Exam #1

One of the things a nurse has taught to a client during preoperative teaching is to have nothing by mouth for the specified time before surgery. The client asks the nurse why this is important. What is the most appropriate response for the client? -"By withholding food for 8 hours before surgery, you will not develop constipation in the postoperative period." -"The presence of food in the stomach interferes with the absorption of anesthetic agents." -"The restriction of food or fluid will prevent the development of pneumonia related to decreased lung capacity." -"You will need to have food and fluid restricted before surgery so you are not at risk for choking."

"You will need to have food and fluid restricted before surgery so you are not at risk for choking."

An intraoperative nurse is applying interventions that will address surgical clients' risks for perioperative positioning injury. What factors contribute to this increased risk for injury in the intraoperative phase of the surgical experience? Select all that apply. -Diminished ability to communicate -Nausea resulting from anesthetic -Reduced blood pressure -Loss of pain sensation -Absence of reflexes

-Diminished ability to communicate -Loss of pain sensation -Absence of reflexes

The surgeon's preoperative assessment of a client has identified that the client is at a high risk for venous thromboembolism. Once the client is admitted to the postsurgical unit, what intervention should the nurse prioritize to reduce the client's risk of this complication? -Perform passive range-of-motion exercises every 8 hours. -Maintain the head of the bed at 45 degrees or higher. -Encourage early ambulation. -Encourage oral fluid intake.

-Encourage early ambulation.

The nurse is preparing a nursing care plan for a child hospitalized for cardiac surgery. Which are examples of interventions that nurses perform in the "building a trusting relationship" stage? Select all that apply. -Gathering information about the child using the child's own toys -Preparing the child for a procedure by playing games -Explaining in simple terms what will happen during surgery -Allowing the child to devise an exercise plan following surgery -Praising the child for how well he is doing following instructions -Giving the child a favorite toy to cuddle following a painful procedure

-Preparing the child for a procedure by playing games -Explaining in simple terms what will happen during surgery -Praising the child for how well he is doing following instructions

A surgical client has been in the PACU for the past 3 hours. What are the determining factors for the client to be discharged from the PACU? Select all that apply. -Stable blood pressure -Absence of pain -Ability to tolerate oral fluids -Sufficient oxygen saturation -Adequate respiratory function

-Stable blood pressure -Ability to tolerate oral fluids -Sufficient oxygen saturation -Adequate respiratory function

The nurse is preparing a hospitalized 7-year-old girl for a lumbar puncture. Which actions would help reduce her stress related to the procedure? Select all that apply. -Teach her the steps of the procedure. -Do not allow her to see or touch the equipment. -Introduce her to the health care personnel. -Tell her not to pay attention to any sounds she might hear. Explain the procedure to her in medical terms. -Pretend to perform the procedure on her doll

-Teach her the steps of the procedure. -Introduce her to the health care personnel. -Pretend to perform the procedure on her doll

The nurse is performing an admission of a 10-year-old boy. Which actions will help the nurse establish a trusting and caring relationship with the child and his family? Select all that apply. -The nurse should not minimize the child's fears by smiling. -The nurse should initiate introductions. -The nurse should not use formal titles at the introduction. -The nurse should maintain eye contact at the appropriate level. -The nurse should start communication with the child first and then move on to the family. -The nurse should use age-appropriate communication with the child.

-The nurse should initiate introductions. -The nurse should maintain eye contact at the appropriate level. -The nurse should start communication with the child first and then move on to the family. -The nurse should use age-appropriate communication with the child.

The nurse is questioning the parents of a 2-year-old child to obtain a functional history. Which topics might the nurse include? Select all that apply. -Use of supplements and vitamins -The child's toileting habits -The child's race and ethnicity -Problems with growth and development -Prenatal and perinatal history -Use of car seats and other safety measures

-Use of supplements and vitamins -The child's toileting habits -Use of car seats and other safety measures

The nurse is admitting a 7-year-old child to the medical-surgical unit. The child answers questions with very short answers, makes little eye contact with the nurse, and looks to the parent to answer most questions. Which interventions would be appropriate during this admission assessment? Select all that apply. -Stop asking questions for the present time and return later when the child feels more comfortable. -Tell the child that you are going to be their nurse so it would be best if they answered your questions. -Ask the child if they are always nervous around new people. When asking questions, look at the child as well as the parent. -Sit at the child's eye level during the admission questioning process.

