Download Clinical Skills Review Workbook File

DEPARTMENT OF NURSING EDUCATION & HEALTH STUDIES
NURSING 3910
CLINICAL SKILLS REVIEW WORKBOOK
REVISED: 2012-08-29
CLINICAL SKILLS
REVIEW WORKBOOK
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DEPARTMENT OF NURSING EDUCATION & HEALTH STUDIES
NURSING 3910
CLINICAL SKILLS REVIEW WORKBOOK
REVISED: 2012-08-29
SUGGESTED SKILLS TO REVIEW / PRACTICE
ASSESSMENTS
Respiratory
Cardiovascular
Circulatory
Pain
Focused Abdominal
Neurological
Wound Care
PROCEDURES
Blood Glucose Monitoring
Aseptic Technique
Sterile Dressing Change
Suture / Staple Removal
Catheterization (M/F)
Venipuncture To Initiate IV
NG Tube Insertion / Care
Central Line Flush / Care
Programming An IV Pump
MEDICATION ADMINISTRATION
Mixing (2) Types of Insulin
Withdrawing From An Ampoule
Reconstituting Powder In A Vial
Adding Medication to a Minibag
Subcutaneous Injection Sites
Landmarking for IM Injections
Hanging A Secondary Med Bag
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DEPARTMENT OF NURSING EDUCATION & HEALTH STUDIES
NURSING 3910
CLINICAL SKILLS REVIEW WORKBOOK
REVISED: 2012-08-29
INJECTION VOLUME REVIEW
Complete the following chart:
TYPE OF INJECTION
SUBCUTANEOUS
INTRAMUSCULAR
INTRADERMAL
SYRINGE SIZE
GAUGE OF NEEDLE
MAXIMUM VOLUME OF
SOLUTION
RECOMMENDED SITES
OXYGEN THERAPY REVIEW
What is the difference between high flow and low flow 02?
What rate of 02 therapies can be administered by the following devices?
NASAL PRONGS
SIMPLE MASK
NON-REBREATHER MASK
MISTY OX
COLD NEB
CIRCULATION ASSESSMENT REVIEW
What does CWPMSS stand for? Discuss what you are assessing for with each section .
CWPMSSPAGE 3 / 19
DEPARTMENT OF NURSING EDUCATION & HEALTH STUDIES
NURSING 3910
CLINICAL SKILLS REVIEW WORKBOOK
REVISED: 2012-08-29
CATHETER CARE REVIEW
What are the most important assessments required for a client with an indwelling catheter?
1.
2.
3.
4.
5.
6.
What are some common complications that may occur with an indwelling catheter?
1.
2.
3.
4.
5.
6.
IV SOLUTIONS REVIEW
Complete the following chart on crystalloids:
CRYSTALLOIDS
CONCENTRATION
ACTION
POTENTIAL COMPLICATIONS
NS
0.9% NORMAL SALINE
LR
LACTATED RINGERS
1/2 NS
0.45% NORMAL SALINE
D5W
5% DEXTROSE IN WATER
D5W ½ NS
5% DEXTROSE IN ½ NS
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DEPARTMENT OF NURSING EDUCATION & HEALTH STUDIES
NURSING 3910
CLINICAL SKILLS REVIEW WORKBOOK
REVISED: 2012-08-29
IV THERAPY & MAINTENANCE REVIEW
Define & describe the following complications:
LOCAL
DEFINITION
CAUSE
SIGNS / SYMPTOMS
ACTION
DEFINITION
CAUSE
SIGNS / SYMPTOMS
ACTION
INFECTION
INTERSTITIAL /
INFILTRATION
PHLEBITIS
SYSTEMIC
THROMBUS
PULMONARY
EMBOLUS
PULMONARY
EDEMA
ANAPHYLAXIS
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DEPARTMENT OF NURSING EDUCATION & HEALTH STUDIES
NURSING 3910
CLINICAL SKILLS REVIEW WORKBOOK
REVISED: 2012-08-29
DIABETES REVIEW
1.
