Foundations Exam 2 // CH 30

A nurse is caring for an inpatient client scheduled to undergo a surgery for the removal of a malignant tumor. What risk factors does the nurse identify that increase the occurrence of perioperative complications? Select all that apply. A. bleeding tendencies B. anxiety C. low hemoglobin D. obesity E. temperature of 99.2°F (37.3°C)

A. bleeding tendencies C. low hemoglobin D. obesity

The procedural physician has initiated performance of a time-out in the operating room before surgery. The student nurse asks the operating room nurse why this is important. What is the operating room nurse's best response? A. "We are checking the client's baseline vital signs during the time-out." B. "The time-out checks to be sure that we have the right client and procedure." C. "We need to be sure the client has had the preoperative antibiotic." D. "The time-out allows us to make sure that the client has had adequate anesthesia."

B. "The time-out checks to be sure that we have the right client and procedure."

Which fact should the nurse keep in mind when obtaining consent forms from clients scheduled to undergo surgery? A. A consent form is legal, even if the client is confused or sedated. B. In emergency situations, the doctor may obtain consent over the telephone. C. The form that is signed is not a legal document and would not hold up in court. D. The responsibility for securing informed consent from the client lies with the nurse.

B. In emergency situations, the doctor may obtain consent over the telephone.

Which nursing action will assist in pain management for a client in the postoperative phase? A. Provide food and medication B. Relaxation techniques C. Client education D. Dim lighting

B. Relaxation techniques

The nurse is assessing clients for postoperative complications. What is the most commonly assessed postanesthesia recovery emergency? A. Dehydration B. Respiratory obstruction C. Cardiac distress D. Wound infection

B. Respiratory obstruction

A nurse is assessing a client who is experiencing pulmonary embolus. What would be the priority nursing intervention for this client? A. Attempt to overhydrate the client with fluids. B. Assist the client to ambulate every 2 to 3 hours. C. Place the client in semi-Fowler's position. D. Instruct the client to perform Valsalva maneuver.

C. Place the client in semi-Fowler's position.

A client is undergoing surgery for an appendectomy. This would be considered what type of surgery? A. diagnostic surgery B. palliative surgery C. elective surgery D. emergency surgery

D. emergency surgery

The nurse is educating a client who is preparing for abdominal surgery tomorrow. A teaching demonstration has just been completed by the nurse related to splinting the incision site with a pillow. Which statement by the client best indicates the instructions provided by the nurse were effective? A. "I will put the pillow on the incision then cough." B. "I should hold my breath and place the pillow over the incision when coughing." C. "I will place the pillow on the incision after I cough." D. "I have to move the pillow from one side of the incision to the other when coughing."

A. "I will put the pillow on the incision then cough."

The nurse is talking with a client who wishes to have a tattoo removed. Which client statement indicates that the client understands how the procedure will be accomplished? A. "The provider will perform this laser surgery in an ambulatory care setting." B. "This inpatient surgical procedure requires me to be at the hospital the morning of surgery." " C. I will talk with the anesthesiologist about anesthesia." D. "I will plan to be hospitalized several days following the procedure."

A. "The provider will perform this laser surgery in an ambulatory care setting."

The nurse is providing education about deep-breathing exercises to a postoperative client whose surgery took place earlier today. Which instruction should the nurse provide? A. "Try to do your exercises every 1 to 2 hours." B. "Take off your oxygen nasal prongs during your exercises and replace them as soon as you're done." C. "It's best to do your exercises before a meal rather than after eating and drinking." D. "If possible, lie flat on your back while you're doing your breathing exercises."

A. "Try to do your exercises every 1 to 2 hours."

The nurse enters a postoperative client's room and finds that the client is bleeding profusely from the surgical incision. What would be the nurse's most appropriate initial response? A. Apply pressure to the surgical site to decrease bleeding. B. Determine the possible cause of the client's bleeding. C. Notify the health care provider. D. Assess the client's vital signs.