-When asking questions, look at the child as well as the parent. -Sit at the child's eye level during the admission questioning process.

Maintaining an aseptic environment in the OR is essential to client safety and infection control. When moving around surgical areas, what distance must the nurse maintain from the sterile field? -18 inches (45 cm) -2 feet (60 cm) -1 foot (30 cm) -6 inches (15 cm)

1 foot (30 cm)

The nurse is planning client teaching for a client who is scheduled for an open hemicolectomy. The nurse intends to address the topics of incision splinting and leg exercises during this teaching session. When is the best time for the nurse to provide teaching? -During the intraoperative period -When the client returns from the PACU -As soon as possible before the surgical procedure -Upon the client's admission to the postanesthesia care unit (PACU)

As soon as possible before the surgical procedure

A 7-year-old boy has reentered the hospital for the second time in a month due to complications after a surgical procedure. Which intervention is particularly important at this time? -Educating his family about the procedure -Notifying the care team about his hospitalization -Assessing his parents' coping abilities -Seeking his parents' input about their child's needs

Assessing his parents' coping abilities

The nurse is preparing a client for surgery. The client states that she is very nervous and really does not understand what the surgical procedure is for or how it will be performed. What is the most appropriate nursing action for the nurse to take? -Explain the procedure clearly to the client and her family. -Have the client sign the informed consent and place it in the chart. -Call the physician to review the procedure with the client. -Provide the client with a pamphlet explaining the procedure.

Call the physician to review the procedure with the client.

The nurse is doing a preoperative assessment of an 87-year-old man who is slated to have a right lung lobe resection to treat lung cancer. What underlying principle should guide the nurse's preoperative assessment of an elderly client? -Elderly clients have less physiologic reserve than younger clients. -Elderly clients require higher medication doses than younger clients. -Elderly clients have more sophisticated coping skills than younger clients. -Elderly clients have a smaller lung capacity than younger clients

Elderly clients have less physiologic reserve than younger clients.

When preparing to apply a restraint to a child, what would be most important for the nurse to do? -Plan to use a square knot to secure the restraint to the side rails. -Expect to keep the restraint on for at least 8 hours. -Use a limb restraint rather than a jacket restraint for most issues. -Explain that safety, not punishment, is the reason for the restraint.

Explain that safety, not punishment, is the reason for the restraint.

The nurse is caring for a 7-year-old boy who needs his left leg immobilized. What is the priority nursing intervention? -Explain that a restraint will be applied if he cannot hold still. -Apply a clove-hitch restraint to the boy's left leg. -Enlist the assistance of a child life specialist. -Explain to the boy that he must keep his leg very still.

Explain to the boy that he must keep his leg very still.

The nurse is caring for families with vulnerable child syndrome. Which situation would be most likely to predispose the family to this condition? -Having a postterm infant -Having a child diagnosed with impetigo at age 10 -Having an infant who is reluctant to feed properly -Having a child with juvenile diabetes

Having an infant who is reluctant to feed properly

An adult client has just been admitted to the PACU following abdominal surgery. As the client begins to awaken, he is uncharacteristically restless. The nurse checks his skin and it is cold, moist, and pale. The nurse concerned the client may be at risk for what? -Postoperative infection -Aspiration -Hemorrhage and shock -Hypertension and dysrhythmias

Hemorrhage and shock

The nurse is preparing an elderly client for a scheduled removal of orthopedic hardware, a procedure to be performed under general anesthetic. For which adverse effect should the nurse most closely monitor the client? -Pulmonary edema -Cerebral ischemia -Hypothermia -Arthritis

