NUR 145 - Module A: Practice Questions
The intraoperative nurse is implementing a care plan that addresses the surgical client's risk for vomiting. Interventions that address the potential for vomiting reduce the risk of what subsequent surgical complication? a. Impaired skin integrity b. Hypoxia c. Malignant hyperthermia d. Hypothermia
b
A circulating nurse provides care in a surgical department that has multiple surgeries scheduled for the day. The nurse should know to monitor which client most closely during the intraoperative period because of the increased risk for hypothermia? a. A 74-year-old client with a low body mass index b. A 17-year-old client with traumatic injuries c. A 45-year-old client having an abdominal hysterectomy d. A 13-year-old client undergoing craniofacial surgery
a
A client has just been admitted to the postanesthesia care unit following abdominal surgery. As the client begins to awaken, the client is uncharacteristically restless. The nurse checks the skin, and it is cold, moist, and pale. The nurse is concerned the client may be at risk for which condition? a. Hemorrhage & shock b. Aspiration c. Postoperative infection d. Hypertension & dysrhythmias
a
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? a. The tube provides an airway for ventilation. b. The tube protect the client's esophagus from trauma. c. The client may receive an antiemetic through the tube. d. The client's vital signs can be monitored with the tube.
a
A clinic nurse is conducting a preoperative interview with an adult client who will soon be scheduled to undergo cardiac surgery. What interview question most directly addresses the client's safety? a. "What prescription and nonprescription medications do you currently take?" b. "Have you previously been admitted to the hospital, either for surgery or for medical treatment?" c. "How long do you expect to be at home recovering after your surgery?" d. "Would you say that you tend to eat a fairly healthy diet?"
a
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? a. Stay with the client & promptly notify the health care provider. b. Attempt to determine the cause of hemorrhage. c. Begin resuscitation. d. Put the client in the Trendelenburg position.
a
An OR nurse will be participating in the intra-operative phase of a client's kidney transplant. What action will the nurse prioritize in this aspect of nursing care? a. Monitoring the client's physiologic status b. Providing emotional support to family c. Maintaining the client's cognitive status d. Maintaining a clean environment
a
An operating room 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 which of the following? a. Sterile surfaces or articles may touch other sterile surfaces. b. Sterile supplies can be used on another client if the packages are intact. c. The outer lip of a sterile solution is considered sterile. d. The scrub nurse may pour a sterile solution form a nonsterile bottle.
a
One of the things a nurse has taught to a client during preoperative teaching is to have nothing by mouth for a specified time before surgery. The client asks the nurse why this is important. What is the most appropriate response for the client. a. "You will need to have food and fluid restricted before surgery so you are not at risk for aspiration." b. "The restriction of food or fluid will prevent the development of pneumonia related to decreased lung capacity." c. "The presence of food in the stomach interferes with the absorption of anesthetic agents." d. "By withholding food for 8 hours before surgery, you will not develop constipation in the postoperative period."
a
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? a. That preoperative teaching was performed b. That the family is aware of the length of the surgery c. That follow-up home care is not necessary d. That the family understands the client will be discharged immediately after surgery
a
The circulating nurse in an outpatient surgery center is assessing a client who is scheduled to receive moderate sedation. Which principle should guide the care of a client receiving this form of anesthesia? a. The client must never be left unattended by the nurse. b. The client should begin a course of antiemetics the day before surgery. c. The client should be informed that the client will remember most of the procedure. d. The client will most be able to maintain the client's own airway.
a
The nurse in pre-admission testing is educating a client about a scheduled surgery. Which response should the nurse give when the client asks about pain management following surgery? a. "Your nurse will use a pain assessment scale to help rate and treat your pain." b. "Wait to ask for pain medication until the pain becomes intolerable." c. "Lying still in bed will help control your pain." d. "Don't worry - most clients do not have much pain from this surgery."
