76. A client is being positioned for radical vulvectomy and a
couple of clinical clerks wanted to come in to watch the
surgery. The circulating nurse advise them to enter the OR
suite later. Foremost, this decision of the nurse is directed
towards

1 Answer

Answer :

D. Preserving privacy

Related questions

Description : The clinical instructor assigned a nursing student to assist the operation. When the nursing student entered the OR suite, her curly long hair was not covered by the head cap. What would the circulating nurse ... in all her hair inside the head cap D. Do not allow the nursing student to scrub in

Last Answer : D. Remind the surgeon to scrub again

Description : When the intern-in-charge did the skin prep and catheterized the client, the circulating nurse noticed when the intern withdrew the catheter from the vagina. What is your appropriate and ... . Offer to change the catheter C. Alcoholize the tip of the catheter before reinserting the catheter

Last Answer : B. Offer to change the catheter

Description : The most significant nursing problem related to continuous tube feedings is a) potential for aspiration Because the normal swallowing mechanism is bypassed, consideration of the danger of ... in fat metabolism and lipoprotein synthesis Tube feedings maintain fat metabolism and lipoprotein synthesis.

Last Answer : a) potential for aspiration Because the normal swallowing mechanism is bypassed, consideration of the danger of aspiration must be foremost in the mind of the nurse caring for the patient receiving continuous tube feedings.

Description : 72. The client is to have surgery in 10 days. Lugol’s solution 4 gtts po was prescribed in 10 days. The client asked the nurse for the purpose of the drug. Which response of the nurse is correct?

Last Answer : A. It decreases the risk of bleeding

Description : The client complained of abdominal pain, nausea and vomiting with abdominal distention. The nurse anticipates which of the following priority management after referring to the surgeon? A. Gastric decompression B. Possible surgery C. Endoscopy D. Rectal tube insertion

Last Answer : A. Gastric decompression

Description : 84. The circulating nurse will document “surgical count” in which of the following?

Last Answer : B. Intraoperative record

Description : 83. The scrub nurse and circulating nurse also counted the sharps and miscellaneous items like instruments before the procedure. Continuous accounting for these items can primarily

Last Answer : C. Minimize injuries and/or liabilities to sterile surgical team

Description : 81. The scrub and circulating nurse should perform sponge count during which phases of an abdominal hysterectomy procedure? 1. Before the procedure 2. Before closing the endometrium 3. Before closing the peritoneum 4. At the skin closure 5. When the scrub nurse goes for a lunch break

Last Answer : A. All except 5

Description : The Code of Ethics states that the nurse's primary commitment is to the client whether an individual of family, group or community. Which nursing activity would best demonstrate the ethical ... is least considered D. The nurse's providing care to maximize health according to available resources

Last Answer : A. The nurse providing care on a “first come – first served” basis

Description : When caring for a patient with an uncomplicated, mild urinary tract infection (UTI), the nurse knows that recent studies have shown which of the following drugs to be a good choice for ... to be significantly more effective than TMP-SMX in community-based patients and in nursing home residents.

Last Answer : a) Levofloxacin (Levaquin) Levofloxacin, a floroquinolone, is a good choice for short-course therapy of uncomplicated, mild to moderate UTI. Clinical trial data show high patient compliance with the 3-day regimen (95.6%) and a high eradication rate for all pathogens (96.4%).

Description : 96. You planned the nursing care of the client together with the nursing student. You asked the nursing student to enumerate the clinical manifestations of a client with polycythemia vera. You expect the nursing student to enumerate the following manifestations except

Last Answer : B. Hepatomegaly

Description : When the female client reports a frothy yellow-brown vaginal discharge, the nurse suspects the client has a vaginal infection caused by a) trichomonas vaginalis. Trichomonas vaginalis causes a ... the external vulva and vaginal walls. d) chlamydia. Chlamydia causes a profuse purulent discharge.

Last Answer : a) trichomonas vaginalis. Trichomonas vaginalis causes a frothy yellow-white or yellow-brown vaginal discharge.

Description : 99. The companion asks why the client was advised to avoid iron supplements or vitamins. The correct response of the nurse would be

Last Answer : A. “These supplements enhance the production of RBC.”

Description : 88. When the nurse ensures that the client has plan for continuous care after leaving the health care facility and assists from the transition from one environment to another, she is doing a

Last Answer : A. Discharge plan

Description : 79. A scrub nurse is assisting an emergency Cesarian section on a 39-year-old laundry woman. Before closing the peritoneum, the surgeon asks, How old is the client? Holding the fallopian ... there is no signed consent for tubal ligation. The nurse just demonstrated which of the following?

Last Answer : C. Advocacy

Description : 77. Nurse Kristine is to inject Demerol 75 mg to a post-TURP (transurethral resection of the prostate) client who is in pain. When she checked the narcotic cabinet, she found out a ... next Demerol vial is available. The action of the nurse violates which of the following ethical principles?

Last Answer : A. Justice

Description : 69. When Marina checked the capillary blood glucose of the client at 6 PM before meals as instructed by the senior nurse, the result showed 65 mg/dl. Which of the following will Marina do first?

