11/11/22, 9:38 AM PRE-TEST
PRE-TEST Total points 36/40
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NOVAL, LYN-JE KIRSTENE M.
Questions: 36 of 40 points
A nurse is developing a care plan for a patient who is at risk for *2/2
developing pneumonia after surgery. Which of the following is not an
appropriate nursing intervention?
A. Encourage patient intake of 3000 ml/day of fluids if not contraindicated
B. Encourage patient to use the incentive spirometer device 10 times every 1-2
hours while awake
C. Encourage early ambulation and patient to eat meals in beside chair
D. Repositioning every 2 hours
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In the recovery room, the postoperative client suddenly becomes *2/2
cyanotic. What is the most appropriate nursing action?
A. Start administration of oxygen through a nasal cannula
B. Call for assistance
C. Reposition the head and determine patency of airway
D. Insert an oral airway and suction the nasopharynx
After surgery your patient starts to shiver uncontrollably. What nursing *2/2
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
A patient reports he hasn't had a bowel movement or passed gas since *2/2
surgery. On assessment, you note the abdomen is distended and no
bowel sounds are noted in the four quadrants. You notify the MD. What
non-invasive nursing interventions can you perform without a MD order?
A. Insert a nasogastric attached to intermittent suction
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B. Administer IV fluids
C. Encourage ambulation, maintain NPO status, and monitor intake & output
D. Encourage at least 3000 ml of fluids per day
A patient is taking Aspirin 325 mg PO by mouth daily. The patient is *2/2
scheduled for surgery in a week. What education do you provide the
patient with before surgery?
A. Educate the patient to take the scheduled dose of Aspirin the day of surgery to
help prevent blood clots
B. To hold his morning dose of Aspirin because the nurse will give it to him before
surgery
C. None of the above are correct
D. The medication should be discontinued for 48 hours prior to the scheduled
surgery date
Option 5
When assessing your patient who is post-opt, you notice that the patient's *2/2
right calf vein feels hard, cord-like, and is tender to the touch. The patient
reports it is aching and painful. What would NOT be an appropriate
nursing intervention for this patient?
A. Allow the patient to dangle the legs to help increase circulation and alleviate
pain
B. Instruct the patient to not sit in one position for a long period of time
C. Elevate the extremity 30 degrees without allowing any pressure on affected area
D. Administer anticoagulants as ordered by MD
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Which of the following is experienced by the patient who is under general *2/2
anesthesia?
A. The patient is unconscious
B. The patient is awake
[Link] patient experiences slight pain
D. The patient experiences loss of sensation in the lower half of the body
You are observing your patient use the incentive spirometry. What *2/2
demonstration by the patient lets you know the patient understands how
to use the device properly?�
A. The patient inhales slowly on the device and maintains the flow indicator
between 600 to 900 level
B. The patient blows on the mouthpiece rapidly.
C. The patient uses the incentive spirometry once a day
D. The patient rapidly inhales on the devices and exhales
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The patient had undergone a total hip replacement. He complains of pain *2/2
in the operative site. Which of the following is the appropriate initial
nursing action?
A. Administer the ordered analgesic
B. Instruct the patient to do deep breathing and coughing exercises
C. Assess the patient’s pain level and vital signs
D. Change the patient’s position
After surgery your patient is semicomatose with vital signs within normal *2/2
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
The nurse is monitoring the patient who is 24 hours post-opt from *2/2
surgery. Which finding requires intervention?
A. BP 100/80
B 24-hour urine output of 300 ml
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B. 24-hour urine output of 300 ml
C. Pain rating of 4 on 1-10 scale
D. Temperature of 99.3' F
As the nurse you are getting the patient ready for surgery. You are *2/2
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
To prevent complications of immobility, which activities would the nurse *2/2
plan for the first postoperative day after a colon resection?
A. Turn, cough, and deep breathe every 30 minutes around the clock
B. Get the client out of bed and ambulate to a bedside chair
C. Provide passive range of motion three times a day
D. It is not necessary to worry about complications of immobility on the first
postoperative day
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The nurse is transferring the patient from the postanesthesia care unit to *2/2
the surgical unit. Which of the following is the primary reason for gradual
change of position of the patient?
A. To prevent muscle injury
B. To prevent sudden drop of blood pressure
C. To prevent respiratory distress
D. To promote comfort
A patient is now in the recovery room after having vaginal surgery. Due to *0/2
the positioning of the procedure, you would want to assess for what while
the patient is in recovery?
A. Bowel Sounds
B. Dysrhythmia
C. Homan's Sign
D. Hemoglobin Level
Correct answer
C. Homan's Sign
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What is a potential postoperative concern regarding a patient who has *2/2
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
The best position for kidney, chest, or hip surgery is: * 2/2
A. Supine
B. Trendelenburg
C. Lithotomy
D. Lateral
As a nurse, which statement is incorrect regarding an informed consent *2/2
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
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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
The nurse is admitting a patient to the operating room. Which of the *2/2
following nursing actions should be given highest priority by the nurse?
A. Assessing the patient’s level of consciousness
B. Checking the patient’s vital signs
C. Checking the patient’s identification and correct operative permit
D. Positioning and performing skin preparation to the patient
A patient is 6 days post-opt from abdominal surgery. The patient is to be *0/2
discharged later today. The patient uses the call light and asks you to
come to his room and look at his surgical site. On arrival, you see that
approximately 2 inches of internal organs are protruding through the
incision. What intervention would you NOT do?
A. Put the patient in prone position with knees extended to put pressure on the site
B. Cover the wound with sterile normal saline dressing
C. Monitor for signs of shock
D. Notify the MD and administer as prescribed antiemetic to prevent vomiting
Correct answer
A. Put the patient in prone position with knees extended to put pressure on the site
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