ch. 9 practice questions

C

A patient is to undergo right total hip replacement after falling at home and reports that the last drink of alcohol was 3 days ago. Which patient assessment would be most concerning to the nurse in the preoperative stage? a. Urine amber color b. Hematocrit 55% c. Signs of delirium tremens d. Hypernatremia

D

A patient who was involved in a motor vehicle accident arrives at the emergency department and requires immediate surgery to stop massive internal hemorrhaging. The patient is unconscious, and no family or spouse is present. Which action would the nurse anticipate? a. Holding surgery until next of kin is present b. Attempting to stop bleeding without surgery c. Contacting a family friend to obtain consent d. Getting written consultation from two other health care providers before surgery

C (Electric clippers are to be used for hair removal because shaving increases the risk for infection by creating skin abrasions.)

Before surgery on a specific limb, which practice is supported by The Joint Commission's National Patient Safety Goals regarding site preparation? a. Two independent licensed practitioners mark the surgical site. b. The patient showers at the hospital for surgery. c. The surgeon and the patient confirm and mark the site. d. The surgical site is shaved and cleansed.

C (Cardiac problems increase surgical risks, and the risk for a myocardial infarction during surgery is higher in patients who have heart problems.)

During a preoperative assessment, which statement by a patient requires further investigation by the nurse to assess surgical risks? a. "I am taking vitamins." b. "I drink a glass of wine a night." c. "I had a heart attack 4 months ago." d. "I don't like latex balloons."

C

For the patient who is scheduled to undergo a total hip replacement, which complaint requires further evaluation by the nurse? a. "It's difficult to have a bowel movement." b. "I feel tired after that medication." c. "I have dull, achy pain in my right calf." d. "These stockings feel really tight."

C

Which assessment is the most critical for the nurse to perform and document on the post-anesthesia care unit (PACU) flow chart record of a patient who is receiving sedative drugs? a. Urine output b. Bowel sounds c. Respiratory rate d. Body temperature

a

The nurse at the hospital is preparing a patient with a history of alcoholism for knee-replacement surgery. Which potential complication is this patient more likely to encounter during surgery? a. Altered response to anesthesia b. Pulmonary complications c. Delirium tremens d. Myocardial infarction

D

The nurse is assessing a patient who is scheduled for surgery and observes dilated pupils, tachycardia, and increased respiration. Which nursing action is most likely to reveal the presence of emotional stress in the patient? a. Performing laboratory tests before surgery b. Teaching the patient about the surgical procedure c. Identifying the presence of an electrolyte imbalance in the reports d. Asking open-ended questions related to any previous surgeries

C

The nurse is monitoring a pt who is receiving sedation. An expected outcome for conscious sedation is: A. Blocked multiple peripheral nerves in a specific region B. Decreased motor fxn in the targeted limb C. Decreased LOC, yet able to respond to verbal commands

a, b, e

Which symptom might the nurse observe in a preoperative patient with anxiety? Select all that apply. One, some, or all responses may be correct. a. Anger b. Crying c. Constipation d. Decreased pulse e. Urinary frequency

B

Which assessment is a priority to perform for a patient in the post-anesthesia care unit (PACU) who was given general anesthesia during surgery? a. Skin b. Respiratory c. Kidney or urinary d. Wound

a

The nurse will monitor for which issue in a patient who is administered codeine sulfate for pain? a. Respiratory depression b. Changes in the level of consciousness c. Abnormal coagulation studies d. GI bleeding

D

Which action will the nurse perform when the nurse finds an open surgical wound with protrusions of internal organs upon assessment of the patient in the post-anesthesia care unit? a. Reinsert the protruded organs into the body. b. Raise the head of the patient's bed to a 90 degree angle. c. Place the patient in prone position with legs stretched. d. Apply a sterile dressing moistened with warm saline and notify the surgeon.

B (The nurse is not responsible for providing detailed information about the surgical procedure. Rather, the nurse's role is to clarify facts that have been presented by the health care provider and dispel myths that the patient or family may have heard about the surgical experience.)

Which action would the nurse take if, after informed consent is obtained, the patient asks, "Now what exactly are they going to do to me?" a. Contact the anesthesiologist. b. Contact the surgeon. c. Explain the procedure. d. Have the patient sign the form.