Hypothermia

The nurse admits a client to the PACU with a blood pressure of 132/90 mm Hg and a pulse of 68 beats per minute. After 30 minutes, the client's blood pressure is 94/47 mm Hg, and the pulse is 110. The nurse documents that the client's skin is cold, moist, and pale. Of what is the client showing signs? -Hypovolemic shock -Neurogenic shock -Malignant hyperthermia -Hypothermia

Hypovolemic shock

The nurse is teaching the student nurse how to perform a physical assessment based on the child's developmental stage. Which statement accurately describes a recommended guideline for setting the tone of the examination for a school-age child? -Speak to the child using mature language and appeal to his or her desire for self-care. -Include the child in all parts of the examination; speak to the caregiver before and after the examination. -Keep up a running dialogue with the caregiver, explaining each step as you do it. -Address the child by name; speak to the caregiver and do the most invasive parts last.

Include the child in all parts of the examination; speak to the caregiver before and after the examination.

The intraoperative nurse knows that the client's emotional state can influence the outcome of their surgical procedure. How should the nurse best address this? -Teach the client strategies for distraction. -Incorporate cultural and religious considerations, as appropriate. -Pair the client with another client who has better coping strategies. -Give the client antianxiety medication.

Incorporate cultural and religious considerations, as appropriate.

A client is positioned on the OR bed prior to knee surgery to correct a sports-related injury. The anesthesiologist administers the appropriate anesthetic. The OR nurse should anticipate which of the following events as the team's next step in the care of this client? -Giving blood -Intubating -Grounding -Making the first incision

Intubating

The anesthetist is coming to the surgical admissions unit to see a client prior to surgery scheduled for tomorrow morning. What is the priority information that the nurse should provide to the anesthetist during the visit? -Difficulty falling asleep -Last bowel movement -Latex allergy -Number of pregnancies

Latex allergy

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 increase the client's muscle mass postoperatively. -Leg exercise help increase the client's level of consciousness after surgery. -Leg exercises help to prevent pressure sores to the sacrum and heels. -Leg exercises improve circulation and prevent venous thrombosis.

Leg exercises improve circulation and prevent venous thrombosis.

An adult client is scheduled for a hemorrhoidectomy. The OR nurse should anticipate assisting the other team members with positioning the client in what manner? -Dorsal recumbent position -Trendelenburg position -Lithotomy position -Sims position

Lithotomy position

An OR nurse is teaching a nursing student about the principles of surgical asepsis as a requirement in the restricted zone of the operating suite. What personal protective equipment should the nurse wear at all times in the restricted zone of the OR? -Goggles -Reusable shoe covers -Mask covering the nose and mouth -Gloves

Mask covering the nose and mouth

During the care of a preoperative client, the nurse has given the client a preoperative benzodiazepine. The client is now requesting to void. What action should the nurse take? -Wait until the client gets to the operating room and is catheterized. -Have the client go to the bathroom. -Offer the client a bedpan or urinal. -Assist the client to the bathroom.

Offer the client a bedpan or urinal.

The nurse is caring for a hospice client who is scheduled for a surgical procedure to reduce the size of his spinal tumor in an effort to relieve his pain. The nurse should plan this client care with the knowledge that his surgical procedure is classified as which of the following? -Laparoscopic -Diagnostic -Curative -Palliative

Palliative

The OR nurse acts in the circulating role during a client's scheduled cesarean section. For what task is this nurse solely responsible? -Setting up the sterile tables -Estimating the client's blood loss -Performing documentation -Keeping track of drains and sponges

Performing documentation

The nurse is caring for a client who is postoperative day 2 following a colon resection. While turning him, wound dehiscence with evisceration occurs. What should be the nurse's first response? -Pull the dehiscence closed using gloved hands. -Assess the client's blood pressure and pulse. -Place saline-soaked sterile dressings on the wound. -Return the client to his previous position and call the physician.

Place saline-soaked sterile dressings on the wound.

