325 Perioperative Nursing

14. which client responses best support the decision to discharge the client from the postanesthesia care unit? 1. Sao2 of 95%, vital signs stable for 20 minutes, active gag reflex 2. tolerable pain, ability to move extremities, dry intact dressing 3. urinary output of 30 mL/hr, awake, turning from side to side 4. afebrile, adventitious breath sounds, ability to cough

1. Sao2 of 95%, vital signs stable for 20 minutes, active gag reflex

18. which is the most common dietary prescription the nurse can anticipate after a client who had abdominal surgery exhibits a return of intestinal peristalsis? 1. clear liquids 2. full liquids 3. low fiber 4. regular

1. clear liquids

16. A nurse is assessing a client who had spinal anesthesia. For which common response should the nurse assess the client? 1. headache 2. neuropathy 3. lower back discomfort 4. increased blood pressure

1. headache

10. which client having emergency surgery should the nurse anticipate to be at the highest risk for postoperative mortality? 1. individual who has alcoholism 2. person who has epilepsy 3. middle-age adult 4. infant

1. individual who has alcoholism

6. Which factor places a client at the highest risk for postoperative nausea and vomiting after receiving general anesthesia? 1. obesity 2. inactivity 3. hypervolemia 4. unconsciousness

1. obesity

21. a nurse is assessing a postoperative client. Which client response identified by the nurse indicates altered renal perfusion? 1. oliguria 2. cachexia 3. yellow sclera 4. suprapubic distention

1. oliguria

27. a postoperative client experiences tachycardia, sudden chest pain, and low blood pressure. Which complication associated with the postoperative period should the nurse conclude that the client most likely experienced? 1. pulmonary embolism 2. hemorrhage 3. heart attack 4. pneumonia

1. pulmonary embolism

25. a nurse is caring for 2 clients. One of the clients has a jackson-pratt drain and the other client has a Hemovac drain. Which does the nurse understand is the difference between these two drains? 1. the size of the collection container 2. how the pressure within the collection container is reestablished 3. the type of pressure that promotes drainage to the collection container 4. where the collection container should be place in relation to the insertion site

1. the size of the collection container

7. on the second postoperative day after an above-the-knee amputation, the client's elastic dressing accidentally comes off. Which should the nurse do first? 1. wrap the residual limb with an elastic compression bandage 2. apply a saline dressing to the residual limb 3. notify the primary health-care provider 4. place 2 pillows under the limb

1. wrap the residual limb with an elastic compression bandage

15. how many days after surgery should the nurse anticipate that a postoperative client will begin to exhibit signs and symptoms of a wound infection if it should occur? 1. 5th day 2. 3rd day 3. 9th day 4. 7th day

2. 3rd day

19. A nurse compares the advantages and disadvantages of a central venous catheter inserted into a peripheral vein and a central venous catheter inserted into a subclavian vein. Which of the following does the nurse conclude is the reason why a peripheral catheter is more desirable? 1. because it will not be in the superior vena cava 2. because it will not cause a tension pneumothorax 3. because it will not prevent the development of an infection 4. because it will not allow large volumes of fluid to be administered

2. because it will not cause a tension pneumothorax

3. a postoperative client is transferred back to the surgical unit with an abdominal dressing and a Penrose drain. Which is the most important nursing action associated with caring for a client with a Penrose drain? 1. removing the excess external portion until drainage stops 2. changing the soiled dressing carefully 3. maintaining the negative pressure 4. pinning the drain to the dressing

2. changing the soiled dressing carefully

29. a nurse is to apply a transparent wound barrier over a client's incision. Which nursing action is appropriate? 1. stretch the transparent dressing snugly over the entire wound 2. clean the skin with normal saline before applying the dressing 3. cover the transparent wound barrier with a gauze dressing and secure with paper tape 4. ensure the reinforcing tape extends several inches beyond the edges of the transparent wound barrier

2. clean the skin with normal saline before applying the dressing

22. a nurse is evaluating the effectiveness of nursing intervention for meeting the nutrient needs of clients during the first 2 days after abdominal surgery. Which outcome is most important? 1. nausea and vomiting have not occured 2. fluid and electrolytes are balanced 3. wound healing is progressing 4. oral intake is reestablished

2. fluid and electrolytes are balanced

1. There are discharge criteria for clients in the postanesthesia care unit (PACU) regardless of the type of anesthesia used and additional criteria for specific types of anesthesia. Which is the criterion specific for the client who has received spinal anesthesia? 1. oxygen saturation reaches the presurgical baseline 2. motor and sensory function returns 3. nausea and vomiting are minimal 4. headache is reported as tolerable

