positions while in bed?Answer →
  274. 274A perioperative nurse is caring for a postoperative patient. The patient has a shallow respiratory pattern and is reluctant to cough or to begin mobilizing. The nurse should prioritize the patient's increased risk for what complication?Answer →
  275. 275A nurse teaches a client scheduled for cataract surgery about postoperative expectations. Which statement by the client demonstrates understanding?Answer →
  276. 276A nurse is caring for a client who is scheduled for heart surgery. Prior to surgery the client states, "I'm not sure I want to go through with this procedure after all." Which of the following actions should the nurse take?Answer →
  277. 277A nurse is caring for a client in the immediate postoperative period who becomes acutely confused, disoriented to time and place, and demonstrates fluctuating levels of consciousness with periods of agitation. Which of the following nursing interventions should the nurse implement to help prevent worsening of the client's condition?Answer →
  278. 278A nurse is collecting data on a client who has a wound that is healing by first intention. Which of the following findings should the nurse expect?Answer →
  279. 279The nurse is assessing a client with restraints. The nurse observes correct use of restraints by checking which of the following?Answer →
  280. 280A nurse is reviewing the client's medical record in the presurgical holding area. Which of the following places the client at risk for a surgical site infection?Answer →
  281. 281A nurse is caring for a client who is experiencing a moderate acute placental abruption. Which of the following actions should be the nurse's priority?Answer →
  282. 282A nurse is preparing to administer Lactated Ringers via intravenous infusion at 75 mL/hr. The drop factor of the manual IV tubing is 10 gtt/mL. At what rate will the nurse set the infusion? ___ gtt/min (If needed, round to the nearest whole number.)Answer →
  283. 283A nurse assesses a patient taking meperidine (Demerol) and finds he is overly sedated and cannot be awakened with a sternal rub. Which medication would the nurse anticipate the healthcare provider to order to be given?Answer →
  284. 284A client with type 1 diabetes is scheduled for surgery at 10:00 a.m. and has been NPO since midnight. The client takes glargine (Lantus) every morning and lispro (Humalog) with meals. Morning blood glucose is 134 mg/dL. At 6:00 a.m., which order should the nurse anticipate?Answer →
  285. 285To prevent thromboembolism in the postoperative client, which intervention should the nurse include in the plan of care?Answer →
  286. 286A nurse needs to contact the physician about a postoperative client experiencing complications. The nurse plans to use the SBAR communication format. Which of the following represents the correct order and content for an SBAR report?Answer →
  287. 287A nurse is preparing to administer ondansetron 4 mg IM stat. The amount available is ondansetron for injection 2 mg/mL. How many mL should the nurse administer? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)Answer →
  288. 288A nurse is assessing lab values and blood volume for a client who is 8 hr postpartum following a vaginal birth. Which of the following is an expected finding?Answer →
  289. 289Two days following abdominal surgery a client begins to report cramping abdominal pain, and the nurse's inspection of the abdomen indicates slight distention. Which action should the nurse implement first?Answer →
  290. 290A nurse is completing a surgical checklist for a client scheduled for surgery. According to the World Health Organization's (WHO) checklist, which of the following terms is used for the phase that takes place after the induction of anesthesia and before the first surgical incision?Answer →
  291. 291A male client who had abdominal surgery 5 days ago, and hospitalized because of a surgical wound infection, tells the nurse that he feels like his insides just spilled out when he coughed. Which action should the nurse take first?Answer →
  292. 292A nurse is caring for a client who is receiving total parenteral nutrition (TPN). The nurse notices that the solution bag is almost empty and there is not another bag of TPN to administer. Which of the following IV solutions should the nurse administer until the next bag of TPN solution is available?Answer →
  293. 293A nurse notes a small section of bowel protruding from the abdominal incision of a client who is postoperative. After calling for assistance. Which of the following actions should the nurse take first?Answer →
  294. 294Which of the following responsibilities can a registered nurse (RN) delegate to a licensed practical nurse (LPN)?Answer →
  295. 295A nurse is caring for a client whose hysterectomy wound has eviscerated. Which of the following actions should the nurse take?Answer →
  296. 296The nurse is planning care for a client who is receiving 24-hour total parenteral nutrition (TPN) via a central IV line access. Which nursing measure is essential for this client's care?Answer →
  297. 297A nurse is planning care for a client who requires insertion of a peripherally inserted central catheter (PICC) line. Which of the following actions should the nurse plan to take?Answer →
  298. 298The family of a client with multiple organ failure presents a living will requesting no life-saving measures. The client is confused and moaning, has crackles throughout all lung fields, and a urine output of 20 mL/hour. Which need is most important for the nurse to include in this client's plan of care (POC)?Answer →
