ATI Perioperative _ 2020 – Rasmussen College | ATI Perioperative _ 2020

ATI Perioperative _ 2020 – Rasmussen College A circulating nurse is monitoring the temperature in a surgical suite. The nurse should identify that cool temperatures reduce a client's risk for which of the following pot ...

ATI Perioperative _ 2020 – Rasmussen College A circulating nurse is monitoring the temperature in a surgical suite. The nurse should identify that cool temperatures reduce a client's risk for which of the following potential complications of surgery? malignant hyperthermia blood clots infection hypoxia Infection The nurse should identify that a cool room temperature with humidity between 30% and 60%, along with a proper air exchange and filtering system, reduces the risk of infection for clients during surgery. A client had an open transverse colectomy 5 days ago. The nurse enters the client's room and recognizes that the wound has eviscerated. After covering the wound with a sterile, saline-soaked dressing, which of the following actions should the nurse take? Go to the nurses station to seek assitance Reinsert the organs into the abdominal cavity Place the client in revere Trendelenburg position Obtain vital signs to assess for shock Obtain vital signs to assess for shock The nurse should obtain vital signs to assess the client's current status.A client is transferred from the surgical suite to the PACU following oral surgery. While monitoring the client's vital signs, the nurse finds that the client's tongue has become swollen and is obstructing the airway. Which of the following actions should the nurse take first? Contact the anesthesiologist - - - - - - - - - - - - - - - - - - - --h of the following actions should the nurse take? Apply an ice pack to the clients right calf Elevate the clients right extremity Administer testosterone to the client Gently massage the clients right calf Elevate the clients right extremity These findings suggest the client has deep-vein thrombosis. The nurse should keep the client's right extremity elevated to promote venous return. A nurse is assessing a client who is 2 hr postoperative following an appendectomy. Which of the following findings should the nurse report to the provider? Urine output of 20mL/hr Temp of 36.5 A 2cmX2cm area bloody drainage on the dressing WBC 9,000 mm3Urine output of 20mL/hr The nurse should notify the provider if the client's urine output is less than 30 mL/hr. Decreased output can indicate hypovolemia and decreased perfusion of the kidneys. A nurse is assessing a client who is preoperative. The nurse should identify that which of the following factors reported by the client increases the risk for a postoperative wound infection? Frequent use of echinacea Long-term use of corticosteroids History of osteoporosis Diet high in Vit C Long-term use of corticosteroids The nurse should identify that the use of corticosteroids inhibits leukocyte response, which increases the client's risk for infection. A nurse is caring for a client who has a surgical wound with a Penrose drain in place. Which of the following interventions should the nurse plan to perform? Cut a slit in a 4in quake gauze pad to place around the drain Use the sterile technique when preforming dressing changes Establish a clamping schedule prior to removal Apply negative pressure when emptying the drain The nurse should change the Penrose drain dressing using the surgical aseptic technique. gauze should never be used as its fibers can become embedded in the woundclamping can lead to infection and a Penrose drain is and open system that drains by gravity A nurse is caring for a client who has bradycardia following a surgical procedure using spinal anesthesia. The nurse should plan to administer which of the following medications to the client? Amiodarone Propranolol Methyldopa Epinephrine Epinephrine The nurse should plan to administer epinephrine, a vasopressor, to increase the client's heart rate and prevent cardiac arrest. A nurse is caring for a client who is 2 days postoperative following a cholecystectomy. The client has been vomiting for the past 24 hr and reports a pain level of 8 on a scale from 0 to 10. The nurse notes a hard, distended abdomen and absent bowel sounds. After conferring with the provider, which of the following actions should the nurse take first? Draw the clients blood for electrolytes Insert an NG tube Administer pain medication Initiate intake and output Insert an NG tube The greatest risk to the client is fluid and electrolyte imbalance as a result ofaccumulated fluid and gas in the gastrointestinal tract. The first action the nurse should take is to insert an NG tube to begin decompression of the bowel. A nurse is caring for a client who is 12 hours postoperative from a gastrectomy and has an NG tube set to continuous low suction. Which of the following