B

Which assessment finding would the nurse report to the primary health care provider when caring for a patient who is scheduled for cardiovascular surgery? a. Absence of pallor b. Absence of peripheral pulses c. Body temperature of 98.6°F d. No history of venous thromboembolism

a, b, c, d, e

Which component is part of an effective postoperative hand-off report? Select all that apply. One, some, or all responses may be correct. a. Type and extent of the surgical procedure b. Preoperative and intraoperative respiratory function and dysfunction c. Any health problems or pathophysiologic conditions d. When the next dose of antibiotics, cardiac drugs, and other medications are due e. Status of current vital signs, including temperature and oxygen saturation

a, b, d

Which condition can contribute to impaired wound healing after surgery? Select all that apply. One, some, or all responses may be correct. a. Obesity b. Diabetes c. Dysrhythmias d. Weak immune system e. Electrolyte imbalances

B

Which condition is indicated by the presence of a pulse deficit when assessing the vital signs of a postoperative patient? a. Dyspnea b. Dysrhythmia c. Hypothermia d. Deep vein thrombosis

c, d

Which condition is likely responsible for altered arterial blood gas levels in a patient who has undergone chest surgery? Select all that apply. One, some, or all responses may be correct. a. Diabetes b. Bandemia c. Hypoxemia d. Acid-base imbalance e. Thrombocytopenia

a, b, d (Obesity stresses the heart and reduces the lung volume; however, it is not related to wound healing. Depletion of vitamins such as vitamin B and vitamin C may cause poor wound healing, but depletion of vitamin D is not responsible for halting the wound healing process.)

Which condition related to obesity and excessive fatty tissue is associated with an increased risk for poor wound healing? Select all that apply. One, some, or all responses may be correct. a. Decreased nutrients b. Fewer BVs c. Reduced lung volumes d. Low amounts of collagen e. Depletion of vitamin D levels

a

Which examination would the nurse anticipate in the preoperative order set for a patient scheduled for spinal surgery? a. CT scan or MRI b. Creatinine level c. X-ray imaging d. International normalized ratio (INR)

C

Which explanation supports the use of electric clippers and depilatories to remove hair at the surgical site? a. It is the easiest method. b. It helps with wound healing. c. It reduces the potential for infection. d. It is a less time-consuming method.

C

Which factor increases the risk for surgical complications? a. Age of 59 years b. Male gender c. Diet-controlled diabetes mellitus d. 10 lbs over the patient's ideal body weight

a, c, d, e

Which information must be provided to the patient when obtaining informed consent for surgery? Select all that apply. One, some, or all responses may be correct. a. The reason for and nature of the surgery b. The identities of nursing staff that may assist in surgery c. The risks associated with the use of anesthesia d. The available options and their possible risks e. The risks associated with the surgical procedure and its potential outcomes

a, b, e

Which instruction would the nurse provide to a patient being discharged after surgery? Select all that apply. One, some, or all responses may be correct. a. "Include extra protein, iron, and vitamin C in your diet." b. "Wash your hands properly before changing dressings or performing catheter care." c. "You may resume your usual activities after completing the full course of antibiotics." d. "You may start lifting weights up to 3 kg as a part of your daily routine 1 week after surgery." e. "Pain killers are to be taken only as prescribed and you should notify the surgeon if there is any sudden increase in pain."

B

Which intervention by the nurse involves promoting surgical care improvement project (SCIP) core measures? a. Placing IV access during the preoperative period b. Ensuring the correct hair removal processes c. Teaching postoperative procedures and exercise before the day of the procedure d. Ensuring that rails are up and the call light is within reach after administering preoperative analgesics and sedatives

C

Which intervention by the nurse is most appropriate to ensure skin integrity in an older adult who is scheduled for surgery? a. Assisting the patient with ambulation b. Allowing extra time to teach the patient c. Padding bony prominences d. Preventing the risk for falls

D

Which intervention in the plan of care for a preoperative patient who is experiencing anxiety needs revision? a. Urging the patient to continue using methods of relaxation b. Delegating to the nursing assistive personnel the task of providing a back rub c. Using an honest and open approach for free expression of feelings d. Instructing the patient to avoid visiting friends 24 hours before surgery

C

Which intervention will the nurse include in the plan of care for a patient who is brought to the inpatient unit from the post-anesthesia care unit (PACU)? a. Assess vital signs every 8 hours. b. Assess lungs every 6 hours. c. Report 25% variation in blood pressure. d. Examine the foot and leg every hour.

a, c, d

Which intervention will the nurse include in the plan of care for a postoperative patient to improve oxygenation and perfusion and promote surgical wound healing? Select all that apply. One, some, or all responses may be correct. a. Use hypoallergenic tape. b. Slide the patient when repositioning. c. Control the patient's room temperature. d. Provide adequate rest throughout the day. e. Maintain oxygen saturation at greater than 90%.

a

Which intervention would the nurse implement specifically for a patient scheduled for surgery who has a history of renal impairment? a. Monitor intake and output of fluids. b. Teach coughing and deep-breathing exercises. c. Teach turning and positioning. d. Orient the patient to his or her surroundings.