A client is on call to the OR for an aortobifemoral bypass and the nurse administers the prescribed preoperative medication. After administering a preoperative medication to the client, what should the nurse do? -Tell the client that he will be asleep before he leaves for surgery. -Encourage light ambulation. -Place the bed in a low position with the side rails up -Take the client's vital signs every 15 minutes.

Place the bed in a low position with the side rails up.

An adolescent is scheduled for outpatient arthroscopic surgery on his knee next week. As part of preparing him for the procedure, which action would be most appropriate? -Discussing the events with the adolescent and his mother upon arrival the morning of the procedure -Encouraging the parent to stay with the adolescent as much as possible before the procedure -Providing detailed explanations of the procedure at least a week in advance of the procedure -Answering the adolescent's questions with simple answers, encouraging him to ask the surgeon

Providing detailed explanations of the procedure at least a week in advance of the procedure

A postoperative client rapidly presents with hypotension; rapid, thready pulse; oliguria; and cold, pale skin. The nurse suspects that the client is experiencing a hemorrhage. What should be the nurse's first action? -Begin resuscitation. -Put the client in the Trendelenberg position. -Quickly attempt to determine the cause of hemorrhage. -Leave and promptly notify the physician.

Quickly attempt to determine the cause of hemorrhage.

The surgical client has been given general anesthesia. The nurse recognizes that the client is in stage II (the excitement stage) of anesthesia. Which intervention would be most appropriate for the nurse to implement during this stage? -Encourage the client to express feelings. -Stroke the client's hand. -Restrain the client. -Rub the client's back.

Restrain the client.

The nurse is caring for a 78-year-old man who has had an outpatient cholecystectomy. The nurse is getting him up for his first walk postoperatively. To decrease the potential for orthostatic hypotension and consequent falls, what should the nurse have the client do? -Perform range-of-motion exercises for each joint. -Drink plenty of fluids to increase circulating blood volume. -Sit in a chair for 10 minutes prior to ambulating. -Stand upright for 2 to 3 minutes prior to ambulating.

Stand upright for 2 to 3 minutes prior to ambulating.

An OR nurse is participating in an interdisciplinary audit of infection control practices in the surgical department. The nurse should know that a basic guideline for maintaining surgical asepsis is what? -The outer lip of a sterile solution is considered sterile. -Sterile supplies can be used on another client if the packages are intact. -Sterile surfaces or articles may touch other sterile surfaces. -The scrub nurse may pour a sterile solution from a nonsterile bottle.

Sterile surfaces or articles may touch other sterile surfaces.

The perioperative nurse is constantly assessing the surgical client for signs and symptoms of complications of surgery. Which symptom should first signal to the nurse the possibility that the client is developing malignant hyperthermia? -Hypotension -Oliguria -Tachycardia -Increased temperature

Tachycardia

Which would be least effective in gaining the cooperation of a toddler during a physical examination? -Permit the child to sit on the parent's lap during the examination. -Tell the child that another child the same age wasn't afraid. -Allow the child to touch and hold the equipment when possible. -Offer immediate praise for holding still or doing what was asked.

Tell the child that another child the same age wasn't afraid.

The admitting nurse in a short-stay surgical unit is responsible for numerous aspects of care. What must the nurse verify before the client is taken to the preoperative holding area? -That the family understands the client will be discharged immediately after surgery. -That preoperative teaching was performed -That follow-up home care is not necessary -That the family is aware of the length of the surgery

That preoperative teaching was performed

The nurse is conducting a physical examination of a child following a comprehensive health history. What should be the focus of the physical examination? -The parents -Chief complaint -The child -Developmental age

The child

The perioperative nurse is preparing to discharge a female client home from day surgery performed under general anesthetic. What instruction should the nurse give the client prior to the client leaving the hospital? -The client should remain in bed for the first 48 hours postoperative. -The client should attempt to eat a large meal at home to aid wound healing. -The client should take an OTC sleeping pill for 2 nights. -The client should not drive herself home.