A. Apply pressure to the surgical site to decrease bleeding.

A nurse is teaching a client about the rationale for fasting from food and fluids prior to surgery. What condition does this measure attempt to avoid? A. Aspiration B. Respiratory distress C. Bowel alterations D. Infection

A. Aspiration

A client is being prepared for discharge home from the postanesthesia care unit (PACU). What action is essential for the nurse to take? A. Check that the client is able to drink liquids without nausea. B. Ensure a client who is dizzy has help at home to prevent falls. C. Confirm the client has been in the PACU for at least 4 hours. D. Determine if the client is able to drive home or can ride the bus.

A. Check that the client is able to drink liquids without nausea.

A nurse is creating a leg exercise regimen for client who is recovering from surgery. Which factors should the nurse consider when recommending leg exercises to this client? Select all that apply. A. Client's physical condition B. Cardiovascular intensity of exercise C. Facility protocol D. Current popularity of the exercise E. Health care provider preference F. Client's individual needs

A. Client's physical condition C. Facility protocol E. Health care provider preference F. Client's individual needs

The preoperative nurse has prepared a client for surgery and has been notified that the operating room staff is ready for the client. The client states, "My bladder feels full. I need to go to the bathroom!" Which action by the nurse is appropriate? A. Inform the operating room staff and assist the client to the bathroom. B. Remind the client that bladder fullness is a common preoperative sensation. C. Inform the client that anesthesia will prevent the bladder from emptying during surgery. D. Insert a catheter into the bladder.

A. Inform the operating room staff and assist the client to the bathroom.

The nurse is supervising a nursing student who is providing postoperative education to a client with an abdominal incision. The nurse sees the student coaching the client to perform coughing exercises, as pictured above. What is the nurse's best action? A. Instruct the student to provide the client with a pillow or folded blanket to hug. B. Remind the student to support the client while she performs the exercises. C. Help the student assist the client into a high Fowler's position. D. Help the client determine whether she is able to dangle at the side of the bed.

A. Instruct the student to provide the client with a pillow or folded blanket to hug.

A nurse is preparing a client for endotracheal intubation. The anesthesiologist has ordered an anticholinergic medication for this client. What is an action of this medication? A. It decreases respiratory secretions. B. It promotes sleep or conscious sedation. C. It promotes induction of anesthesia. D. It decreases gastric acidity and volume.

A. It decreases respiratory secretions.

A nurse is dressing the wound of a client who is admitted to the outpatient surgical unit. What is a major advantage of outpatient surgery? A. It interferes less with the client's daily routine. B. It requires intensive preoperative education in a short time. C. It allows less opportunity for family contact and support. D. It reduces the time for establishing a nurse-client rapport.

A. It interferes less with the client's daily routine.

A client is scheduled for elective hernia surgery. While taking a medical history, the nurse learns that the client is taking antibiotics for an infection. Which surgical risk should the nurse monitor based on this antibiotic use? A. Respiratory paralysis B. Hemorrhage C. Electrolyte imbalances D. Cardiovascular collapse

A. Respiratory paralysis

Which methods would the nurse anesthetist use when administering regional anesthesia to surgical clients? Select all that apply. A. Spinal block B. Inhalation C. Intravenous D. Oral route E. Epidural block F. Nerve block

A. Spinal block E. Epidural block F. Nerve block

The nurse is preparing a client for a surgical procedure that is scheduled for the next morning. What nursing action is important for the preparation to limit the risk of intraoperative and postoperative complications? Select all that apply. A. checking that all diagnostic tests are completed B. having the client void immediately before surgery C. educating client about postoperative care D. shaving the operative area the night before the operation E. maintaining strict NPO (nothing by mouth) status for at least 6 hours F. measuring baseline vital signs

A. checking that all diagnostic tests are completed B. having the client void immediately before surgery C. educating client about postoperative care F. measuring baseline vital signs

A nurse is employed in an operative setting. Which of these roles is within the registered nurse (RN) scope of practice? Select all that apply. A. counting sponges before and after surgery B. administering inhalation anesthetics C. positioning the client on the operating table D. monitoring the client's vital signs E. administering regional nerve blocks

A. counting sponges before and after surgery C. positioning the client on the operating table D. monitoring the client's vital signs

A client scheduled for surgery has been taking aspirin since his heart attack in 1997. The client is at risk for: A. hemorrhage. B. thrombophlebitis. C. blood clots. D. infection.