a
The nurse is performing a pre-admission assessment of a client scheduled for a bilateral mastectomy. The nurse should recognize which purpose as a valid reason for pre-admission assessment? a. Verifies completion of preoperative diagnostic testing b. Discusses and reviews client's financial status c. Determines the client's suitability as a surgical candidate d. Informs the client of need for postoperative transportation
a
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? a. Hypothermia b. Pulmonary edema c. Cerebral ischemia D. Arthritis
a
The operating room nurse is participating in the appendectomy of a client who has a dangerously low body mass index. The nurse recognizes the client's consequent risk for hypothermia. Which action should the nurse implement to prevent the development of hypothermia? a. Ensure that intravenous (IV) fluids are warmed to the client's body temperature. b. Transfuse packed red blood cells to increase oxygen-carrying capacity. c. Wrap the client in drape that has been soaked in hot water. d. Monitor the client's blood pressure & hear rate vigilantly.
a
The perioperative nurse is preparing to discharge a client home from day surgery performed under general anesthesia. Which instruction should the nurse give the client prior to the client leaving the hospital? a. Do not drive yourself home. b. Take an over-the-counter (OTC) sleeping pill for 2 nights. c. Attempt to eat a large meal at home to aid wound healing. d. Remain in bed for the first 48 hours' postoperative.
a
The nurse is providing preoperative teaching to a client scheduled for hip replacement surgery in 1 month. During the preoperative teaching, the client gives the nurse a list of medications the client takes, along with their dosage and frequency. What intervention provides the client with the most accurate information? a. Instruct the client to stop taking St. John's wort at least 2 weeks prior to surgery due to its interaction with anesthetic agents. b. Instruct the client to continue taking ephedrine prior to surgery due to its beneficial effect on blood pressure. c. Instruct the client to discontinue levothyroxine sodium due to its effect on blood coagulation and the potential for heart dysrhythmias. d. Instruct the client to continue any herbal supplements unless otherwise instructed, and inform the client that these supplements have a minimal effect on the surgical procedure.
a - Because of the potential effects of herbal medications on coagulation and potential lethal interactions with other medications. - Recommended that the use of herbal products be discontinued at least 2 weeks before surgery.
The nurse is performing the shift assessment of a postsurgical client. The nurse finds the client's mental status, level of consciousness, speech, and orientation are intact and at baseline, but the client appears unusually restless. What should the nurse do next? a. Assess the client's oxygen levels. b. Administer antianxiety medications. c. Page the client's health care provider. d. Initiate a social work referral.
a - although a change in mental status or postoperative restlessness may be related to anxiety, pain, or medications, it may also be a symptom of oxygen deficit or hemorrhage.
The perioperative nurse is providing care for a client who is recovering on the postsurgical unit following a transurethral prostate resection (TUPR). The client is reluctant to ambulate, citing the need to recover in bed. For what complication is the client most at risk? a. Atelectasis b. Anemia c. Dehydration d. Peripheral edema
a - atelectasis occurs when the postoperative client fails to move, cough, and breathe deeply.
The operating room nurse acts in the circulating role during a client's scheduled cesarean section. For which task is this nurse responsible? a. Performing documentation b. Estimating the client's blood loss c. Setting up the sterile tables d. Giving the surgeon instruments during surgery
a - main responsibilities of circulating nurse include verifying consent; coordinating the team; and ensuring cleanliness, proper temperature & humidity, lighting, safe function of equipment, and availability of supplies & materials.
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? a. Trendelenburg b. Prone c. Dorsal recumbent d. Lithotomy
a - shoulder braces must be well padded to prevent irreparable nerve injury, especially when the Trendelenburg position is necessary.
A nurse in the preoperative holding area is admitting a woman prior to reduction mammoplasty. What should the nurse include in the care given to this client? Select all that apply. a. Establishing an IV line b. Verifying the surgical site with the client c. Taking measures to ensure the client's comfort d. Applying a grounding device to the client e. Preparing the medications to be given in the OR
a, b , c
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. a. Absence of reflexes b. Diminished ability to communicate c. Loss of pain sensation d. Nausea resulting from anesthetic e. Reduced blood pressure
a, b, c
The nurse in pre-admission testing learns that a client scheduled for a total hip replacement in three weeks smokes one pack of cigarettes per day. Which action(s) should the nurse take? Select all that apply. a. Notify the surgeon that the client is a cigarette smoker. b. Encourage smoking cessation before surgery. c. Explain the increased risk for venous thromboembolism after surgery. d. Tell the client to stop smoking the day before surgery. e. Provide resources for smoking cessation.
