NURS 120 Midterm

Question 1

A 17-year-old patient with a leg fracture who is scheduled for surgery is an emancipated minor. She has a statement from the court for verification. Which action would the nurse take?

A. Witness the patient signing the permit after the surgeon obtains consent
B. Call a parent or legal guardian to sign the permit since the patient is under 18
C. Notify the hospital attorney that an emancipated minor is consenting for surgery
D. Obtain verbal consent since written consent is not necessary for emancipated minors

Answer 1

A. Witness the patient signing the permit after the surgeon obtains consent

Question 2

SATA: The nurse is caring for a patient undergoing surgery for a knee replacement. Which factors are critical to the patient’s safety during the procedure?

1. Universal protocol is following
2. The patient has adequate health insurance
3. The patient’s family is in the surgery waiting area
4. The ACP is an anesthesiologist
5. The patient’s allergy are conveyed to the surgical team

Answer 2

1, 5

Question 3

Which order should a nurse question in the plan of care for an older adult, immobile stroke patient with a pink, clean stage 3 pressure injury?

A. Pack the wound with foam dressing
B. Turn and position the patient every hour
C. Clean the wound daily with a cytotoxic solution
D. Assess for pain and medication before dressing change

Answer 3

C. Clean the wound daily with a cytotoxic solution

Question 4

Why is IV induction for general anesthesia the method of choice for most patients?

A. The patient is not intubated
B. The agents are nonexplosive
C. Induction is rapid and controlled
D. Emergence is longer but with fewer complications

Answer 4

C. Induction is rapid and controlled

Question 5

SATA: Which preoperative considerations would the nurse plan for the care of an older adult?

1. Using only large-print educational materials
2. Speaking louder for patients with hearing aids
3. Recognizing that sensory deficits may be present
4. Providing warm blankets to prevent hypothermia
5. Teaching important information early in the morning

Answer 5

3, 4

Question 6

The nurse assessing a patient with a chronic leg wound finds redness and edema. The patient reports pain at the wound site. What would the nurse expect to be ordered to assess the patient’s systemic response?

A. Serum protein analysis
B. WBC count and differential
C. Punch biopsy of the center of the wound
D. Culture and sensitivity of the wound

Answer 6

B. WBC count and differential

Question 7

Which actions would the nurse prioritize when admitting a patient to the PACU?

A. Assess the surgical site, noting presence and character of drainage
B. Assess the amount of urine output and the presence of bladder distention
C. Assess for airway patency and quality of respirations and obtain vital signs
D. Review results of intraoperative laboratory values and medications received

Answer 7

C. Assess for airway patency and quality of respirations and obtain vital signs

Question 8

A patient is admitted to the PACU after major abdominal surgery. During the initial assessment the patient tells the nurse, “I think I am going to throw up.” Which is the priority intervention?

A. Increase the rate of the IV fluids
B. Give antiemetic medication as ordered
C. Obtain vital signs, including O2 saturation
D. Position patient in lateral recovery position

Answer 8

D. Position patient in lateral recovery position

Question 9

A patient 1 day postoperative after abdominal surgery has incisional pain, 99.5 F, slight redness at the incision margins, and 30 mL serosanguinous drainage in the Jackson-Pratt drain. Based on this assessment, what conclusion would the nurse make?

A. The patient has a normal inflammatory response
B. The abdominal incision shows signs of an infection
C. The abdominal incision shows signs of impending dehiscence
D. The patient’s health care provider must be notified about their condition

Answer 9

A. The patient has a normal inflammatory response

Question 10

Which intervention would the nurse prioritize to aid a preoperative patient in coping with the fear of postoperative pain?

A. Inform the patient that pain medication will be available
B. Teach the patient to guided imagery to help manage pain
C. Describe the type of pain expected after the patient’s surgery
D. Explain the pain management plan and the use of a pain rating scale

Answer 10

D. Explain the pain management plan and the use of a pain rating scale

Question 11

SATA: Which patients are at most risk for pressure injuries?

1. A patient with right-sided paralysis and fecal incontinence
2. An older adult who is alert and needs assistance to ambulate
3. A young adult patient with paraplegia after a gunshot wound
4. A morbidly obese patient who has an open abdominal wound
5. An ambulatory patient who has occasional stress incontinence
6. A young adult with a tibial fracture from a motor vehicle accident

Answer 11

1, 3, 4

Question 12

A patient is scheduled for surgery requiring general anesthesia at an ambulatory surgical center. The nurse asks him when he ate last. He replies that he had a light breakfast a couple of hours before coming to the surgery center. Which action would the nurse take?

A. Tell the patient to come back tomorrow since he ate a meal
B. Have the patient void before giving any preoperative medication
C. Proceed with the preoperative checklist, including site identification
D. Notify the anesthesia care provider of when and what the patient last ate

Answer 12

D. Notify the anesthesia care provider of when and what the patient last ate

Question 13

Which patient has the greatest risk for delayed wound healing?

A. A 65-year-old woman with stress incontinence
B. A 52-year-old obese woman with type 2 diabetes
C. A 78-year-old man who has a history of hypertension
D. A 30-year-old man who drinks 2 alcoholic beverages per day

Answer 13

B. A 52-year-old obese woman with type 2 diabetes

Question 14

A 59-year-old man scheduled for herniorrhaphy in 2 days reports that he takes an anticoagulant agent daily. Which action would the nurse take?

