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50 Cards in this Set

  • Front
  • Back
Most appropriate teaching for patient with abdominal surgery
deep breath and cough
Patient having elective hysterectomy surgery says she is afraid she will die like her mother did. Nurses response
o “Tell me more about what happened to your mother.”
• Assess patient who is having inguinal hernia repair at outpatient clinic, nurse checks to see if patient
o Has family member or friend available for transportation and care at home
• 36 year old women in for knew surgery. What info needs to be reported to the surgeon?
o Possibility of early, unplanned pregnancy
• Why do you need to get all the patients current use of medication during a preoperative assessment?
o Other meds may cause interaction with anesthetics
• There is a risk for a latex allergy in patients who already has an allergy to
o Avocados and bananas
• Patient tells the nurse that the doctor has not told him whats involved in surgery, Nurses response
o Delay patients signature on consent and notify physician that patient has not been informed
• 20 minutes after an IM injection of morphine in a preoperative patient, patient asks to go to the bathroom
o nurse should offer urinal to patient and position him in bed to promote voiding
• Nursing intervention for insulin dependent diabetic patient scheduled for surgery
o Consult surgeon and anesthesiologist on insulin dosages
• No food or water before surgery
to prevent aspiration into lungs
• Assessment finding that would indicate a need for special positioning during surgery
o History of spinal and hip arthritis
• Physical environment and traffic control measures of the operating room are designed to
o Prevent transmission of infection
• Nurse should identify a drowsy patient by
o Asking patient to state their name, in addition to checking the hospital number on their ID band and chart
• Due to family history…patient may be at risk for malignant hyperthermia during anesthesia. Nurse explains to patient that
o Anesthesia can be administered with minimal risk with use of appropriate precautions and medications.
• Who is local anesthesia beneficial to?
o Patient who has recently taken food and fluids
• Classic signs of hypovolemic shock
o Hypotension, tachycardia, cold clammy skin
• Patient admitted to PACU from surgery, highest priority on assessing is
o Adequacy of respiratory function
• Patient woth dsocated shoulder having closed manual reduction of dislocation with conscious sedation
o Nurse should anticipate administration of IV midazolam (Versed) and opioid (morphine)
• Last nursing intervention to be preformed on morning of surgery?
o Administer pre-anesthetic medication LAST
• Post op finding that requires immediate attention
o Urine output of 80cc over 4 hours
• Patient is transferred from PACU to surgical floor, what should nurse do first?
o Take vital signs
• To promote safety following administration of pre-anesthetic meds the nurse would
o Have patient maintain on bed rest with the side rails up.
• Patient is to have IM injection of morphine for post-op pain. What must the nurse assess prior to giving narcotic analgesic?
o Clients level of alertness and respiratory rate
• Patient is post abdominal surgery and is on IV morphine and a clear liquid diet. Patient feels distended with sharp cramping gas pains. Most appropriate nursing intervention
o Assist patient to ambulate in hall ways
• Patient post op day 1 after abdominal surgery, nurse notices sanguineous drainage in hemovac
o Nurse should monitor drainage and most common 1st post op day finding
• 36 hours post op, patient has temperature of 100 F
o this is a normal surgical stress response
• Best method to evaluate patients pain
o Rate the pain by number on a scale from 0-10
• Best nursing response to patient who asked about metastasis cancer
o “This means your cancer has spread through your body or lymph to one of your other organs”
• care for patient who is receiving external beam radiation therapy
o avoid direct sun exposure to the treated area for at least one year
• Patient post op right mastectomy, appropriate nursing intervention is
o Position sign at bedside warning against blood pressure or venipunctures in right arm
• Teaching patient with left mastectomy, correct response by patient?
o “I should exercise my left arm several times a day with finger walking up the wall.”
• Patient preparing for breast lumpectomy says, “I just do not know how to handle all of this” Nurses response?
o “ Would you like to talk about how you are feeling?”
• Evaluating lab report on cell differentation, worst prognosis is
o Anaplasia
• Difference between benign and malignant tumors?
o Benign tumors do not metastasize to other tissues and organs.
• Patient has family history of colon polps. Patient should…
o Have fecal occult blood test every year starting at the age of 50
• Needle biopsy of a tumor can tell you
o Appearance of cells and degree of differentiation
• Expected outcome of a debulking procedure
o Reduction of tumor burden to enhance other treatment modalities
• Patient has lost 10 pounds after 3 weeks of radiation therapy, nursing diagnosis would be
o Altered nutrition: less than body requirements related to anorexia
• Cancer patient experiences severe vomiting following each administration of chemotherapy. Nursing intervention
o Administer prescribed antiemetic ATC
• Help manage low self esteem of cancer patient who is on chemotherapy drugs that cause alopecia, nurse would
o Encourage the patient to purchase a wig before her hair loss begins
• Divorced mother of 4 hospitalized with metastatic cancer tells nurse she does not know what will happen to her kids when she dies. Nurses response
o Why don’t we talk about he options you have for the care of your children
• 63 year old male with terminal cancer who has severe pain in abdominal area, teaching regarding pain management has been successful when patient
o takes analgesics ATC on a regular schedule, using additional doses for breakthrough pain
• Patient with lung cancer has lost 10% of body weight, has nursing diagnosis of altered nutrition: less than body requirements, appropriate nursing intervention would be
o Allow patient to select his own food choices
• Nurse is teaching a patient about cancer prevention, which is NOT accurate info
o “ Your diet should include lots of red meat as a protein source”
• Critical factor in the prevention of cancer development is
o Diet
• Patient receiving doxorubicin (Adriamycin) for treatment of breast cancer, nurse should anticipate order which diagnostic test?
o Electrocardiogram
• Intervention for patient with treatment induced thrombocytopenia
o Assess the patient for petechiae, bruising, and bleeding
• A patient with small-cell lung cancer has developed facial swelling, neck vein distention and left arm edema. The nurse should monitor this patient for further complications of
o Superior vena cava syndrome
• Highest priority for patient who developed severe stomatitis following chemotherapy
o Pain related to the side effects of chemotherapy
• Most appropriate nursing diagnosis for patient receiving chemotherapy with vascular Hickman catheter
o Risk for infection