A. hemorrhage.

Which client will see the greatest permanent changes in lifestyle following surgery? A. ileostomy B. appendectomy C. left mastectomy D. right total knee replacement

A. ileostomy

In the postoperative phase of abdominal surgery, the client reports severe abdominal pain. In the second postoperative day, the client's bowel sounds are absent. What does the nurse suspect? A. paralytic ileus B. hernia development C. normal response D. abdominal infection

A. paralytic ileus

A nurse teaches deep breathing exercises to a client scheduled for surgery. In which perioperative phase would this action occur? A. preoperative B. intraoperative C. postoperative D. postanesthesia care unit (PACU)

A. preoperative

The nurse has been waiting until after the administration of a toddler's anesthesia before removing the child's clothing and applying monitoring equipment. Doing these actions after the administration of anesthesia will: A. prevent anxiety. B. provide more accurate baseline vital signs. C. enhance thermoregulation. D. minimize blood loss.

A. prevent anxiety.

The preoperative nurse is teaching a client about deep-breathing exercises. The client asks, "Why do I need to learn about this?" Which response by the nurse is correct? A. "If you learn how to perform these exercises correctly, you will not need supplemental oxygen during surgery." B. "After surgery, deep-breathing exercises help to remove anesthetic gases and mucus and improve oxygen supply to body tissues." C. "These types of exercises help distract you from the postoperative pain." D. "These techniques will prevent trapped air from accumulating in your lungs."

B. "After surgery, deep-breathing exercises help to remove anesthetic gases and mucus and improve oxygen supply to body tissues."

The nurse is teaching a client about postoperative pain management. The client states, "I would like to use as little medication as possible after surgery. Will anything else help to relieve my pain?" Which response is appropriate? A. "Your pain needs to be managed with medication for the first 24 hours, then you can try nonpharmacologic methods." B. "There are several nonpharmacologic methods to reduce pain and anxiety. Let me teach you about some of them." C. "There are nonpharmacologic methods, but they only work when clients have practiced them extensively beforehand." D. "Are you afraid of becoming addicted to pain medications?"

B. "There are several nonpharmacologic methods to reduce pain and anxiety. Let me teach you about some of them."

The nurse assists a client to turn in the bed. The client has just returned from abdominal surgery. How does the nurse instruct the client? A. "Raise the head of the bed before turning." B. "Use a pillow to splint the incision." C. "Change your position frequently." D. "Wait for assistance before moving in bed."

B. "Use a pillow to splint the incision."

An elder adult client underwent a hip replacement and now states to the nurse, "My parents are coming to visit me today. I need to mow the lawn and run errands." The client is trying to get out of the bed. What does the nurse identify is occurring with this client? A. Boredom B. Delirium C. Narcotic overuse D. Dementia

B. Delirium

The nurse needs to evaluate the effectiveness of a preoperative teaching session with a client scheduled for abdominal surgery. Which client statement indicates the need for further clarification? A. "I will sit up in bed before using my incentive spirometer." B. "I will splint my incision while I cough." C. "Every 2 hours while I am awake, I will take deep breaths and cough." D. "While my pneumatic compression device is on, I don't need to do leg exercises."

D. "While my pneumatic compression device is on, I don't need to do leg exercises."

The nurse is performing a preoperative assessment of a client who has been scheduled for a reduction mammoplasty (breast reduction). The client states, "I'm starting to wonder if I made the right decision in going ahead with this." What should the nurse do next? A. Ask the client about her understanding of the potential benefits of the surgery. B. Explore the client's feelings and inform the surgeon. C. Assess the client's rationale and affirm that she has made a good decision. D. Remind the client that she has signed the informed consent documents.

B. Explore the client's feelings and inform the surgeon.

A nurse caring for clients in a PACU assesses a client who is displaying signs and symptoms of shock. What is the priority nursing intervention for this client? A. Place the client in the prone position. B. Place the client in a flat position with legs elevated 45 degrees. C. Remove extra coverings on the client to keep temperature down. D. Do not administer any further medication.