A. Inform the surgeon since the procedure may have to be rescheduled
B. Tell the patient to continue to take the drug up to the day before surgery
C. Ask the patient if he has any side effects from taking this drug supplement
D. Notify the anesthesia care provider since this drug may interfere with anesthetics

Answer 14

A. Inform the surgeon since the procedure may have to be rescheduled

Question 15

The patient reports that she has noticed a skin reaction when wearing disposable gloves. Which action would the nurse take?

A. Notify the surgeon so that the surgery can be cancelled
B. Ask further questions to assess for a possible latex allergy
C. Notify the OR staff at once so they can use latex-free supplies
D. No action is needed because the patient’s reaction has no bearing on surgery

Answer 15

B. Ask further questions to assess for a possible latex allergy

Question 16

SATA: Which factors would the nurse include in discharge criteria for a Phase II patient?

1. Nausea and vomiting controlled
2. Ability to drive themselves home
3. No respiratory depression present
4. Written discharge instructions understood
5. Opioid pain medications given 45 minutes ago

Answer 16

1, 3, 4, 5

Question 17

A patient in the unit has a 103.7 F temperature. Which intervention would be most effective in restoring normal body temperature?

A. Using a cooling blanket while the patient is febrile
B. Giving antipyretics on an around-the-clock schedule
C. Providing increased fluids and have the AP give sponge baths
D. Giving prescribed antibiotics and placing warm blankets for comfort

Answer 17

B. Giving antipyretics on an around-the-clock schedule

Question 18

Which items would the nurse wear for proper attire in the semirestricted area of the surgery department?

A. Street clothing
B. Surgical attire and head cover
C. Street clothing and shoe covers
D. Surgical attire, head cover, shoe covers

Answer 18

D. Surgical attire, head cover, shoe covers

Question 19

SATA: Which activities might the nurse perform in the role of a scrub nurse during surgery?

1. Checking electrical equipment
2. Preparing the instrument table
3. Assisting with draping the patient
4. Passing instruments to the surgeon and assistants
5. The patient’s allergies are conveyed to the surgical team

Answer 19

2, 3, 4

Question 20

Which action would the nurse take when scrubbing at the scrub sink?

A. Scrub from elbows to hands
B. Scrub without mechanical friction
C. Scrub for a minimum of 10 minutes
D. Hold the hands higher than the elbows

Answer 20

D. Hold the hands higher than the elbows

Question 21

A patient who takes metformin 500 mg every morning for control of type 2 diabetes asks if she should take her medication the day of surgery. Which recommendation would the nurse make?

A. Skip her medication the day of surgery
B. Get instructions from the surgeon about medication adjustments
C. Take her usual morning dose at bedtime the night before surgery
D. Take her medication as usual with a sip of water in the morning

Answer 21

B. Get instructions from the surgeon about medication adjustments

Question 22

SATA: A 70-kg postoperative patient has an average urine output of 25 mL/hr during the first 8 hours. Which interventions would the nurse prioritize?

1. Obtain a bladder ultrasound scan
2. Perform a straight catheterization
3. Continue to monitor this normal finding
4. Evaluate the patient’s fluid volume status

Answer 22

1, 4

Question 23

After admitting a postoperative patient to the clinical unit, which assessment data require attention first?

A. O2 saturation of 85%
B. Respiratory rate of 13/min
C. Temperature of 100.4 F
D. Blood pressure of 90/60 mmHg

Answer 23

A. O2 saturation of 85%

Question 24

A nurse is caring for a patient who has a pressure injury that is treated with debridement, irrigations, and moist gauze dressings. How would the nurse expect healing to occur?

A. Cell regeneration
B. Tertiary intention
C. Secondary intention
D. Remodeling of tissues

Answer 24

C. Secondary intention

Question 25

SATA: Which factors in positioning a patient for surgery increase the risk of patient injury?

1. Loss of pain perception
2. Incorrect musculoskeletal alignment
3. Vasoconstriction of the peripheral vessels
4. Hypovolemia contributing to decreased perfusion
5. Inability to sense pressure over bony prominences

Answer 25

1, 2, 4

Question 26

An 82-year-old man is being cared for at home by his family. A pressure injury on his right buttock measures 1 x 2 x 0.8 cm, and pink subcutaneous tissue is completely visible on the wound bed. Which stage would the nurse document on the wound assessment form?

A. Stage 1
B. Stage 2
C. Stage 3
D. Stage 4

Answer 26

C. Stage 3

Question 27

An 85-year-old patient has a score of 16 on the Braden Scale. What should the nurse include in the plan of care?

A. Implementing a 1-hour turning schedule with skin assessment
B. Elevating the head of the bed 90 degrees when the patient is supine
C. Continuing with weekly skin assessments with no special precautions
D. Placing a silicon foam dressing on the patient’s sacrum to prevent breakdown

Answer 27

A. Implementing a 1-hour turning schedule with skin assessment

Question 28

A patient with obesity (BMI 42.1 kg/m2) is scheduled for a laparoscopic cholecystectomy in an outpatient surgery setting. Which information would the nurse include in the plan of care?

A. The patient will be in the hospital for several days
B. Surgery will involve removing a part of the liver
C. The setting is not appropriate for the planned procedure
D. Special equipment may be needed for the patient’s care

Answer 28

D. Special equipment may be needed for the patient’s care

Question 29

Which action is the nurse’s primary responsibility for the care of the patient undergoing surgery?

A. Developing a patient-centered plan of nursing care
B. Carrying out tasks related to surgical policies and procedure
C. Ensuring that the patient has been assessed for safe administration of anesthesia
D. Performing a preoperative history and physical assessment to identify patient needs

Answer 29

A. Developing a patient-centered plan of nursing care