2.
3.
4.
5.
Hypoglycemia is a blood sugar less then?
a. 8 mmol/L
b. 3 mmol/L
c. 1mmol/L
d. 4 mmol/L
Hyperglycemia is a blood sugar more then?
a. 10
b. 12
c. 6
d. 8 mmol/L
A client who has insulin dependent diabetes, is sweating, grey in color, difficult to arouse, and shaky,
might have:
a. Severe hyperglycemia
b. Hyperglycemia
c. Hypoglycemia
d. Severe hypoglycemia
A client who again has insulin dependent diabetes has blurred vision, oliguria, and is always hungry ,
might have:
a. Severe hyperglycemia
b. Hyperglycemia
c. Hypoglycemia
d. Severe hypoglycemia
If you were the nurse of the client in the first scenario (severe hypoglycemia), what would your plan of
action be?
a. Notification of physician
b. Subcutaneous or intramuscular injection of glucagon
c. IV administration of 20-50 mL of dextrose 50% in water (D50W) given over 1-3min.
d. Diagnostics: blood glucose monitoring / health history
e. Determination of cause of hypoglycemia
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DEPARTMENT OF NURSING EDUCATION & HEALTH STUDIES
NURSING 3910
CLINICAL SKILLS REVIEW WORKBOOK
REVISED: 2012-08-29
INSULIN REVIEW
Match the term to the appropriate insulin
Terms
Type of Insulin
Onset
Peak
Duration
Intermediate
Humalog
15 m
60 m
4h
Combination /
Premixed
NPH
3- 4 h
6-12 h
18-28 h
Long Acting
R (Toronto)
30-60m
2-4 h
5-7 h
Short Acting
Lantus
1- 1 ½ h
no peak
24 h
Rapid
Novolin 30/70
30 min
4-8 h
24 h
Name the type of insulin suggested by the statements below:
This type of insulin is generally taken twice a day before meals and contains a combination of specific
proportions of insulin(s).
This type of insulin covers needs for meals eaten at the same time of the injection.
This type of insulin covers ½ the day or night and is often combined with rapid or short acting.
This is the only type of insulin that can be administered intravenously.
CARDIOVASCULAR REVIEW
1. Describe the Rational/ pathophysiology behind the prominent cardiovascular risk factors listed below.
a. Diabetes
b. Sedentary Lifestyle
c. Cocaine Use
d. High Cholesterol
e. Smoking Family Predisposition
f. Hypertension Alcohol Abuse
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DEPARTMENT OF NURSING EDUCATION & HEALTH STUDIES
NURSING 3910
CLINICAL SKILLS REVIEW WORKBOOK
REVISED: 2012-08-29
2. When performing a chest pain assessment it is important to take the Apical heart rate and not a radial
rate because:
a. It takes too long to feel a radial pulse
b. The Apex provides an accurate depiction of how the atria are functioning
c. The radial pulse may not be an accurate depiction of what the heart is doing
d. The Apex provides a base line for accessory sounds and rhythms
3. When a client is on Telemetry (inpatient cardiac monitoring) the following things must be ordered to
ensure best practice.
a. Saline lock, nitro, oxygen as needed, ECG daily
b. Saline lock, nitro , oxygen as needed, ASA , Routine vital signs
c. Saline lock, nitro, oxygen as needed, ECG with chest pain, vital signs QID with Apex
d. Saline lock, nitro , oxygen as needed, ASA , ECG daily
4. The difference between a STEMI and NSTEMI is?
a. The characteristics of the chest pain experienced and the depth of heart muscle involved
b. The location and severity of the chest pain experienced, the elevation of the T wave on an ECG
c. The elevation of the T wave on an ECG only
d. The elevation of the T wave on an ECG and the depth of heart muscle involved
5. Patients diagnosed with CAD (coronary artery disease) or are experiencing ACS (acute coronary
syndrome) are prescribed 5 medications. Discuss the importance of the 5 drug classes listed below in
relation to cardiovascular disease?
a. ECASA
b. Anticoagulants
c. Beta Blockers
d. ACE inhibitors / ARB
e. Statin/Dyslipidemic Agent
6. When performing an assessment after a patient has gone to Edmonton for an angiogram it is
important to take vitals for what reason?
