326 PrepU: surgical client quiz

The nurse is admitting a client to the medical-surgical unit from the PACU. What should the nurse do to help the client clear secretions and help prevent pneumonia?

Encourage the client to use the incentive spirometer every 2 hours

Which action should a nurse perform to prevent deep vein thrombosis when caring for a postsurgical client?

reinforce the need to perform leg exercises every hour when awake

The patient asks the nurse why food is withheld before surgery. What is the best response by the nurse?

"Aspiration is a concern and can be a complication if food or fluid is taken close to the surgery time."

The circulating nurse is performing a skin preparation for a client who is unconscious from general anesthesia when the scrub nurse states, "I know her, she sure has gotten fat!" What is the best response by the circulating nurse?

"It is inappropriate to make comments even when clients appear to be unconscious from anesthesia."

The client asks the nurse how the spinal anesthesia will be administered. What is the best response by the nurse?

"The anesthesiologist will inject the anesthetic into the space around your lower spinal cord."

A client has been transported to the operating room for emergent surgery. Which statement by the nurse best supports the need for emergent surgery?

"The client was unresponsive, had a distended abdomen, and had unstable vital signs after a motor vehicle accident."

The nurse is completing a preoperative assessment. The nurse notices the client is tearful and constantly wringing their hands. The client states, "I'm really nervous about this surgery. Do you think it will be ok?" What is the nurse's best response?

"What are your concerns?"

The parent of a 16-year-old client asks the nurse, "How could the surgeon operate without my consent?" What is the best response by the nurse?

"Your child had life-threatening injuries that required immediate surgery."

The nurse in preadmission testing is educating a client about a scheduled surgery. Which response should the nurse give when the client asks about pain management following surgery?

"Your nurse will use a pain assessment scale to help rate and treat your pain."

In the immediate postoperative period, vital signs are taken at least every

15 minutes

A nurse is caring for a client with a postoperative wound evisceration. Which action should the nurse perform first?

Cover the protruding internal organs with sterile gauze moistened with sterile saline solution

The nurse is aware that a religious group that refuses blood transfusions for religious reasons is:

Jehovah's Witnesses

A nurse on the surgical team has been assigned the role of scrub nurse. What action by the scrub nurse is appropriate?

Handing instruments to the surgeon and assistants

A nurse is providing preoperative teaching to a client who will soon undergo a cardiac bypass. The nurse's teaching plan includes exercises of the extremities. What is the purpose of teaching a client leg exercises prior to surgery?

Leg exercises improve circulation and prevent venous thrombosis

Following admission of the postoperative client to the clinical unit, which of the following assessment data requires the most immediate attention?

Oxygen saturation of 82%

The nurse has administered preanesthetic medication. What action should the nurse take next?

Place the client on bed rest with the side rails up

The nurse is educating a client scheduled for elective surgery. The client currently takes aspirin daily. What education should the nurse provide with regard to this medication?

Stop taking the aspirin 7 days before the surgery, unless otherwise directed by your physician

The nurse is planning care for a client following abdominal surgery. Which outcome demonstrates a return of functioning to the gastrointestinal tract?

The client reports a small bowel movement and flatus

A client waiting in the presurgical holding area asks the nurse, "Why exactly do they have to put a breathing tube into me? My surgery is on my knee." What is the best rationale for intubation during a surgical procedure that the nurse should describe?

The tube provides an airway for ventilation

The circulating nurse is admitting a client prior to surgery and proceeds to greet the client and discuss what the client can expect in surgery. Which aspect of therapeutic communication should the nurse implement?

Use a tone that decreases the client's anxiety

Which of the following sets of clinical data would allow the nurse to conclude that the nursing actions taken to prevent postoperative pneumonia have been effective?

Vital signs within normal limits; absence of chills and cough

At what point does the preoperative period end?

When the client is transferred onto the operating table

A client is scheduled for an invasive procedure. What priority documentation is needed regarding the procedure?

a signed consent form from the client

The nurse is concerned that a postoperative patient may have a paralytic ileus. What assessment data may indicate that the patient does have a paralytic ileus?

absence of peristalsis

A patient is scheduled for a surgical procedure. For which surgical procedure should the nurse prepare an informed consent form for the surgeon to sign?

an open reduction of a fracture

It is important for the nurse to assist a postsurgical client to sit up and turn the head to one side when vomiting in order to

avoid aspiration

In which phase of perioperative care will the nurse prepare the client's skin, encourage the client to void, and remove the client's dentures?

preoperative

A registered nurse who is responsible for coordinating and documenting client care in the operating room is a

circulating nurse

Which is the least important issue concerning safety for the perioperative team before proceeding to the operating room?

client's ambulatory aids

What is the major purpose of withholding food and fluid before surgery?

prevent aspirations

A term used to describe a partial or complete separation of wound edges is

dehiscence

The perioperative nurse is preparing to discharge a client home from day surgery performed under general anesthetia. Which instruction should the nurse give the client prior to the client leaving the hospital?

do not drive yourself home

In which instance may a surgeon operate without informed consent?

emergency situations

The nurse is aware that loss of consciousness occurs with which type of anesthesia?

general

In advance of a client's scheduled appendectomy, the nurse spends significant time explaining to the client what will happen, both before the procedure and after the procedure is complete. The primary reason the nurse puts so much effort into preoperative teaching is to:

increase the likelihood of a successful recovery

Which action should not be allowed when wearing masks in the operating room?

letting masks hang around the neck

he client complains of weakness and dizziness as the nurse assists the client to sit on the side of the bed. The nurse recognizes the client is experiencing:

orthostatic hypotension

In which zone of the surgical area are street clothes allowed?

unrestricted

The nurse is caring for a client during the immediate postoperative period and is assessing for signs of shock. What signs and symptoms indicate that the client may be in shock?

weak and rapid pulse rate

The nurse is caring for a client during the immediate postoperative period. What signs and symptoms indicate that the client may be in shock?

weak and rapid pulse rate