B. Place the client in a flat position with legs elevated 45 degrees. Placing the client in a flat position with the legs elevated 45 degrees uses gravity to help direct blood to the vital organs. Removing extra coverings would cause the client's temperature to drop further during the blood loss occurring during shock. Medications will likely be ordered to help treat the shock. Prone position would be contraindicated.

A nurse is providing education to a client having same-day surgery. Which statement would be accurate regarding this type of surgery? A. Same-day surgery must be performed in a hospital setting. B. Some major surgeries can be done as same-day surgery. C. Clients without a strong support system are not candidates for same-day surgery. D. Older adult clients are generally not permitted to have same-day surgery.

B. Some major surgeries can be done as same-day surgery.

A nurse is reinforcing wound edges and applying a blinder to the separated incisions of a client after a surgery. Which postoperative complication has the client developed? A. evisceration B. dehiscence C. hypoxemia D. shock

B. dehiscence

The nurse is assessing an obese client scheduled for heart surgery. Which priority surgical risk related to obesity should the nurse monitor? A. nutritional maintenance B. delayed wound healing and wound infection C. hemorrhage D. alterations in fluid and electrolyte balance

B. delayed wound healing and wound infection

The recovery nurse is caring for a surgical client in the PACU. The client's blood pressure is dropping and the heart rate is increasing. The nurse suspects the client is: A. experiencing normal adaptation to the postoperative period. B. developing shock. C. allergic to the anesthesia. D. overmedicated.

B. developing shock.

Which nursing action provides the greatest assistance in healing? A. allowing family members to visit often B. maintaining a restful environment C. providing solid food in the first day D. keeping the client recumbent

B. maintaining a restful environment

A client will be having a surgical procedure requiring general anesthesia. Which desired outcomes of general anesthesia does the nurse expect to observe? Select all that apply. A. loss of sensation in specific area B. relaxed skeletal muscles C. depressed reflexes D. analgesia E. loss of consciousness

B. relaxed skeletal muscles C. depressed reflexes D. analgesia E. loss of consciousness

When preparing a client who has diabetes mellitus for surgery, the nurse should be aware of what surgical risk associated with this disease? A. respiratory depression from anesthesia B. slow wound healing C. altered metabolism and excretion of drugs D. fluid and electrolyte imbalance

B. slow wound healing

Which statement, if made by an adolescent preparing for abdominal surgery, would indicate to the nurse that the client requires additional instruction? A. "When I can eat again, the best meal would be steak and orange juice." B. "I might be sick to my stomach and throw up after surgery." C. "I can have a hamburger and French fries as soon as I wake up." D. "The better I eat before surgery, the more likely I will heal."

C. "I can have a hamburger and French fries as soon as I wake up."

A client who is scheduled to undergo coronary bypass surgery in a week asks the nurse whether he should discontinue taking his cholesterol medicine ahead of the surgery. Which should be the nurse's response? A. "Yes—you should be off all of your medications for 24 hours before surgery." B. "You should stay on your cholesterol medicine but stop taking all other medications 12 hours before surgery." C. "I will need to check with your health care provider about that." D. "No—you should stay on your normal medication schedule before the surgery."

C. "I will need to check with your health care provider about that."

A nurse is caring for an older adult following hip surgery. When teaching the client to use an incentive spirometer, the nurse should explain that this reduces the risk of what complication? A. Asthma B. Bronchitis C. DVT D. Pneumonia

D. Pneumonia

Which clients would the nurse schedule for surgery based on purpose? Select all that apply. A. a client in respiratory distress who needs a tracheostomy B. a client who has uncontrolled bleeding C. A client post mastectomy who decides to have breast reconstruction D. a client needing a cleft palate repair E. a client needing a bowel resection F. a client undergoing a breast biopsy

C. A client post mastectomy who decides to have breast reconstruction D. a client needing a cleft palate repair E. a client needing a bowel resection F. a client undergoing a breast biopsy

A 2-year-old toddler just underwent a tonsillectomy and adenoidectomy surgery. The postanesthesia care unit (PACU) nurse is checking on him. What is the best course of action regarding the developmental care of this child? A. Give the child a new teddy bear. B. Administer acetaminophen before the child wakes. C. Allow the parents into the PACU before the child wakes. D. Extubate the child as soon as possible.