2. motor and sensory function returns

35. a nurse is performing preoperative teaching a week before surgery. The client is taking 650 mg of aspirin twice a day for arthritis. Which instruction should the nurse expect the surgeon to have the nurse include in the preoperative teaching? 1. continue to take the aspirin indefinitely 2. stop taking the aspirin 5 days before surgery 3. withhold the dose of aspirin on the morning of surgery 4. reduce the dose of aspirin to 81 mg a day until after surgery

2. stop taking the aspirin 5 days before surgery

13. a client arrives in the postanesthesia care unit. Which is the most important information that the nurse needs to know? 1. anxiety level before surgery 2. type and extent of the surgery 3. type of intravenous fluids administered 4. special requests that were expressed by the client

2. type and extent of the surgery

31. When should the nurse initiate planned interventions regarding a client's perioperative management? 1. when the consent form is signed 2. when the decision for surgery is made 3. when the client is admitted for surgery 4. when the client is transferred to the operating room

2. when the decision for surgery is made

9. A client received conscious sedation during a colonoscopy. Which should the nurse expect regarding the client's experience with the procedure? 1. client will be unresponsive and pain free 2. client will be at risk for malignant hyperthermia 3. client will be sleepy but able to follow verbal commands 4. client will be positioned in the supine position to prevent headache

3. client will be sleepy but able to follow verbal commands

8. A nurse is caring for a postoperative client. Which action is effective in preventing postoperative urinary tract infections? 1. eating foods with roughage 2. taking sitz baths twice a day 3. drinking an adequate amount of fluid 4. increasing the intake of citrus fruit juices

3. drinking an adequate amount of fluid

11. a nurse is caring for a client who had an abdominal hysterectomy. Which intervention best prevents postoperative thrombophlebitis? 1. utilization of compression stockings at night 2. deep breathing and coughing exercises daily 3. leg exercises 10 times per hour when awake 4. elevation of the legs on 2 pillows

3. leg exercises 10 times per hour when awake

24. a client's perineal area must be examined by the primary health-care provider prior to surgery. In which the position should the nurse place the client for this physical assessment? 1. sims 2. supine 3. lithotomy 4. trendelenburg

3. lithotomy

5. Four days after abdominal surgery, while being transferred from a bed to a chair, a client says to a nurse, "my incision feels funny all of a sudden." which should the nurse do first? 1. take the vital signs 2. apply an abdominal binder immediately 3. place the client in the low-fowler position 4. encourage slow deep breathing by the client

3. place the client in the low-fowler position

34. A nurse is considering the commonalities and differences of equipment used for gastric decompression. Which is the major advantage to using a double-lumen tube? 1. minimizes the risk of bowel obstruction 2. ensures drainage of the intestines 3. prevents gastric mucosal damage 4. promotes gastric rest

3. prevents gastric mucosal damage

30. a nurse is to position a client in the postanesthesia care unit. Which factor is most important for the nurse to consider? 1. allow for skeletal deformities 2. prevent pressure on bony prominences 3. provide for adequate thoracic expansion 4. avoid stretching of neuromuscular tissue

3. provide for adequate thoracic expansion

12. an obese client has abdominal surgery for removal of the gallbladder. Which should the nurse be most concerned about if exhibited by the client? 1. constipation 2. urinary retention 3. shallow breathing 4. inability to provide self-care

3. shallow breathing

23. which is the next most important assessment made by the nurse after ensuring a postoperative client has a patent airway? 1. condition of drains 2. level of consciousness 3. stability of the vital signs 4. location of the surgical dressing

3. stability of the vital signs

4. a client has abdominal surgery. Which should the nurse do to best assess for a sign of postoperatvie ileus in this client after surgery? 1. identify the time of the first bowel movement 2. monitor the tolerance of a clear liquid diet 3. palpate for abdominal distention 4. auscultate for bowel sounds

4. auscultate for bowel sounds

32. One hour after the reduction of a compound fracture of the ulna and radius and application of a cast, the nurse observes a centimeter circle of drainage on the client's cast. Which should the nurse do first? 1. inform the surgeon immediately 2. reinforce the cast with a gauze dressing 3. monitor the area frequently for expansion 4. circle the spot with a pen and date, time, and initial the area

4. circle the spot with a pen and date, time, and initial the area

36. a client has negative pressure would therapy (vacuum-assisted closure (VAC) after the amputation of a toe. The tube is connected to intermittent negative pressure. What should the nurse do when the film over the wound collapses when negative pressure is exerted? 1. notify the primary health-care provider 2. decrease the extent of negative pressure 3. apply a new transparent film over the wound 4. continue to observe the functioning of the device

