You are the nurse caring for 82 year old women in the PACU. The woman begins to awaken and responds to her name but is confused, restless and agitated.

424. You are the nurse caring for 82 year old women in the PACU. The woman begins to awaken and responds to her name but is confused, restless and agitated. What are you aware of? A. Postoperative confusion is an indication of an oxygen problem or possibly a stroke during surgery. B. Confusion, restlessness, and agitation are normal postoperative findings and will diminish in time C. Postoperative confusion is common in the elderly, but it could also indicate a significant blood loss D. Confusion, restlessness, and agitation indicate inadequate pain management, and analgesics will help/

425. You admit a patient to the postanesthesia care unit with a blood pressure of 130/90 and a pulse of 68 per minute. After 30 minutes, the patient’s blood pressure is 120/65, and pulse is 100. You document the patient’s skin as cold and pale. What patient showing signs of? A. Hypothermia B. Hypovolemic shock C. Neurogenic shock D. Malignant hypothermia

426. You are caring for a postoperative patient on the medical-surgical unit. During each patient assessment, you evaluate for patient for infection. Which signor symptom would be most indicative of infection? A. Presence of an indwelling urinary catheter B. Rectal temperature of 100 degree F ( 37.8 degree C C. Red, warm, tender incision D. White blood cell (WBC. count of 8,000 mL

427. You admit a patient to the PACU who has undergone a surgical procedure that required the use of general anesthesia. What is the patient most at risk for following general anesthesia? A. Atlectasis B. Anemia C. Dehydration D. Peripheral edema

428. The registered nurse had just admitted a client with severe depression. What domain should be the priority focus as the nurse identifies the nursing diagnoses? A. Nutrition B. Elimination C. Activity D. Safety

430. The nurse is caring for a client in the coronary care unit. The display on the cardiac monitor indicates ventricular fibrillation. What should the nurse do first? A. Perform defibrillation

441. The nurse is preparing to perform a physical examination on an 8-month old who is sitting contently on his mother’s lap. Which of the following should the nurse do first? A. Elicit reflexes B. Measure height and weight C. Ausculate heart and lungs D. Examine the ears

442. A client is unconscious following a tonic-clonic seizure. What should the nurse do first? A. Check the pulse
B. Administer valium C. Place the client in a side-lying position D. Place a tongue blade in the mouth

443. When counseling parents of a child who has recently been diagnosed with hemophilia, what must the nurse know about the offspring father and a carrier mother? A. It is likely that all sons are affected B. There is a 50% probability that sons will have the disease C. Every daughter is likely to be a carrier D. There is a 25% chance a daughter will be a carrier

444. The nurses on a unit are planning for stoma care for clients who have a stoma for fecal diversion. Which stomal diverionposes the highest for skin breakdown A. Illeostomy B. Transverse colostomy C. Illeal conduit D. Sigmoid colostomy

445. The nurse is assessing a client with delayed wound healing. Which of the following risk factors is most important in this situation? A. Glucose level of 120 B. History of myocardial infarction C. Long term steroid usage D. Diet high in carbohydrates.

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