  299. 299A nurse is preparing to administer aspirin 650 mg PO every 12 hr. The amount available is aspirin 325 mg tablets. How many tablets should the nurse administer? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.) tabletsAnswer →
  300. 300A nurse is preparing a client to be transferred to the operating room. The nurse informs the client that there is a delay and they will not be transferred for another 15 min. Which of the following actions should the nurse take during this delay?Answer →
  301. 301Which phase of wound healing occurs around day 21 and involves the strengthening of collagen and the restoration of a more normal appearance?Answer →
  302. 302A nurse is caring for a client who is 1 day postoperative following a left lower lobectomy and has a chest tube in place. When assessing the client's three-chamber drainage system, the nurse notes that there is no bubbling in the suction control chamber. Which of the following actions should the nurse take?Answer →
  303. 303A nurse is preparing to administer cefazolin IVPB over 20 min. Available is cefazolin 1 g in 100 mL of dextrose 5% in water (D5W). The drop factor of the manual IV tubing is 15gtt/mL. The nurse should set the IV infusion to deliver how many gtt/min? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.) gtt/minAnswer →
  304. 304The nurse plans to administer a 1-mL intramuscular injection. The nurse understands that the most desirable muscle for the administration of this medication is the:Answer →
  305. 305A 90 kg postoperative patient's average urine output during the first 8 hours is 30 mL/hr. Which intervention would the nurse prioritize?Answer →
  306. 306A nurse is collecting data from a client who is receiving continuous IV therapy through a peripheral IV. The catheter site is cool and taut, and there is IV fluid leaking. The nurse should identify that the client has manifestations of which of the following complications?Answer →
  307. 307A client is receiving a continuous IV infusion of 0.45% normal saline at a rate of one liter every 10 hours. At 7:00 am, the nurse determines the current bag of solution contains 400 mL. At what time should the nurse plan to add another liter bag of intravenous fluid?Answer →
  308. 308When preparing to administer a narcotic, what is essential for both compliance with guidelines and legal documentation?Answer →
  309. 309An orthopedic nurse is caring for a client who is postoperative day 1 following foot surgery. What nursing intervention should be included in the client's subsequent care?Answer →
  310. 310A client has a central venous access device (CVAD) with a gauze dressing that was last changed 48 hours ago and appears to be clean and dry. According to standard protocol, how soon should the dressing be changed again?Answer →
  311. 311A nurse is preparing to administer dextrose 5% in water (D5W) IV to infuse at 100 ml/hr. The drop factor of the manual IV tubing is 15 gtt/ml. The nurse should set the manual IV infusion to deliver how many gtt/min? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)Answer →
  312. 312A nurse is providing discharge teaching to a client who is at 26 weeks of gestation and has cervical insufficiency. Which of the following information should the nurse include in the teaching?Answer →
  313. 313Which abbreviation means immediately?Answer →
  314. 314A hospitalized patient has advanced directives stating "full code." The patient has a nasogastric tube and during a bolus feeding the patient vomits and begins to choke. Which action should the nurse take first?Answer →
  315. 315A nurse is preparing a patient for surgery and is completing the preoperative checklist. The patient reports consuming a glass of water an hour ago. What is the nurse's next action?Answer →
  316. 316A 31-year-old woman is 2 days postoperative following a total abdominal hysterectomy and reports severe pain. She has a history of fibromyalgia and migraine headaches. Which approach can offer the most comprehensive pain management in this scenario?Answer →
  317. 317A nurse in the PACU is performing oral suctioning for a patient with an oropharyngeal airway, when the patient begins to vomit. What is the nurse's priority nursing action at this time?Answer →
  318. 318A client who speaks limited English is scheduled for an appendectomy. The healthcare provider has reviewed the procedure with the client. The nurse provides the consent form in English and asks the client to sign it. The client nods but appears confused. What action should the nurse take?Answer →
  319. 319A nurse in the PACU (surgery recovery) is preparing to receive a patient from surgery who sustained a ruptured spleen in a motor vehicle accident. Which of these system assessments will take priority?Answer →
  320. 320It is most important for the nurse to use a filtered needle when preparing a parenteral medication that:Answer →
  321. 321A pregnant woman has received an epidural analgesic prior to delivery. Assessment for which outcome to the medication will the nurse prioritize?Answer →
  322. 322The nurse is caring for an 88-year-old client recovering from an iliofemoral bypass graft. On postoperative day 2, the client, previously mentally intact, is now confused and has disturbed sleep patterns and impaired psychomotor skills. What should the nurse suspect?Answer →