C. Allow the parents into the PACU before the child wakes.

A client postoperative from an appendectomy reports feeling cold and has a temperature of 96.2°F (35.7°C). Which action should the nurse perform first? A. Notify the health care provider. B. Check the client's blood pressure. C. Apply warm blankets to the client. D. Apply an oxygen saturation monitor.

C. Apply warm blankets to the client.

A nurse is giving preoperative information to a client scheduled for outpatient surgery. What are recommended education guidelines? Select all that apply. A. Wear clothing without buttons or zippers. B. Continue with all medications routinely taken. C. Have someone available for transportation home after recovery from anesthesia. D. List allergies and be sure the operating staff is aware of these. E. Notify the surgeon's office if a cold or infection develops before surgery.

C. Have someone available for transportation home after recovery from anesthesia. D. List allergies and be sure the operating staff is aware of these. E. Notify the surgeon's office if a cold or infection develops before surgery.

The preoperative nurse is reviewing the chart of a client whose surgery is scheduled to begin in the next 15 minutes and notices that the consent form is not signed. The nurse contacts the surgeon who states, "We have already reviewed this procedure extensively, so ask the client to sign the consent form and I will verify it in the operating room." Which action by the nurse is appropriate? A. Ask the client to sign the consent; witness the signature and inform the operating room staff of the modification in the procedure. B. Ask the operating room staff to delay the procedure until the consent is signed. C. Keep the client in the preoperative area and inform the surgeon that it is the health care provider's responsibility to obtain consent for surgery. D. Send the client to the operating room and inform the staff that the consent form needs to be signed.

C. Keep the client in the preoperative area and inform the surgeon that it is the health care provider's responsibility to obtain consent for surgery.

A client had an open cholecystectomy (gallbladder removal) 36 hours earlier, and the nurse's assessment this morning confirms that the client has not yet had a bowel movement since prior to surgery. How should the nurse best respond to this assessment finding? A. Contact the physician to come assess the client. B. Immediately administer a cleansing enema. C. Monitor the client closely and promote fluid intake. D. Increase the rate of the client's intravenous infusion.

C. Monitor the client closely and promote fluid intake.

The nurse is caring for a client who had abdominal surgery yesterday and is reluctant to cough and perform deep breathing. Which strategy will most likely increase the client's willingness to cough and perform deep breathing? A. Remind the client of the serious complications that can result from ineffective coughing and deep breathing. B. Assist the client to a side-lying position to cough. C. Teach the client how to splint the abdomen while coughing. D. Administer respiratory treatments to encourage coughing.

C. Teach the client how to splint the abdomen while coughing.

A client has arrived to the postanesthesia care unit (PACU) and is drowsy with a respiratory rate of 12 breaths per minute. What would be an accurate interpretation by the nurse? A. The client should be returned to the operating room for further evaluation. B. The procedural physician should be notified immediately of client findings. C. This is an expected finding in the immediate postoperative period. D. The client needs to have the neurologic status fully evaluated.

C. This is an expected finding in the immediate postoperative period.

A 9-month-old baby is scheduled for heart surgery. When preparing this client for surgery, the nurse should consider which surgical risk associated with infants? A. Congestive heart failure B. Gastrointestinal upset C. Prolonged wound healing D. Potential for hypothermia or hyperthermia

D. Potential for hypothermia or hyperthermia

Which factor is most important in the nurse's decision on assessment data, outcomes, and the monitoring needs of a client in preparing for surgery? A. Age of client B. Client's support system C. Type of surgery D. Type of anesthesia

C. Type of surgery

When an older adult client is brought to the recovery room and presents with irregular, loud respirations, the nurse determines that this is most likely a result of: A. the normal return of reflexes. B. the effects of anesthesia. C. a partial airway obstruction. D. the type of surgery.