The client should not drive herself home.

In anticipation of a client's scheduled surgery, the nurse is teaching her to perform deep breathing and coughing to use postoperatively. What action should the nurse teach the client? -The client should rapidly inhale, hold for 30 seconds or as long as possible, and exhale slowly. -The client should take a deep breath in through the mouth and exhale through the mouth, take a short breath, and cough from deep in the lungs. -The client should take three deep breaths and exhale forcefully and then take a quick short breath and cough from deep in the lungs. The client should take three deep breaths and cough hard three times, at least every 15 minutes for the immediately postoperative period.

The client should take a deep breath in through the mouth and exhale through the mouth, take a short breath, and cough from deep in the lungs.

The nurse uses family-centered care to care for children in a pediatric office. Upon what concept is family-centered care based? -The family is the constant in the child's life and the primary source of strength. -The wishes of the family should direct the nursing care plan for the child. -The child must be prepared to be his or her own source of strength during times of crisis. -The care provider is the constant in the child's life and the primary source of strength.

The family is the constant in the child's life and the primary source of strength.

The nurse is preparing a child and his family for a lumbar puncture. Which would be a primary intervention instituted to keep the child safe? -Distraction methods -Therapeutic hugging -Stimulation methods -Therapeutic touch

Therapeutic hugging

The nurse in the ED is caring for a man who has returned to the ED 4 days after receiving stitches for a knife wound on his hand. The wound is now infected, so the stitches were removed, and the wound is cleaned and packed with gauze. The ED doctor plans to have the man return tomorrow to remove the packing and resuture the wound. This client's wound will now heal by what means? -Third intention -Second intention -Late intention -First intention

Third intention

The nurse is performing a physical examination on a sleeping newborn. Which body system should the nurse examine last? -Heart -Lungs -Throat -Abdomen

Throat

The dressing surrounding a mastectomy client's Jackson-Pratt drain has scant drainage on it. The nurse believes that the amount of drainage on the dressing may be increasing. How can the nurse best confirm this suspicion? -Describe the appearance of the dressing in the electronic health record. -Trace the outline of the drainage on the dressing for future comparison. -Photograph the client's abdomen for later comparison using a smartphone. -Remove and weigh the dressing, reapply it, and then repeat in 8 hours.

Trace the outline of the drainage on the dressing for future comparison.

The PACU nurse is caring for a client who has arrived from the OR. During the initial assessment, the nurse observes that the client's skin has become blue and dusky. The nurse looks, listens, and feels for breathing, and determines the client is not breathing. What is the priority intervention? -Treat the possible airway obstruction by tilting the head back and pushing forward on the angle of the lower jaw. -Reintubate the client. -Assess the arterial pulses, and place the client in the Trendelenburg position. -Check the client's oxygen saturation level, continue to monitor for apnea, and perform a focused assessment.

Treat the possible airway obstruction by tilting the head back and pushing forward on the angle of the lower jaw.

A client who underwent a bowel resection to correct diverticula suffered irreparable nerve damage. During the case review, the team is determining if incorrect positioning may have contributed to the client's nerve damage. What surgical position places the client at highest risk for nerve damage? -Trendelenburg -Prone -Dorsal recumbent -Lithotomy

Trendelenburg

A client is admitted to the ED complaining of severe abdominal pain, stating that he has been vomiting "coffee-ground" like emesis. The client is diagnosed with a perforated gastric ulcer and is informed that he needs surgery. When can the client most likely anticipate that the surgery will be scheduled? -Within 24 hours -Within the next week -Without delay because the bleed is emergent -As soon as all the day's elective surgeries have been completed

Without delay because the bleed is emergent

The nurse is admitting a client to the medical-surgical unit from the PACU. In order to help the client clear secretions and help prevent pneumonia, the nurse should encourage the client to: -use the incentive spirometer every 2 hours. -take medications as prescribed. -eat a balanced diet that is high in protein. -limit activity for the first 72 hours.

use the incentive spirometer every 2 hours.