findings requires intervention by the nurse? Gastric distension Absent bowel sounds Urine output of 150 mL over the last 4 hrs Yellow drainage in the NG tube Gastric distension Gastric distention is an indication that the NG tube is not patent. The nurse should check the tubing for kinks, blockages, and loose connections. The nurse should also reposition the client to facilitate drainage. The nurse should avoid removing or irrigating the tube unless directed to do so by the surgeon. A nurse is caring for a client who is postoperative following abdominal surgery. Which of the following nursing interventions should the nurse perform to prevent respiratory complications? Instruct the client to exhale into the incentive spirometer every 1 to 2 hrs Minimize the amount of pain medication the client receives to prevent sedation Advise the client to splint the surgical incision when coughing and deep breathing Reposition the client very 8hr for the first 48hr Advise the client to splint the surgical incision when coughing and deep breathingSplinting the incision supports the surgical site and decreases pain during coughing and deep breathing. A nurse is caring for a client who is preoperative and is asking multiple question about risk of the procedure. Which of the following actions should the nurse take? Explain the risk and benefits of the surgery to the client Ask the surgeon to speak to the client for clarification Reassure the client that the procedure is necessary for recovery Notify the circulating nurse that the client has questions about the procedure Ask the surgeon to speak to the client for clarification The nurse should notify the surgeon that the client has questions about the procedure. It is the responsibility of the surgeon to explain the risks and benefits of the surgery A nurse is caring for a client who is receiving moderate (conscious) sedation with midazolam. The client's respiratory rate decreases from 16/min to 6/min, and the oxygen saturation decreases from 92% to 85%. Which of the following medicaitons should the nurse administer? Atropine Acetylcysteine Flumazenil Protamine sulfate Flumazenil The client's respiratory rate and oxygen saturation level indicate increased sedation caused from a benzodiazepine. The nurse should administer flumazenil, a benzodiazepine agonist, to reverse the sedative effects of the medication.A nurse is creating a plan of care for a client who is preoperative for a total hip arthroplasty, practices Judaism, and adheres to a kosher diet. Which of the following interventions is the nurse's priority? Listen and allow the client to express feelings about the surgery Determine if the clients faith conflicts with the treatment plan Ensure the clients meal plan serves only kosher food following the surgery Tea- - - - - - - - - - - - - - - - - - - - The nurse should identify that clopidogrel is an oral antiplatelet medication used to prevent coronary artery stenosis and other vascular incidents. Therefore, the mediation should be discontinued 5 days prior to surgery because it acts similarly to aspirin and can cause the client to experience increased bleeding during and after surgery. A surgical nurse enters a surgical suite to ensure surgical asepsis is maintained. Which of the following findings requires intervention by the nurse?The scrub technologist is wearing a watch under his scrubs The circulating nurse opens dressing packages before applying sterile gloves the surgeon has her hands folded 5 cm above her waist The holding area nurse is preforming client education The scrub technologist is wearing a watch under his scrubs Finger and wrist jewelry are likely contaminated with microorganisms and bacteria. Therefore, the scrub technologist should remove jewelry before handling sterile objects A nurse is assessing a client who received a preoperative IV dose of metoclopramide 1 hr ago. For which of the following findings should the nurse notify the provider? a) dry mouth b) muscle rigidity c) tinnitus d) diarrhea b) Muscle rigidity. Explanation: • Metochlopromide is used a drug of choice for GERD,vomiting,heartburn etc. • Muscle rigidity is a serious side effect of metochlopromide which leads to problems in body positioning and movement. • So the nurse should notify the physician if muscle rigidity occurs after metochlopromide administration. A client had an open transverse colectomy 5 days ago. The nurse enters the client's room and recognizes that the wound has eviscerated. After covering the wound with a sterile, saline-soaked dressing, which of the following actions should the nurse take? A. Go to nurses' station to seek assistanceB. Reinsert the organs into the abdominal cavity. C. Place client in reverse Trendelenburg position D. Obtain V/S to assess for shock. D. Obtain V/S to assess for shock. Rationale: Nurse should obtain V/S to assess pts current status.