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DEPARTMENT OF NURSING EDUCATION & HEALTH STUDIES
NURSING 3910
CLINICAL SKILLS REVIEW WORKBOOK
REVISED: 2012-08-29
7. Discuss below the importance of using acronyms such as OLDCART or PQRST when assessing chest
pain.
OLDCARTOR
PQRST8. Describe (6) nursing interventions you would implement after your patient has complained of chest
pain and you have assessed it.
1.
2.
3.
4.
5.
6.
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DEPARTMENT OF NURSING EDUCATION & HEALTH STUDIES
NURSING 3910
CLINICAL SKILLS REVIEW WORKBOOK
REVISED: 2012-08-29
9. Sustained tachycardia is a concern for patients because:
a. The faster the heart beats the less chance it has to fill
b. The faster the heart beats the more oxygen it requires
c. The faster the heart beats the less time there is between contractions, the less blood enters the
coronary arteries decreasing oxygen and nutrient availability to the heart.
d. Tachycardia is physically exhausting, like exercising 24 hours a day
10. Describe which two vital signs will provide you with the most information about a patients
cardiovascular status?
1.
2.
MEDICAL REVIEW QUESTIONS
1. Bleeding of which of the following locations would constitute an upper GI bleed?
a. Jejunum
b. Duodenum
c. Ilium
d. Colon
2. Which of the following terms means bright red blood found in the feces?
a. Hematochezia
b. Hematemisis
c. Melena
d. Melemesis
3. Which of the following is a sign of a brisk upper GI bleed?
a. Hematochezia
b. Melena
c. Hematemesis (Bloody vomitus; fresh, bright red blood)
d. “Coffee- grounds” emesis
4. Which is the most common cause of upper GI bleeds?
a. Gastric ulcer hemorrhage
b. Duodenal Ulcer
c. Diverticulosis
d. Peptic Ulcer
5. Gastroesophageal Variceal Bleeding… [Med/Surg – pg. 1177-1180]
a. Is a minor disease with low mortality
b. Has a fatality rate of about 5%
c. Leads to death only if untreated for long periods of time
d. Has a high mortality rate – from 30% to 50%
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DEPARTMENT OF NURSING EDUCATION & HEALTH STUDIES
NURSING 3910
CLINICAL SKILLS REVIEW WORKBOOK
REVISED: 2012-08-29
6. Which would be a sign of a brisk lower GI bleed?
a. Melena
b. Hematemisis
c. Coffee ground emesis
d. Hematochezia
7. The order of a bowel assessment is inspection, auscultation, percussion, palpation for what reason?
8. Acute upper bowel obstructions create what type of noise?
a. Gurgling (normal)
b. Tinkling, high pitched
c. Clicking (normal)
d. Wheezing
9. Diarrhea is common when patients are on antibiotics due to what cause?
10. Iron supplements often cause stool to appear? Should this appearance concern you?
11. What could be another cause of stool discoloration?
12. A history of excessive use of NSAIDs followed by sharp mid epigastric pain would lead you to suspect?
SURGICAL REVIEW QUESTIONS
1.
2.
During the preoperative interview, a client scheduled for an elective hysterectomy to treat benign
tumours of the uterus tells the nurse that she does not know whether she can go through with the
surgery because she knows she will die in surgery, as her mother did. What is the most appropriate
response?
a. “Tell me more about what happened to your mother.”
b. “Have you discussed these feelings with anyone else?”
c. “I am sure surgical techniques have improved since your mother had surgery.”
d. “Think positively! Positive thoughts have been shown to influence a positive surgical outcome.”