4. continue to observe the functioning of the device

26. a nurse is caring for several clients who received general anesthesia. A client with which concurrent health problem poses the highest risk for the development of a postoperative complication? 1. gastroesophageal reflux disease 2. reduced reflexes 3. hypothyroidism 4. emphysema

4. emphysema

28. a client spikes a fever during the first postoperative day after major abdominal surgery. The nurse suspects that the fever indicates an infection. Which site does the nurse conclude most likely is the source of the infection? 1. intestines 2. bladder 3. wound 4. lungs

4. lungs

17. a hospitalized client who has been receiving medications via a variety of routes for several days is schedule for surgery at 10 am. Which should the nurse plan to do on the day of surgery? 1. use an alternative route for the oral medications 2. withhold all the previously prescribed medications 3. withhold the oral medications and administer the other drugs 4. obtain directions from the primary health care provider regarding the medications

4. obtain directions from the primary health care provider regarding the medications

20. a nurse is caring for a client who had abdominal surgery. Which type of incisional drainage should the nurse expect 4 hours after surgery? 1. serous wound drainage 2. purulent wound drainage 3. sanguineous wound drainage 4. serosanguineous wound drainage

4. serosanguineous wound drainage

33. A nurse is caring for a client with a nasogastric tube attached to suction. What is the most important nursing action in relation to the nasogastric tube? 1. using sterile technique when irrigating the tube 2. recording intake and output every 2 hours 3. providing oral hygiene every 4 hours 4. setting suction at the prescribed level

4. setting suction at the prescribed level

2. A client is admitted to the postanesthesia care unit. Which nursing action is most important during the client's stay in this unit? 1. monitoring urinary output 2. assessing level of consciousness 3. ensuring patency of drainage tubes 4. suctioning mucus from respiratory passages

4. suctioning mucus from respiratory passages

40. A client had a tonsilectomy and is on a soft diet. which of the following should the nurse encourage this client to have during the first 24 hours after surgery? select all that apply warm pudding milk shakes apple juice ice pops gelatin

apple juice ice pops gelatin

38. a nurse is caring for a client recovering from abdominal surgery. which nursing action is effective in facilitating ventilation. select all that apply encouraging fluid intake preventing abdominal distention positioning in the side-lying position implementing passive range-of motion exercises ensuring that an incentive spirometer is used every hour when awake

encouraging fluid intake preventing abdominal distention ensuring that an incentive spirometer is used every hour when awake

44. a client has a right abdominal incision. which should the nurse teach the client to do when getting out of bed? select all that apply exit from the left side of the bed ask the nurse to apply an abdominal binder hold a pillow against the abdomen with both hands use the left arm to push up to a sitting position on the side of the bed sit on the side of the bed for a few minutes before moving to a standing position

exit from the left side of the bed use the left arm to push up to a sitting position on the side of the bed sit on the side of the bed for a few minutes before moving to a standing position

42. A nurse is caring for a postoperative client. the client asks the nurse why vitamin c was prescribed by the primary health care provider. which information should the nurse include in a response to this question? select all that apply facilitates healing improves digestive processess increases transport of oxygen to cells encourages growth of red blood cells minimizes formation of deep vein thrombosis

facilitates healing

48. a nurse is caring for a postoperative client who had abdominal surgery. the client states "the incision just felt like it gave way" the nurse identifies that the client has a dehisence with slight eviceration. which of the following should the nurse implement. select all that apply instruct the client to avoid coughing or bending down notify the primary health care provider immediately position the client in the low-fowler position cover the incision with a sterile dressing prepare the client for surgery

instruct the client to avoid coughing or bending down notify the primary health care provider immediately position the client in the low-fowler position cover the incision with a sterile dressing prepare the client for surgery

48. which of the following independent and dependent nursing interventions help prevent thrombophlebitis during the postoperative period? select all that apply applying lower extremity sequential compression devices when in bed wearing antiembolism stockings when out of bed walking in the hall several times a day using an incentive spirometer coughing and deep breathing keeping the legs uncrossed

wearing antiembolism stockings when out of bed walking in the hall several times a day keeping the legs uncrossed

46. A nurse is teaching a postoperative client the nutrients that are the best for supporting collagen production that promotes wound healing. which food selected by the client indicates that the teaching was effective. select all that apply yellow bell peppers whole-grain bread cantaloupe oranges kiwi

yellow bell peppers cantaloupe oranges kiwi