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WorksheetsSurgical Site/Pain/Cell Reg
Total questions: 25
Worksheet time: 17mins
Mr. Jones just underwent abdominal surgery and has a pH 7.29, PaCO2 54, HCO3 23. What could be the cause of this ABG imbalance?
Too much IV fluid
Too much sedation
Breathing too fast
Patient is vomiting
A client requests the nurse to come to the room. When the nurse enters the room, this is what they see: (see picture). What would the nurses IMMEDIATE action be?
Push it back into place
Ask the client if they are hurting
Cover the intestine with sterile gauze covered with saline
Cover with a dry towel
The nurse is preparing a client for surgery. Which is part of the preop assessment?
Observing a time out
Assessing the client for Malignant hyperthermia
Assessment of the wound
Manage pain
Which assessment is PRIORITY when the client arrives in PACU?
The nurse is concerned a client is developing malignant hyperthermia. Which symptom would support the hypothesis?
The nurse is caring for a client who is post-surgery. The client has a temp of 99.2. Which intervention would be best to help with the temperature?
Encourage the client to use an incentive spirometer
Administer acetaminophen
Match the following complication with the preventative measure
DVT
Early ambulation
Constipation
docusate
PE
Anticoagulation therapy
Urinary retention
I & O monitoring
Pressure ulcer
Regular repositioning
A client has had a right below the knee amputation. The RN removes the dressing and assesses the wound. (see the picture). What would the nurse note is happening to the wound?
Cellulitis
Normal healing
Dehiscence
Sepsis
What is the Post-operative period?
This period occurs after the surgery where the provider monitors the patient on a timely basis to make sure that the patient is safe & comfortable
This period occurs prior to the surgery where the provider gathers all the relevant information to make sure there is no obstacle when performing the surgery
This is a period where actual surgery is performed
All of the above
A client is experiencing difficulty breathing post-surgery. What is the nurse's first action?
Administer oxygen
Call the physician
Check the client's airway
Elevate the head of the bed
The nurse is assessing a post-operative client for signs of infection. Which symptom would be most concerning?
Redness around the incision
Temperature of 101°F
Clear drainage from the wound
Increased pain at the surgical site
A client is in the PACU and begins to shiver. What is the most appropriate intervention by the nurse?
Administer a warming blanket
Give the client warm fluids
Increase the room temperature
Administer a sedative
What is the Post-operative period?
This period occurs after the surgery where the provider monitors the patient on a timely basis to make sure that the patient is safe & comfortable
This period occurs prior to the surgery where the provider gathers all the relevant information to make sure there is no obstacle when performing the surgery
This is a period where actual surgery is performed
All of the above
A client shows up to the ED with complaints of fatigue and random nose bleeds. The nurse notices the client is pale and has random bruising. Labs show WBC 75, 000, Hct 6, platelets 45,000. VS 112/76, 112, 26, temp 100.6, and SpO2 94%. Which 4 of these are most concerning? (a) (b) (c) (d)
The nurse is caring for a client who has undergone brachytherapy for prostate cancer. Which visitor should not be allowed in the room?
His granddaughter who is pregnant
His wife who has COPD
His sister who is from out of state
His friend he plays poker with on the weekend
Match the following important teaching to the prompt
Lung Cancer
Eating small meals throughout the day
Lymphoma
May need to consult a fertility clinic
Post Surgery
How to care for the wound
Breast Cancer
Importance of monthly self exam
Leukemia
S/S of neutropenia/thrombocytopenia
A client has undergone a lymphadenectomy to the left side. Whichpost-opp instruction would be important to discuss?
Use of incentive spirometer
No BP/IV/Blood draws can be done on the left side
Early ambulation
Post op wound care
Importance of nutrition
Which finding would be the MOST concerning for breast cancer in a client?
Dimpling of the nipple
Painful lump
Drainage in the nipple
Thickening of the nipple
fever
The nurse is caring for a client is who receiving doxorubicin. Which finding should the nurse report to the provider?
Red urine
Changes in the EKG
Increase in liver enzymes
Vomiting
Antineoplastic agents target the cancer cells and kill the cancer.
True
False
The nurse is caring for a client who has lymphoma. The client starts complaining of tingling and numbness in their feet. What could this client potentially be developing?
Myelodysplasia
Spinal Cord Compression
Superior Vena Cava Syndrome
Hypercalcemia
One hour after receiving pain medication, a postoperative client reports intense pain. What is the nurse's most appropriate first action?
Discuss the frequency of pain medication orders with the client.
Assess the client to determine the cause of the pain
Consult with the healthcare provider for additional pain orders
Assist the client to reposition and splint the incision site
Which would be a primary prevention?
Not smoking
Having chemo performed
Routine Colonoscopies
Receiving radiation for a brain tumor
Which client would be most appropriate for a PCA pump?
A client who was involved in a MVA with a fractured femur who has sustained a concussion.
A client with Alzheimer's who has underwent a colon resection for colon cancer.
A client who has undergone a mastectomy who has COPD.
A client who is on a sedative and has undergone a craniotomy.
The nurse is caring for a client who has just undergone a bone marrow biopsy. Which finding would be the most concerning?
Pain at the site
Bleeding on the dressing
Nausea
Fatigue
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