A 36-year-old woman has been admitted to the hospital for knee surgery. Which of the following
information that was obtained by the nurse during the preoperative assessment should be reported to
the surgeon before surgery is performed?
a. Lack of knowledge about postoperative pain control
b. Knowledge of the possibility of an early, unplanned pregnancy
c. History of a postoperative infection following a prior cholecystectomy
d. Concern that she will be physically limited in caring for her children for a period postoperatively
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DEPARTMENT OF NURSING EDUCATION & HEALTH STUDIES
NURSING 3910
CLINICAL SKILLS REVIEW WORKBOOK
REVISED: 2012-08-29
3.
4.
5.
6.
7.
During a preoperative assessment, which of the following reported allergies does the nurse recognize
as a risk for latex allergy in the client?
a. Iodine
b. Penicillin
c. Eggs and milk
d. Avocados and bananas
Why is it especially important for the nurse to determine the client’s current use of medications during
the preoperative assessment?
a. These medications may alter the client’s perceptions about surgery.
b. Anaesthetics alter renal and hepatic function, causing toxicity by other drugs.
c. Other medications may cause interactions with anaesthetics, altering the potency and effect of
the drugs.
d. Routine medications are usually withheld the day of surgery, requiring dosage and schedule
adjustments.
Sarah, 46, is in the preoperative assessment area awaiting surgery. She is wringing her hands and
perspiring and has a worried affect. The nurse’s communication with Sarah is based on the knowledge
that the most prevalent fear of clients awaiting surgery is which of the following?
a. Pain
b. Altered body image
c. Potential for death
d. Results of the procedure
What is it especially important for the nurse to do when performing a physical examination of a client
who smokes and who is preparing for surgery?
a. Calculate the pack-years of smoking history.
b. Auscultate the lungs for normal and adventitious breath sounds.
c. Encourage the client to stop smoking during the postoperative period.
d. Tell the client that smoking increases the risk for postoperative respiratory complications.
What does appropriate preoperative teaching for a client scheduled for abdominal surgery include?
a. How to care for the wound
b. How to breathe deeply and cough
c. What medications will be used during surgery
d. What drains and tubes will be present after surgery
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DEPARTMENT OF NURSING EDUCATION & HEALTH STUDIES
NURSING 3910
CLINICAL SKILLS REVIEW WORKBOOK
REVISED: 2012-08-29
8.
An 82-year-old man is admitted to the hospital the evening before a prostatectomy for cancer of the
prostate. He is alert and oriented but has difficulty seeing and hearing. His wife is at his bedside and
answers most questions directed to the client. What should the nurse do to accomplish preoperative
teaching with the client?
a. Use printed materials for instruction because the client does not hear well.
b. Direct the teaching toward the wife because she is the obvious support and caregiver for the
client.
c. Provide additional time for the client to understand preoperative instructions and carry out
procedures.
d. Ask the client’s wife to wait in the hall in order to focus on preoperative teaching with the client
himself.
9. A client with diabetes that is well controlled with insulin injections has been on nothing by mouth
(NPO) status since midnight before having a mastectomy. The nurse notes that there are no
preoperative orders regarding the client’s daily insulin dose. What is the most appropriate nursing
action?
a. Withhold any insulin dose because none is ordered and the client is NPO status.
b. Call the physician to clarify whether insulin should be given and at what dosage.
c. Give the client half of her usual daily insulin dose because she will not be eating in the morning.
d. Give the client her usual daily insulin dose because the stress of surgery will increase her blood
glucose level.
10. A preoperative client’s complete blood count (CBC) results include red blood cell count 4.6 × 106/µL;
white blood cell count 10.2 × 103/µL; hemoglobin 9.3 mmol/L (15 g/dL); hematocrit 45%; and platelets
150 × 103/µL. What do these results indicate to the nurse?
a. The client has impaired oxygen-carrying capacity of the blood.
b. The client is at risk for intraoperative or postoperative bleeding.
c. The client has an infection that could require IV antibiotics during surgery.
d. The client has no obvious risk for complications related to blood cell function.