Last Answer : C. Check the physician’s order in case CBG is below 70 mg/dl

Description : 64. The client was placed on a low sodium diet. The wife asks the nurse which foods to include in the client’s diet while at home. The nurse should instruct to include which of these?

Last Answer : C. Fruits and vegetables

Description : 62. A 30-year-old client had cholesterol blood test before admission to the hospital. The nurse in charge would teach the family and significant others that the client should exercise to help keep the total cholesterol to a desired level of

Last Answer : A. 140 mg/dl

Description : 61. A client with gout asks the nurse what food must be avoided so that the family can provide support. Which food has the highest in purine content and must be excluded from the dietary plan?

Last Answer : D. Liver

Description : 57. The client was prescribed Ocreotide acetate (Sandostatin). Nurse Carla would monitor for which of the following side effects?

Last Answer : A. Abdominal pain

Description : 55. The nurse wants to know if the client is aware of the side effects of NSAID. What would be the most appropriate question of the nurse?

Last Answer : B. “Have you ever vomited blood or noticed very black stools?”

Description : 51. Albert came to the hospital with chest pain and fever. After a thorough assessment by the doctor, he was admitted for pericarditis management. The nurse positions the client to reduce pain and discomfort. Describe this position.

Last Answer : C. Sit the client upright and lean forward

Description : 42. The nurse is to inject Vitamin B intramuscularly to another elderly client. Before injecting, the nurse explained that the client may feel some discomfort. This is an example of

Last Answer : C. Anticipatory response

Description : 41. For a client complaining of mild musculoskeletal pain, the nurse will anticipate that the treatment for this client’s level of discomfort will include which of the following?

Last Answer : B. Acetaminophen

Description : 40. The nurse should ensure that all components of medications are documented. Identify all these components. 1. Dosage, route and frequency 2. Name of client and medication 3. Date and time ... and strength 5. Physician's signature and specialty 6. Physician's signature and PRC license number

Last Answer : C. All except 5 and 6

Description : 38. A nurse encounters a client who refuses to take a prescribed medication. What is the appropriate action of the nurse?

Last Answer : C. Explore the possible reason why the client refuses the prescribed medication

Description : Reviewing the laboratory findings of the client, the nurse would found which findings are elevated? 1. White blood cell count 2. Total serum bilirubin 3. Alkaline phosphate 4. Red blood cell count 5. Cholesterol 6. Serum amylase A. 1, 2, and 3 B. 2, 3, and 4 C. 3, 5, and 6 D. 1, 2, and 6

Last Answer : A. 1, 2, and 3

Description : To confirm the diagnosis of cholecystitis, the attending physician ordered a procedure that can detect gallstones as small as 1 - 2 cm and inflammation. The nurse would prepare ... specific diagnostic procedure? A. Cholangiography B. Ultrasonography C. Gall bladder series D. Oral cholecystogram

Last Answer : B. Ultrasonography

Description : As the nurse monitors the client, she notices a bright red spot on the dressings which measures 4cm in diameter. The nurse should initially do which appropriate nursing intervention? A. Change the ... C. Notify the clients surgeon of a potential hemorrhage D. Assess the presence of a drain

Last Answer : D. Assess the presence of a drain

Description : The nurse instructs the nursing attendant to perform cleansing enema until the return flow is clear. The nursing attendant understood the instruction when she says, I will A. Call you when the return flow is ... flow D. Put the client in left Sim's position to achieve the desired return flow.

Last Answer : A. Call you when the return flow is clear”

Description : In the immediate post-operative period, the nurse assesses coarse, high-pitched sound on inspiration by listening over the trachea with a stethoscope. The nurse should immediately A. Position client to ... the client that he is doing fine C. Suction the tracheostomy tube D. Report to the surgeon

Last Answer : Which of the following expected outcomes for the patient is most relevant for the nursing diagnosis “At risk for imbalanced nutrition related to impaired swallowing”? A. Appropriate body weight maintained B. Fear of choking relieved C. Oral intake increased D. Swallowing of soft foods facilitated

Description : Pre-operatively, the nurse identified the nursing dagnosis, Knowledge Deficit: Post-operative communication strategies . Which of the following is a relevant nursing intervention? A. ... uses an alternative form of verbal communication D. Illustrate means of communicating post- operatively

Last Answer : D. Illustrate means of communicating post- operatively

Description : What safety actions does the nurse need to take for a patient on oxygen therapy who is undergoing magnetic resonance imaging (MRI)? a) Ensure that no patient care equipment containing metal enters the ... oxygen tanks) that contains metal or metal parts enters the room where the MRI is located.

Last Answer : a) Ensure that no patient care equipment containing metal enters the room where the MRI is located. For patient safety the nurse must make sure no patient care equipment (e.g., portable oxygen ... literally be pulled away with such great force that they can fly like projectiles towards the magnet.

Description : In order to avoid hip dislocation after replacement surgery, the nurse teaches the patient which of the following guidelines? a) Never cross the affected leg when seated. Crossing the affected leg may result ... a chair. The patient should be taught to avoid bending forward when seated in a chair.