C. a partial airway obstruction.

The nurse knows the term perioperative phase refers to care given to the client: A. from the start of surgery until its conclusion. B. immediately after the operative phase. C. before, during, and after the operative phase. D. immediately before an operative procedure.

C. before, during, and after the operative phase.

An operating room nurse is bringing a client to the nurse in the postanesthesia care unit (PACU). Which information would the operating room nurse provide during a hand-off report? Select all that apply. A. all personnel present in operating room B. performance of time-out before surgery C. medications given in operating room D. length of surgery E. drains inserted in surgery

C. medications given in operating room D. length of surgery E. drains inserted in surgery

As a circulating nurse caring for a 45-year-old man undergoing left knee arthroscopic exploratory surgery, which task ensures that the team is on the same page and will perform the procedure on the right client and at the right site? A. operative site marking B. preoperative checklist C. procedural pause (time-out) D. informed consent

C. procedural pause (time-out)

The nurse recognizes that palliative surgery is performed for what purpose? A. to make or confirm a diagnosis B. to remove a part of the body that is diseased C. to lessen the intensity of an illness D. to restore function to tissue that is traumatized

C. to lessen the intensity of an illness

What is the nurse's role in the informed consent process for a surgical procedure? A. providing benefits and risks of the procedure B. granting permission for surgery to be done C. witnessing the signed informed consent document D. explaining what takes place during the procedure

C. witnessing the signed informed consent document

Which surgical client does the nurse in the preoperative setting anticipate having the greatest potential for surgical complications? A. 40-year-old client with type 2 diabetes mellitus and a history of anxiety B. 6-month-old client who has just been introduced to solid food C. 50-year-old overweight client with controlled hypertension D. 76-year-old client with a history of renal failure and chronic bronchitis

D. 76-year-old client with a history of renal failure and chronic bronchitis

A client has presented to the outpatient surgical center for a scheduled procedure. Which action should the nurse perform prior to the procedure? A. Have the client perform leg exercises every 30 minutes. B. Encourage the client to create an advance directive. C. Administer analgesia (pain medications). D. Assess the client's allergy status.

D. Assess the client's allergy status.

Which nursing action should the PACU nurse take to prevent postoperative complications in clients? A. Avoid turning the client in bed until the incision is no longer painful. B. Encourage the client to breathe shallowly to prevent collapse of the alveoli. C. Instruct the client to avoid coughing to prevent injury to the incision. D. Assist the client to do leg exercises to increase venous return.

D. Assist the client to do leg exercises to increase venous return.

A nurse is monitoring a client post cardiac surgery. What action would help to prevent cardiovascular complications for this client? A. Position the client in bed with pillows placed under his knees to hasten venous return. B. Keep the client from ambulating until the day after surgery. C. Keep the client cool and uncovered to prevent elevated temperature. D. Implement leg exercises and turn the client in bed every 2 hours.

D. Implement leg exercises and turn the client in bed every 2 hours.

A client is scheduled for hip replacement surgery this morning but admits to the nurse that he had a small piece of toast and some water after waking up. What is the nurse's most appropriate response? A. Ask the client if he did not understand the preoperative instructions. B. Assess the client's abdomen by inspection and auscultation. C. Explain the rationale for preoperative fasting to the client. D. Inform the anesthesiologist or surgeon of this fact.

D. Inform the anesthesiologist or surgeon of this fact.

A nurse teaches deep breathing exercises to a preoperative client. Which action should the nurse perform? A. Instruct the client to place the palms of both hands along the upper posterior rib cage. B. Instruct the client to breathe in through the nose as deeply as possible and hold the breath for 10 seconds. C. Assist or place the client in a supine position for the exercises. D. Instruct the client to exhale gently and completely before inhaling.

D. Instruct the client to exhale gently and completely before inhaling. The nurse should assist the client to sit up and place the palms of both hands along the lower anterior rib cage. The client should then exhale gently and completely inhale through the nose as deeply as possible, holding the breath for 3 seconds.