11. Five minutes after receiving a preoperative sedative medication by IV injection, a client asks the nurse
if he get up to go to the washroom and urinate. Which of the following is the most appropriate action
for the nurse to take?
a. Assist client to bathroom and stay next to the door to assist client back to bed when he is done.
b. Allow the client to go to the washroom, since the onset of the medication will be more than 5
minutes.
c. Offer the client the use of a urinal/bedpan after explaining the need to maintain safety.
d. Ask client to hold his urine for a short period of time, since a urinary catheter will be placed in
the operating room.
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DEPARTMENT OF NURSING EDUCATION & HEALTH STUDIES
NURSING 3910
CLINICAL SKILLS REVIEW WORKBOOK
REVISED: 2012-08-29
12. As the nurse is preparing a client for surgery, the client refuses to remove her wedding ring. Which of
the following is the most appropriate action by the nurse?
a. Note the presence of the ring in the nurse’s notes on the chart.
b. Insist the client remove the ring.
c. Explain that the hospital will not be responsible for the ring.
d. Tape the ring securely to the finger.
13. While the nurse is performing preoperative teaching, the client asks when she needs to stop drinking
water before the surgery. Based on the most recent practice guidelines established by the Canadian
Anesthesiologists' Society, what should the nurse tell the client?
a. She must be NPO after breakfast.
b. She needs to be NPO after midnight.
c. She can drink clear liquids up to 2 hours before surgery.
d. She can drink clear liquids up until she is taken to the OR.
14. The nurse is admitting a client to the same-day surgery unit. The client tells the nurse that he was so
nervous he had to take kava the previous evening, to help him sleep. Which of the following nursing
actions would be most appropriate in this instance?
a. Inform the anaesthesiologist of the client’s ingestion of kava.
b. Tell the client that using kava to help him sleep was a good idea.
c. Tell the client that the kava should continue to help him relax before surgery.
d. Inform the client about the dangers of taking herbal medicines without first consulting his health
care provider.
15. The nurse would be alerted to the occurrence of malignant hyperthermia when the client
demonstrates which of the following?
a. Hypocapnia
b. Muscle rigidity
c. Decreased body temperature
d. Confusion upon arousal from anaesthesia
16. Before admitting a client to the operating room, the nurse recognizes that which one of the following
must be attached to the chart for all clients?
a. A functional status evaluation
b. Renal and liver function tests
c. A physical examination report
d. An electrocardiogram
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DEPARTMENT OF NURSING EDUCATION & HEALTH STUDIES
NURSING 3910
CLINICAL SKILLS REVIEW WORKBOOK
REVISED: 2012-08-29
17. Unless contraindicated by the surgical procedure, which of the following positions is preferred for the
unconscious client immediately postoperative?
a. Supine
b. Lateral
c. Semi-Fowler’s
d. High-Fowler’s
18. A postoperative client is transferred from the postanaesthesia unit to the medical-surgical nursing
floor. The nurse notes that the client has an order for D5 ½ NS to infuse at 125 mL/hr. Until an IV pump
is available, the nurse regulates the IV flow rate at which of the following drops/min, noting that the
tubing has a drop factor of 10 drops/mL?
a. 13 drops/min
b. 31 drops/min
c. 25 drops/min
d. 21 drops/min
19. The nurse is preparing to administer cefazolin (Ancef) 2 g in 100 mL IVPB to a postoperative client.
Which of the following IV rates will infuse this medication over 20 minutes?
a. 100 mL/hr
b. 150 mL/hr
c. 200 mL/hr
d. 300 mL/hr
20. The nurse is working on a surgical floor and is preparing to receive a postoperative client from the
postanaesthesia unit. Which of the following should be the nurse's initial action upon the client's
arrival?
a. Check the physician’s postoperative orders.
b. Assess the client’s pain.
c. Check the rate of the IV infusion.
d. Assess the client’s vital signs.
21. When assessing a client's surgical dressing on the first postoperative day, the nurse notes new brightred drainage about 5 cm in diameter. In response to this finding, the nurse should do which of the
following?
a. Assess the client’s blood pressure and heart rate.
b. Remove the dressing and assess the surgical incision.
c. Recheck the dressing in 1 hour for increased drainage.
d. Notify the surgeon of a potential hemorrhage.