a, b, c, e
The PACU nurse is caring for a client who had minimally invasive knee surgery. Which actions are the responsibility of the nurse in the PACU? Select all that apply. a. Monitoring the safe recovery from anesthesia b. Answering family questions about recovery c. Ensuring that informed consent has been signed d. Providing light nourishment e. Assessing the operative sight for hemorrhage
a, b, d, e
The nurse is planning the care of a client who has type 1 diabetes and who will be undergoing knee replacement surgery. This client's care plan should reflect an increased risk of what post-surgical complication(s)? Select all that apply. a. Hypoglycemia b. Delirium c. Acidosis d. Glucosuria e. Fluid overload
a, c, d
The nurse is developing a plan of care for a client having surgery under general anesthesia. Which nursing diagnos(es) would be appropriate? Select all that apply. a. Risk for compromised human dignity related to general anesthesia. b. Risk for impaired nutrition: less than body requirements related to anesthesia. c. Risk of latex allergy response related to surgical exposure. d. Disturbed body image related to anesthesia. e. Anxiety related to surgical concerns.
a, c, e
The surgical nurse is preparing to send a client from the pre-surgical area to the OR and is reviewing the client's informed consent form. What are the criteria for legally valid informed consent? Select all that apply a. Consent must be freely given. b. Consent must be notarized. c. Consent must be signed on the day of surgery. d. Consent must be obtained by a health care provider. e. Signature must be witnessed by a professional staff member.
a, d, e
A client is 2 hours' postoperative with an indwelling urinary catheter. The last hourly urine output recorded for this client was 10 mL. The tubing of the catheter is confirmed to be patent. What should the nurse do? a. Irrigate the catheter with 30 mL normal saline. b. Notify the health care provider & continue to monitor the hourly urine output. c. Decrease the intravenous fluid rate & massage the client's abdomen. d. Have the client sit in high-Flower position.
b
A client is being asked to choose between an ambulatory surgical center and a hospital-based surgical unit. What guidance should the nurse provide? a. "Clients who go to ambulatory surgery centers are more independent." b. "Clients admitted to the hospital for surgery usually have multiple needs." c. "In most cases, only emergency & trauma clients are admitted to the hospital." d. "Clients who have surgery in the hospital are those who need to have anesthesia given."
b
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? a. Encourage light ambulation. b. Place the bed in a low position with the side rails up. c. Tell the client that the client will be asleep before it is time to leave for surgery. d. Take the client's vital signs every 15 minutes.
b
A client's coronary artery bypass graft has been successful, and discharge planning is underway. When planning the client's subsequent care, the nurse should know that the postoperative phase of perioperative nursing ends at what time? a. When the client is returned to the room after surgery b. When a follow-up evaluation in the clinical or home setting is done c. When the client is fully recovered from all effects of the surgery d. When the family becomes partly responsible for the client's care
b
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? a. Leg exercises increase the client's muscle mass postoperatively. b. Leg exercises improve circulation and prevent venous thrombosis. c. Leg exercises help to prevent pressure sores to the sacrum and heels. d. Leg exercises help increase the client's level of consciousness after surgery.
b
A presurgical client asks, "Why will I go to the postanesthesia care unit (PACU) instead of just going straight up to the postsurgical unit?" Which response by the nurse would be best? a. "It allows recovery from anesthesia in a stimulating environment to facilitate awakening & reorientation." b. "It allows us to observe you until you're oriented & have stable vital signs & no complications." c. "The medical-surgical unit is short of beds, and the PACU is an excellent place to triage clients." d. "The surgeon likely will need to reinforce or alter your incision in the hours following surgery."
b
A surgical client has been given general anesthesia and is in stage II (the excitement stage) of anesthesia. Which intervention would be most appropriate for the nurse to implement during this stage? a. Rub the client's back. b. Provide for client safety. c. Encourage the client to express feelings. D. Stroke the client's hand.