Last Answer : a) Never cross the affected leg when seated. Crossing the affected leg may result in dislocation of the hip joint after total hip replacement.

Description : The nurse knows that a postoperative vision-threatening complication of LASIK refractive surgery, diffuse lamellar keratitis (DLK) occurs a) in the first week after surgery. DLK is a peculiar, non-infectious, ... after surgery. d) 6 months after surgery. DLK occurs in the first week after surgery.

Last Answer : a) in the first week after surgery. DLK is a peculiar, non-infectious, inflammatory reaction in the lamellar interface after LASIK. It is characterized by a white granular, diffuse culture-negative ... no single agent appears to be solely the cause of DLK, a multifactorial etiology is likely.

Description : The nurse teaches the patient whose surgery will result in a sigmoid colostomy that the feces expelled through the colostomy will be a) solid. With a sigmoid colostomy, the feces are solid. b) semi- ... colostomy, the feces are mushy. d) fluid. With an ascending colostomy, the feces are fluid.

Last Answer : a) solid. With a sigmoid colostomy, the feces are solid.

Description : When the nurse notes that the post cardiac surgery patient demonstrates low urine output (< 25 ml/hr) with high specific gravity (> 1.025), the nurse suspects: a) Inadequate fluid volume Urine ... by high urine output with low specific gravity. d) Anuria The anuric patient does not produce urine.

Last Answer : a) Inadequate fluid volume Urine output of less than 25 ml/hr may indicate a decrease in cardiac output. A high specific gravity indicates increased concentration of solutes in the urine which occurs with inadequate fluid volume.

Description : When the post-cardiac surgery patient demonstrates restlessness, nausea, weakness, and peaked T waves, the nurse reviews the patient's serum electrolytes anticipating which abnormality? a) Hyperkalemia ... likely be indicated by weakness, fatigue, and confusion without change in T wave formation

Last Answer : a) Hyperkalemia Hyperkalemia is indicated by mental confusion, restlessness, nausea, weakness, and dysrhythmias (tall, peaked T waves).

Description : Which of the following actions is most appropriate for the nurse to take when the patient demonstrates subcutaneous emphysema along the suture line or chest dressing 2 hours after chest ... finding to the physician immediately. Subcutaneous emphysema results from air entering the tissue planes.

Last Answer : a) Record the observation. Subcutaneous emphysema occurs after chest surgery as the air that is located within the pleural cavity is expelled through the tissue opening created by the surgical procedure.

Description : When the indication for surgery is without delay, the nurse recognizes that the surgery will be classified as a) emergency. Emergency surgery means that the patient requires immediate attention and the ... there is an indication for surgery, but failure to have surgery will not be catastrophic.

Last Answer : a) emergency. Emergency surgery means that the patient requires immediate attention and the disorder may be life-threatening.

Description : 73. When the client returns to the unit after surgery, which technique is most appropriate to monitor bleeding from the incision?

Last Answer : B. Assess for dampness at the back of the client’s neck

Description : To facilitate entry of a catheter into the male urethra, the penis should be positioned at which of the following degree angles (in relation to the body)? a) 90 degrees A right ... and inappropriately positioned for catheterization. d) 270 degrees A 270-degree angle is a physical impossibility.

Last Answer : a) 90 degrees A right angle straightens the urethra and makes it easier to insert the catheter.

Description : To prevent footdrop, the patient is positioned in: a) Order to keep the feet at right angles to the leg When the patient is supine in bed, padded splints or protective boots are used. b) ... must be supported. d) A side-lying position Side-lying positions do not provide support to prevent footdrop.

Last Answer : a) Order to keep the feet at right angles to the leg When the patient is supine in bed, padded splints or protective boots are used.

Description : During which stage of the immune response does the circulating lymphocyte containing the antigenic message return to the nearest lymph node? a) Proliferation Once in the node, the sensitized lymphocyte ... cellular response reaches and couples with the antigen on the surface of the foreign invader.

Last Answer : a) Proliferation Once in the node, the sensitized lymphocyte stimulates some of the resident dormant T and B lymphocytes to enlarge, divide, and proliferate.

Description : To assess circulating oxygen levels the 2001 Kidney Disease Outcomes Quality Initiative: Management of Anemia Guidelines recommends the use of which of the following diagnostic tests? a) Hemoglobin ... gases Arterial blood gases assess the adequacy of oxygenation, ventilation, and acid-base status.

Last Answer : a) Hemoglobin Although hematocrit has always been the blood test of choice to assess for anemia, the 2001 Kidney Disease Outcomes Quality Initiative: Management of Anemia Guidelines, recommend that ... rather than hematocrit measurements, as it is more accurate in assessment of circulating oxygen.

Description : Which of the following disorders is characterized by a group of symptoms produced by an excess of free circulating cortisol from the adrenal cortex? a) Cushing's syndrome The patient ... individual with Hashimoto's disease demonstrates inflammation of the thyroid gland, resulting in hypothyroidism.

Last Answer : a) Cushing’s syndrome The patient with Cushing’s syndrome demonstrates truncal obesity, moon face, acne, abdominal striae, and hypertension.