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DEPARTMENT OF NURSING EDUCATION & HEALTH STUDIES
NURSING 3910
CLINICAL SKILLS REVIEW WORKBOOK
REVISED: 2012-08-29
22. In planning postoperative interventions to promote ambulation, coughing, deep breathing, and
turning, the nurse recognizes that which of the following actions will best enable the client to achieve
the desired outcomes?
a. Giving the client positive feedback when the activities are completed.
b. Administering adequate analgesics to promote relative freedom from pain.
c. Warning the client about possible complications if the activities are not performed.
d. Asking the client to verbalize understanding of and demonstrate performance of activity.
23. On admission of a client to the postanaesthesia care unit (PACU) from surgery, the nurse should place
the highest priority on assessing which of the following?
a. The condition of the surgical site
b. The client’s level of consciousness
c. The adequacy of respiratory function
d. The status of fluid and electrolyte balance
24. A 42-year-old client is recovering from anaesthesia in the PACU following a hysterectomy. Her
preoperative blood pressure was 120/68 mm Hg, and on admission to the PACU, her blood pressure
was 124/70 mm Hg. Thirty minutes after admission, her blood pressure falls to 112/60 mm Hg. Her
pulse is 72 beats/min, and her skin is warm and dry. What is the most appropriate nursing action at this
time?
a. Administer oxygen therapy per mask.
b. Notify the anaesthesiologist immediately.
c. Increase the rate of the client’s intravenous (IV) fluid replacement.
d. Continue to monitor the client, taking vital signs every 15 minutes.
25. A 70-year-old client becomes restless and agitated as he begins to regain consciousness in the PACU,
and his SpO2 is 88%. What is the most common cause of hypoxemia during anaesthesia recovery that
the nurse bases her knowledge on to intervene?
a. Atelectasis
b. Bronchospasm
c. Pulmonary edema
d. Aspiration of gastric contents
26. During recovery from anaesthesia in the PACU, a client’s vital signs for the past hour have been as
follows: blood pressure 112/82, 110/82, 112/80, and 114/82 mm Hg; pulse 76, 78, 78, and 80
beats/min; and respirations 22, 24, 24, and 26 breaths/min; her SpO2 is 90%. She is sleepy but
awakens easily and is oriented when spoken to. Her surgical dressing is dry and intact. What is the
most appropriate nursing action?
a. Position the client in a lateral position.
b. Encourage the client to take deep breaths.
c. Check the client’s temperature and apply warm blankets.
d. Notify the anaesthesiologist that the client is ready for discharge from the PACU.
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DEPARTMENT OF NURSING EDUCATION & HEALTH STUDIES
NURSING 3910
CLINICAL SKILLS REVIEW WORKBOOK
REVISED: 2012-08-29
27. When a postoperative client in the PACU complains of pain at the incision site, what should the nurse
do?
a. Administer analgesics as written in the client’s postoperative orders.
b. Administer half of the postoperative dose of analgesic ordered for the client.
c. Tell the client that pain medication cannot be given until transfer to the postoperative clinical
unit.
d. Consult with the anaesthesiologist to determine an effective, reduced dose of an analgesic for
the client.
28. While assessing clients for complications during recovery from anaesthesia, the nurse recognizes that
which of the following clients is at the greatest risk for developing postoperative hypothermia?
a. A 78-year-old female client undergoing a vaginal hysterectomy under general anaesthesia
b. A 58-year-old male client undergoing repair of a knee cartilage under general anaesthesia
c. A 68-year-old female client with diabetes undergoing a great toe amputation under local
anaesthesia
d. A 72-year-old male client undergoing bowel resection for colon cancer under general
anaesthesia
29. A client’s blood pressure in the PACU has dropped from an admission blood pressure of 138/84 to
110/78 mm Hg, with a pulse change of 68 to 84 beats/min. What is the first nursing action to be
performed?
a. Administer oxygen.
b. Assess for a full bladder.
c. Auscultate the client’s lungs.
d. Check the client’s temperature.
