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Peripheral Edema Assessment Worksheet

Total questions: 20

Worksheet time: 10mins

Name
Class
Date
1.

The best method of evaluating the amount of peripheral edema is:

a)

Weighing the client daily

b)

Measuring the extremity

c)

Measuring the intake and output

d)

Checking for pitting

2.

Which action by the healthcare worker indicates a need for further teaching?

a)

The nursing assistant ambulates the elderly client using a gait belt

b)

The nurse wears goggles while performing a venipuncture

c)

The nurse washes his hands after changing a dressing

d)

The nurse wears gloves to monitor the IV infusion rate

3.

As a nurse, which statement is incorrect regarding an informed consent signed by a patient?

a)

The nurse is responsible for obtaining the consent for surgery

b)

Patients under 18 years of age may need a parent or legal guardian to sign a consent form

c)

The nurse can witness the client signing the consent form

d)

It is the nurse's responsibility to ensure the patient has been educated by the physician about the procedure before informed consent is obtained

4.

As the nurse you are getting the patient ready for surgery. You are completing the preoperative checklist. Which of the following is not part of the preoperative checklist?

a)

Assess for allergies

b)

Conducting the Time Out

c)

Informed consent is signed

d)

Ensuring that the history and physical examination has been completed

5.

What is a potential postoperative concern regarding a patient who has already resumed a solid diet?

a)

Failure to pass stool within 12 hours of eating solid foods

b)

Failure to pass stool within 48 hours of eating solid foods

c)

Passage of excessive flatus

d)

Patient reports a decreased appetite

6.

After surgery your patient starts to shiver uncontrollably. What nursing intervention would you do FIRST?

a)

Apply warm blankets & continue oxygen as prescribed

b)

Take the patient's rectal temperature

c)

Page the doctor for further orders

d)

Adjust the thermostat in the room

7.

After surgery your patient is semicomatose with vital signs within normal limits. As the nurse, what position would be best for this patient?

a)

Semi-Fowlers

b)

prone

c)

Low-Fowlers

d)

Side positioning preferably on the left side

8.

A patient is scheduled for abdominal surgery. The nurse educates the patient about deep breathing exercises. What is the primary goal of deep breathing exercises postoperatively?

a)

Preventing infection at the incision site

b)

Strengthening the abdominal muscles

c)

Reducing the risk of blood clots

d)

Enhancing lung function and preventing atelectasis

9.

A patient is receiving general anesthesia for surgery. The nurse knows that general anesthesia affects which body system the most?

a)

Cardiovascular system

b)

Respiratory system

c)

Gastrointestinal system

d)

Central nervous system

10.

A patient is scheduled for surgery later in the day. The nurse performs a preoperative assessment and finds that the patient has not followed the fasting guidelines. What is the nurse's most appropriate action?

a)

Cancel the surgery immediately

b)

Notify the surgeon and anesthesiologist

c)

Administer antacid medications to neutralize stomach acid

d)

Proceed with surgery as scheduled

11.

The nurse receives a telephone call from the post-anesthesia care unit stating that a client is being transferred to the surgical unit. The nurse plans to take which action first on arrival of the client?

a)

Assess the patency of the airway

b)

Check tubes or drains for patency

c)

Check the dressing to assess for bleeding

d)

Assess the vital signs to compare with preoperative measurements

12.

The nurse assesses a client's surgical incision for signs of infection. Which finding by the nurse would be interpreted as a normal finding at the surgical site?

a)

Red, hard skin

b)

Serous drainage

c)

Purulent drainage

d)

Warm tender skin

13.

A preoperative client expresses anxiety to the nurse about upcoming surgery. Which response by the nurse is most likely to stimulate further discussion between the client and the nurse?

a)

If it's any help, everyone is nervous before surgery

b)

I will be happy to explain the entire surgical procedure with you

c)

Can you share with me what you've been told about your surgery?

d)

Let me tell you about the care you'll receive after surgery and the amount of pain you can anticipate

14.

The nurse is developing a plan of care for a client scheduled for surgery. The nurse should include which activity in the nursing care plan for the client on the day of surgery?

a)

Avoid oral hygiene and rinsing with mouthwash

b)

Verify that the client has not eaten for the last 24 hours

c)

Have the client void immediately before going into surgery

d)

Report immediately any slight increase in BP or pulse

15.

A postoperative client asks the nurse why it is so important to deep-breathe and cough after surgery. When formulating a response, the nurse incorporates the understanding that retained pulmonary secretions in a postoperative client can lead to which condition?

a)

Pneumonia

b)

Hypoxemia

c)

Fluid imbalance

d)

Pulmonary embolism

16.

The nurse is caring for a patient who suddenly becomes confused and tries to remove an IV fusion. Which priority action will the nurse take?

a)

Assess the patient

b)

Gather restraint supplies

c)

Try alternatives to restraints

d)

Call the health care provider for a restraint order

17.

The nurse is caring for a hospitalized patient. Which behavior alerts the nurse to consider the need for a restraint?

a)

the patient refuses to call for help to go to the bathroom

b)

The patient continues to remove the nasogastric tube

c)

The patient gets confused regarding the time at night

d)

The patient does not sleep and continues to ask for items

18.

The nurse is planning room assignments for the day. Which client should be assigned to a private room if only one is available?

a)

The client with methicillin resistant-staphylococcus aureus (MRSA)

b)

The client with diabetes

c)

The client with pancreatitis

d)

The client with Addison’s disease

19.

The nurse is suspected of charting medication administration that he did not give. After talking to the nurse, the charge nurse should:

a)

Call the Board of Nursing

b)

File a formal reprimand

c)

Terminate the nurse

d)

Charge the nurse with a tort

20.

The emergency room is flooded with clients injured in a tornado. Which clients can be assigned to share a room in the emergency department during the disaster?

a)

A. A client having auditory hallucinations and the client with ulcerative colitis

b)

B. The client who is pregnant and the client with a broken arm

c)

C. A child who is cyanotic with severe dyspnea and a client with a frontal head injury

d)

D. The client who arrives with a large puncture wound to the abdomen and the client with chest pain