  323. 323The nurse admits a client to the post anesthesia care unit with a blood pressure of 132/90 mm Hg and a pulse of 68 beats/min. After 30 minutes, the client's blood pressure is 94/47 mm Hg and pulse is 110 beats/min. The client's skin is cold, moist, and pale. These findings suggest which potential complication?Answer →
  324. 324A nurse is caring for a client in the operating room. Which of the following interventions is the priority to perform prior to surgery in order to prevent mistakes?Answer →
  325. 325Based on the patient's statement, what is the nurse's priority action?Answer →
  326. 326A nurse is planning care for a client who is 8 hr postoperative following a coronary artery bypass grafting. Which of the following assessments should the nurse plan to perform first?Answer →
  327. 327The provider has ordered IV fluids to infuse at a rate of 125 mL/hr. Using a drop factor of 15 gtt/mL, how many gtts/min will the nurse regulate the IV to infuse? (Provide answer as a number only, round answer to the nearest whole number)Answer →
  328. 328How does charting by exception (CBE) differ from narrative documentation?Answer →
  329. 329A nurse is teaching a client recovering from abdominal surgery about using the incentive spirometer. The nurse should explain that regular use of this device helps prevent which postoperative complication?Answer →
  330. 330The postoperative client is transferred from the PACU to the surgical unit. Which action should the nurse implement first?Answer →
  331. 331The philosophy of emergency management is that only patients with urgent and critical needs will be treated in the emergency department. Is this statement true or false?Answer →
  332. 332A nurse is caring for a client who is postoperative and develops respiratory depression after receiving morphine for pain control. Which of the following medications should the nurse expect the provider to prescribe?Answer →
  333. 333A nurse is performing medication reconciliation for a newly admitted client. Which of the following actions should the nurse take?Answer →
  334. 334A nurse is caring for a client who is receiving morphine via a patient controlled analgesia (PCA) infusion device after abdominal surgery. Which of the following statements indicates that the client knows how to use the device?Answer →
  335. 335A nurse is caring for a postoperative client who is at high risk for developing atelectasis. Which interdisciplinary collaboration is most appropriate to help prevent this complication?Answer →
  336. 336A nurse is performing this step of I & O and drainage assessment for a postoperative patient. She has just emptied the drain. What step will the nurse take next before leaving the patient?Answer →
  337. 337The nurse has done fall prevention teaching with the family of a client who is being discharged home. Which of the following actions by the client and family indicates that the teaching has been effective?Answer →
  338. 338The nurse cares for a client who is at risk for wound dehiscence after abdominal surgery. Which action is the priority to minimize this risk?Answer →
  339. 339A patient is receiving an infusion of D5W 1000 ml. at a rate of 100mL/hour. The drop factor is 15 gtts/mL. Calculate the rate of gtts/min the patient will receive. Round to the nearest whole number. (Enter response as a number ONLY)Answer →
  340. 340A nurse is preparing to instill an enteral feeding for a client who has an NG tube in place. Which of the following actions is the nurse's highest assessment priority before performing this procedure?Answer →
  341. 341A bilingual nurse verifies a Spanish speaking woman's signature on the surgical consent form for an abdominal hysterectomy. The client tells the nurse that she understands that the surgery will stop her bleeding. When the nurse further explains that it will also result in her not being able to have more children, the client becomes alarmed and exclaims, "No." Which action should the nurse take?Answer →
  342. 342The charge nurse observes a new nurse preparing to irrigate an intravenous catheter. The new nurse is attaching an 18-gauge needle. Which action should the charge nurse take?Answer →
  343. 343A client with chronic obstructive pulmonary disease (COPD) is admitted for a nonemergent cholecystectomy. The admission arterial blood gas (ABG) findings are a pH 7.35, PaCO2 48 mm Hg, and a HCO3- 28 mEq/L (28 mmol/L). Based on these results, which intervention should the nurse implement?Answer →
  344. 344For each 1-hr postoperative finding, click to specify if the finding requires immediate action or is an expected finding.Answer →
  345. 345A nurse is calculating fluid input for a client who is receiving a continuous IV infusion of 0.9% sodium chloride at 125 mL/hr and cefazolin 50 mL IV bolus every 4 hr. How many mL did the client receive per IV infusion over the past 24 hr? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)Answer →
  346. 346A nurse is caring for a client who is receiving a continuous IV infusion through a peripheral device. Which of the following actions should the nurse take?Answer →
  347. 347A patient in surgery receives a neuromuscular blocking agent as an adjunct to general anesthesia. While in the post anesthesia care unit (PACU), which assessment finding is most important for the nurse to report?Answer →
  348. 348A clear liquid breakfast is prescribed for a client who is scheduled for surgery later today. The client asks the nurse for a small cup of chocolate ice cream. Which action should the nurse take?Answer →