30. A client who had abdominal surgery 2 days ago has orders for morphine sulphate 4 mg IV q2h and a
clear liquid diet. The client tells the nurse that she feels distended and has sharp, cramping gas pains.
What is the most appropriate intervention in response to the client’s complaint?
a. Obtain an order for a laxative.
b. Withhold all oral fluid and food.
c. Assist the client to ambulate in the hall.
d. Administer the prescribed morphine sulphate.
31. Postoperatively, a client is receiving low–molecular weight heparin (LMWH). What should the nurse do
when administering this drug?
a. Explain that the drug will help prevent clot formation in the legs.
b. Administer the dose with meals to prevent GI irritation and bleeding.
c. Check the results of the partial thromboplastin time before administration.
d. Inform the client that blood will be drawn every 6 hours to monitor the prothrombin time.
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DEPARTMENT OF NURSING EDUCATION & HEALTH STUDIES
NURSING 3910
CLINICAL SKILLS REVIEW WORKBOOK
REVISED: 2012-08-29
32. Following gallbladder surgery, a client has a T-tube with thick, dark green drainage. When the client
asks about the tube and the drainage, what is the nurse’s best response?
a. “The tube you see has been placed in the bile duct, and the drainage is normal bile.”
b. “The drainage is from your gallbladder, but it should be bright yellow rather than green.”
c. “The drainage is old blood and fluid that accumulates at the surgical site, and its removal will
promote healing.”
d. “The tube is draining secretions from the duodenum and small bowel, and this is normal
drainage from this area.”
33. A postoperative client has not voided for 7 hours after return to the postsurgical unit. Initially, what
should the nurse do?
a. Call the physician.
b. Palpate and percuss the bladder.
c. Ambulate the client to the bathroom.
d. Check the postoperative orders for catheterization orders.
34. While caring for a client with abdominal surgery the first postoperative day, the nurse notices new
bright red drainage about 6 cm in diameter on his dressing. In response to this finding, what should the
nurse do first?
a. Take the client’s vital signs.
b. Notify the surgeon of a potential hemorrhage.
c. Remove the dressing and assess the surgical incision.
d. Recheck the dressing every 8 hours for increased drainage.
35. During planning to promote ambulation, coughing, deep breathing, and turning in a postoperative
client, which of the following does the nurse know will help ensure that the desired outcomes will
most readily be met?
a. The client understands the rationale for these activities.
b. The client receives praise when the activities are completed.
c. The client receives enough analgesics to promote relative freedom from pain.
d. The client is warned about complications that can occur without the activities.
36. How does the nurse evaluate the outcomes for the nursing diagnosis of ineffective airway clearance for
a postoperative client?
a. By observing the client’s use of the incentive spirometer
b. By taking vital signs, including temperature, every 4 hours
c. By measuring the client’s SpO2 following respiratory interventions
d. By auscultating breath sounds before and after respiratory exercises
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DEPARTMENT OF NURSING EDUCATION & HEALTH STUDIES
NURSING 3910
CLINICAL SKILLS REVIEW WORKBOOK
REVISED: 2012-08-29
37. While caring for a postoperative client, what should the nurse expect that a physiological response to
stress during the first 2 to 5 days postoperatively will result in?
a. Tachycardia
b. Hyperventilation
c. Fluid retention with decreased urinary output
d. An elevation of body temperature to 38.3°C
38. To teach a postoperative client to breathe deeply and cough, how should the nurse instruct the client?
a. Take a deep breath, hold it 5 seconds, and force the air from the lungs in a cough.
b. Use a spirometer to measure the depth of inhalation and cough into the spirometer, noting the
amount of air coughed out.
c. Place the hands on the upper abdomen and inhale slowly through the nose 10 to 12 times an
hour, coughing after each deep breath.
d. Inhale slowly through the nose, hold the breath a few seconds, and exhale slowly through the
mouth, coughing after every four to six breaths.
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