Fundamentals of Nursing
A.Bowel Sounds.
B.Dysrhythmia.
C. Homan's Sign.
D. Hemoglobin Level.
2. 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.
3. 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.
4. The nurse is monitoring the patient who is 24 hours post-opt from surgery. Which finding requires intervention: ?
A. BP 100/80 .
B. 24-hour urine output of 300 ml
C. Pain rating of 4 on 1-10 scale .
D. Temperature of 99.3' F .
5. A patient is 6 days post-opt from abdominal surgery. The patient is to be 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
6. A patient reports he hasn't had a bowel movement or passed gas since 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
B. Administer IV fluids
C. Encourage ambulation, maintain NPO status, and monitor intake & output
D. Encourage at least 3000 ml of fluids per day
7. 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
8.A nurse is developing a care plan for a patient who is at risk for 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 3-4 hours
9.When assessing your patient who is post-opt, you notice that the patient's 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
10. A patient is recovering from surgery. The patient is very restless, heart rate is 120 bpm and blood pressure is 70/53, skin is cool/clammy. As the nurse you would ?
A. Continue to monitor the patient
B. Notify the MD
C. Obtain an EKG
D. Check the patient's blood glucose