  349. 349The post anesthesia care unit nurse is caring for a client after a hernia repair. The client's blood pressure is 164/92 mm Hg. The client has no history of hypertension, and the preoperative blood pressure was 112/68 mm Hg. The nurse should assess for which causes of postoperative hypertension?Answer →
  350. 350A nurse is developing a care plan for a client with obesity on postoperative day one following bariatric surgery. Which intervention should the nurse question before including in the care plan?Answer →
  351. 351A nurse has admitted a client to the hospital for a surgical procedure. Which of the following should the plan of care primarily focus on during the perioperative period?Answer →
  352. 352A nurse is reviewing privacy practices with a group of newly hired staff members. Which actions demonstrate compliance with HIPAA privacy regulations in a clinical setting? (Select all that apply.)Answer →
  353. 353Drag from the choices below to specify what condition the client is most likely experiencing [blank1], 2 actions the nurse should take to address that condition [blank2] and [blank3], and 2 parameters the nurse should monitor to assess the client's progress [blank4] and [blank5].Answer →
  354. 354The nurse is providing care for a patient who was assaulted with a baseball bat resulting in physical trauma to the abdomen. Which type of injury does the patient have?Answer →
  355. 355A nurse is planning to assign the vital signs of postoperative clients to an assistive personnel (AP). Which of the following clients should the nurse assign to the AP?Answer →
  356. 356A nurse is teaching a newly licensed nurse how to set up a sterile field. Which of the following instructions should the nurse include? (Select all that apply)Answer →
  357. 357A 40-year-old male patient has had a herniorrhaphy to repair an incarcerated inguinal hernia. Which patient teaching will the nurse provide before discharge?Answer →
  358. 358A nurse is providing discharge teaching to the parent of a child who is prescribed diphenhydramine 25 mg elixir every 4 hr as needed. The amount available is diphenhydramine elixir 12.5 mg/5 mL. How many mL should the nurse administer per dose? (Round the answer to the nearest tenth. Use a leading zero if it applies. Do not use a trailing zero.)Answer →
  359. 359A client asks the nurse to explain their recent laboratory results, but the healthcare provider has not yet discussed them with the client. How should the nurse respond?Answer →
  360. 360A nurse is caring for a client who is 2 days postoperative following abdominal surgery and has a prescription for opioid analgesia. Which of the following actions should the nurse implement to help facilitate the client's recovery?Answer →
  361. 361During a mass casualty incident, a nurse must triage patients. Which action demonstrates the ethical principle of justice?Answer →
  362. 362The surgical team is ready to make the surgical incision for a client who is having a right below the knee amputation (BKA). Which action is important for the circulating nurse to take first?Answer →
  363. 363A nurse is preparing to discharge a client who does not speak English. The client's family member offers to translate the discharge instructions. Which action by the nurse best demonstrates client advocacy and ensures accurate communication?Answer →
  364. 364The nurse has been assigned to an adult male client who is less than 24 hours post op. In report, the nurse learns that he rings his call light frequently, is anxious, and has had pain medication ordered. Which of the following nondrug nursing interventions should the nurse include when caring for this client?Answer →
  365. 365A nurse is caring for a client who has wound dehiscence one week postoperative. Which of the following actions should the nurse take?Answer →
  366. 366A client is scheduled for surgery in 36 hours. The client reports taking daily aspirin 81 mg. What is the nurse's priority action?Answer →
  367. 367A nurse is assisting with teaching a newly licensed nurse about maintaining correct posture when transferring clients. Which of the following statements should the nurse make?Answer →
  368. 368The physician orders a 75 units/kg bolus of heparin for the patient. The patient weighs 165lb. The heparin vial contains Heparin 5000units/mL. What volume will the nurse administer? Round to the nearest tenth.Answer →
  369. 369Based on the client assessment, the nurse suspects the client is most likely experiencing [blank1] of [blank2], which is a complication of the client's surgical procedure.Answer →
  370. 370A postoperative client who underwent abdominal surgery is prescribed morphine for moderate to severe pain. During the nursing assessment, the client is drowsy with a respiratory rate of 8 breaths per minute. What is the most appropriate immediate nursing action?Answer →
  371. 371A nurse is caring for a client who reports insomnia. Which of the following actions should the nurse take?Answer →
  372. 372Which statement reflects the "Right supervision and evaluation" principle of delegation?Answer →
  373. 373The nurse receives diphenhydramine 25 mg in a 100 mL bag of normal saline, which is to be administered over 30 minutes. The IV pump should be set to administer how many mL/hour? (Enter numeric value only.)Answer →
  374. 374An older adult who is scheduled for a hip replacement is taking several medications on a regular basis. Which group of medications does the nurse identify as a surgical risk for this patient?Answer →