D

Which is an example of an elective surgery? a. Appendectomy b. Acute cholecystitis c. Intestinal obstruction d. Total knee replacement

C

Which item is provided by the blood collection center to the patient after autologous blood donation? a. Money b. Medicine c. Matching tag d. Vitamin preparations

a, b, c, e

Which laboratory and/or diagnostic test is routinely carried out before any surgery is performed? Select all that apply. One, some, or all responses may be correct. a. Urinalysis b. Electrolyte levels c. Hemoglobin level d. MRI examination e. Blood type and screen

a

Which measurement is essential when determining anti-embolic stocking size for a patient? a. Leg length b. Foot length c. Height d. Weight

D (A surgeon is responsible for providing detailed information about the surgery to be performed. The nurse is not responsible for providing these details because it may increase anxiety levels)

Which nursing action related to informed consent for a surgical procedure would need correction? a. Verifying whether the consent form is signed b. Serving as a witness to the signature of the patient c. Clarifying facts that have been presented by the surgeon d. Providing detailed information about the surgery to be performed

D (Slight swelling under the sutures or staples is normal. A yellow serous-like drainage of the wound is normal during the first few days of healing. A pink crusting incision lining around the wound is caused by inflammation from the surgical procedure.)

Which surgical wound assessment finding would indicate a wound infection? a. Slight swelling under the sutures b. Yellow serous-like drainage c. Crusting on the incision line d. Purulent and odorous drainage

d (Encouraging ambulation helps prevent complications of immobility but may not prevent fatigue. Frequent toileting should be encouraged to prevent incontinence and falls but may actually increase fatigue. Coughing and deep-breathing exercises will help prevent pulmonary complications but may also increase fatigue.)

Which nursing action will help prevent fatigue in a patient diagnosed with a decrease in cardiac output? a. Encouraging ambulation b. Providing frequent toileting opportunities c. Teaching coughing and deep-breathing exercises d. Determining the patient's normal activity levels

C

Which nursing action will provide comfort to a patient who has developed nausea and vomiting after eye surgery? a. Administer normal saline. b. Listen for bowel sounds. c. Encourage side-lying position. d. Advise the patient to cough rapidly.

D

Which nursing intervention would be included in the plan of care for a preoperative patient with dry skin and less subcutaneous fat? a. Applying tape to the skin b. Allowing extra time for teaching the patient c. Assessing the patient's mobility d. Teaching the patient to change position every 2 hours

b, c, e

Which observation in the older preoperative patient indicates a poor nutritional status? Select all that apply. One, some, or all responses may be correct. a. Urinary incontinence b. Presence of brittle nails c. Decrease in serum protein level d. Clubbed fingertips e. Decrease in skin turgor

B, C, E (The nurse should ask appropriate questions to assess the patient response to verbal stimuli, which helps detect alterations in the patient's mental status. Bleeding or drainage on the dressing determines surgical incision site and status. Observing the color, clarity, and volume of urine output provides evidence of returning kidney function and hydration status)

Which parameter will the nurse assess for a patient who received general anesthesia who has arrived at the medical-surgical unit after discharge from the post-anesthesia care unit (PACU)? Select all that apply. One, some, or all responses may be correct. a. Headache in the occipital region b. Patient response to verbal stimuli c. Bleeding or drainage on the dressing d. Back pain while coughing or straining e. Color, clarity, and volume of urine output

C (Partial mastectomy is a simple surgery. Radical prostatectomy is a radical surgery. Mitral valve replacement is major surgery.)

Which procedure is an example of a minimally invasive surgery (MIS)? a. Partial mastectomy b. Radical prostatectomy c. Arthroscopy d. Mitral valve replacement

C, D, E

Which prophylactic measure may be included in postoperative care to reduce the risk for venous thromboembolism (VTE)? Select all that apply. One, some, or all responses may be correct. a. Record vital signs. b. Record heart sounds. c. Administer prescribed anticoagulants. d. Encourage early ambulation. e. Apply pneumatic compression devices.

D

Which question would the nurse ask the patient when completing the preoperative assessment? a. "What is your weight?" b. "What is your occupation?" c. "What type of insurance do you have?" d. "What medications are you currently taking?"

D (Enemas are not the best solution because they may cause severe anorectal discomfort for the patient with hemorrhoids and other side effects)

Which therapy would be the safest to assist the patient in evacuating the bowels before hemorrhoid surgery? a. Enema b. Herbal remedies c. IV preparation d. Potent laxatives

a, c, d, e (Incision care is taught during the postoperative period.)

Which topic is included in preoperative patient teaching? Select all that apply. One, some, or all responses may be correct. a. Splinting b. Incisional care c. Pain management d. Incentive spirometry e. Lower extremity exercises