Which surgical clients will return to activities in their everyday lives more quickly? A. Open-heart surgery B. Vaginal hysterectomy C. Right nephrectomy D. Laparoscopic cholecystectomy

D. Laparoscopic cholecystectomy

A nurse asks a preoperative client which medications he is currently taking. Which statement describes an accurate guideline for client teaching regarding these medications? A. Cardiac drugs must be stopped for 1 week before surgery. B. If the client is diabetic and takes insulin, the dose will be increased before surgery. C. Aspirin is generally stopped 1 month before surgery. D. Many respiratory drugs may be taken the day of surgery per health care provider's order.

D. Many respiratory drugs may be taken the day of surgery per health care provider's order. Adjustments in taking medications may be needed before surgery. Anticoagulants are stopped days before surgery. Certain cardiac and respiratory drugs may be taken the day of surgery per health care provider's order. If the client is diabetic and takes insulin, the insulin dosage may be reduced.

The healthy adult client is given a narcotic prior to a surgical procedure. The nurse is completing the chart and notices the consent form was not signed by the client. Which of the following should the nurse do first? A. Ask the client if he still wants to proceed with the procedure. B. Immediately have the client sign the consent form. C. Have the client's family member sign the consent form. D. Notify the physician of the oversight.

D. Notify the physician of the oversight.

Which measure would the nurse implement for prevention of deep vein thrombosis (DVT) in a postoperative client? A. Elevate bilateral legs when the client is lying in bed. B. Encourage the client to elevate the head of the bed. C. Educate the client about the use of an incentive spirometer. D. Place graduated compression stockings on the client.

D. Place graduated compression stockings on the client.

The nurse is teaching the client who recently experienced abdominal surgery to deep breathe and cough effectively. What observable action serves to best minimize pain that may result from the intervention? A. Exhaling through the mouth with lips pursed to slowly empty the lungs B. Offering emotional support to help minimize concern of abdominal pain C. Supporting the head and shoulders effectively to prevent muscle strain D. Providing support to abdominal and accessory respiratory muscles

D. Providing support to abdominal and accessory respiratory muscles

Following a surgical procedure, who is generally responsible for moving the client to the recovery area? A. The orderly B. The surgeon C. The recovery nurses D. The anesthesiologist, circulating nurse, and surgeon

D. The anesthesiologist, circulating nurse, and surgeon

A female client age 54 years has been scheduled for a bunionectomy (removal of bone tissue from the base of the great toe) which will be conducted on an ambulatory basis. Which characteristic applies to this type of surgery? A. The surgery is classified as urgent rather than elective. B. The client must be previously healthy with low surgical risks. C. The surgery will be conducted using moderate sedation rather than general anesthesia. D. The client will be admitted the day of surgery and return home the same day.

D. The client will be admitted the day of surgery and return home the same day.

Which client in the postanesthesia care unit (PACU) requires the most immediate attention by the nurse? A. an 80-year-old client who is disoriented to place and time B. a 30-year-old client who is drowsy and reporting pain C. a 6-year-old client who is crying for a parent to visit D. a 26-year-old client who is exhibiting a crowing sound

D. a 26-year-old client who is exhibiting a crowing sound

The nurse recognizes the value of leg exercises in the prevention of postoperative thrombophlebitis. When should the nurse teach the correct technique for leg exercises to a client? A. in postanesthesia recovery B. upon transfer from the postanesthesia care unit (PACU) to the postoperative unit C. when early signs of venous stasis are evident D. prior to surgery

D. prior to surgery

A nurse from the ambulatory surgical center is preparing discharge instructions for a client who has had pelvic surgery. Which criterion would the client need to demonstrate to ensure that she is ready for discharge? A. verbalize absence of pain B. exhibit no bleeding C. eat without nausea D. void normally

D. void normally

A nurse is discussing a surgical procedure with a client who needs to sign his informed consent. Which of these tasks is part of the nursing role? A. determining for the client what other treatment options exist B. explaining to the client about potential risks of having the surgery C. describing how the client will benefit from the surgical procedure D. witnessing the client signature with their consent for surgery

D. witnessing the client signature with their consent for surgery