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