b
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? a. Assist the client to the bathroom. b. Offer the client a bedpan or urinal. c. Wait until the client gets to the operating room and is catheterized. d. Have the client go to the bathroom.
b
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? a. Last bowel movement b. Latex allergy c. Number of pregnancies D. Difficulty falling asleep
b
The client's surgery is nearly finished and the surgeon has opted to use tissue adhesives to close the surgical wound. This requires the nurse to prioritize assessments related to what complication? a. Hypothermia b. Anaphylaxis c. Infection d. Malignant hyperthermia
b
The nurse is caring for an unconscious trauma client who needs emergency surgery. The client has an adult child, is legally divorced, and is planning to marry a partner in a few weeks. The client's parents are at the hospital with the other family members. The health care provider has explained the need for surgery, the procedure to be done, and the risks to the child, the parents, and the partner. Who should be asked to sign the surgery consent form? a. The partner b. The child c. The health care provider, acting as a surrogate d. The client's father
b
The nurse is performing a preoperative assessment on a client going to surgery. The client reports to the nurse he's been drinking approximately two bottles of wine each day for the last several years. What postoperative difficulties should the nurse anticipate for this client? a. Nonadherence to prescribed treatment after surgery b. Increased risk for postoperative complications c. Alcohol withdrawal syndrome upon administration of general anesthesia d. Increased risk for allergic reactions
b
The nurse is preparing a client for surgery. The client reports being nervous and not really understanding the surgical procedure or its purpose. What is the most appropriate action for the nurse to take? a. Have the client sign the informed consent and place it in the chart. b. Call the health care provider to review the procedure with the client. c. Explain the procedure clearly to the client and the family. d. Provide the client with a pamphlet explaining the procedure.
b
The nurse is preparing to change a client's abdominal dressing. The nurse recognizes that the first step is to provide the client with information regarding the procedure. Which explanation should the nurse provide to the client? a. "The dressing change is often painful, so we will give you pain medication beforehand." b. "I will provide privacy. The dressing change should not be painful; you may look at the incision and help." c. "The dressing change should not be painful, but you can never be sure, and infection is always a concern." d. "The best time for a dressing change is during lung. I will provide privacy, and it should not be painful."
b
The nurse is providing preoperative teaching to a client scheduled for surgery. The nurse is instructing the client on the use of deep breathing, coughing, and the use of incentive spirometry when the client states, "I don't know why you're focusing on my breathing. My surgery is on my hip, not my chest." What rationale for these instructions should the nurse provide? a. To prevent chronic obstructive pulmonary disease (COPD) b. To promote optimal lung expansion c. To enhance peripheral circulation d. To prevent pneumothorax
b
The nurse is taking the client into the operating room (OR) when the client informs the nurse that the client's grandparent spiked a very high temperature in the OR and nearly died 15 years ago. What relevance does this information have regarding the client? a. The client may be experiencing presurgical anxiety. b. The client may be at risk for malignant hyperthermia. c. The grandparents surgery has minimal relevance to the client's surgery. d. The client may be at risk for a sudden onset of postsurgical infection.
b
The nurse knows that older clients are at higher risk for complications and adverse outcomes during the intraoperative period. What is the best rationale for this phenomenon? a. A more angular bone structure than a younger person b. Reduced ability to adjust rapidly to emotional & physical stress c. Increase susceptibility to hyperthermia d. Impaired ability to decrease one's metabolic rate
b
Verification that all required documentation is completed is an important function of the intraoperative nurse. The intraoperative nurse should confirm that the client's accompanying documentation includes which of the following? a. Discharge planning b. Informed consent c. Analgesia prescription d. Educational resources
b
While the surgical client is anesthetized, the scrub nurse hears a member of the surgical team make an inappropriate remark about the client's weight. How should the nurse best respond? a. Ignore the comment because the client is unconscious. b. Discourage the colleague from making such comments. c. Report the comment immediately to a supervisor. d. Realize that humor is needed in the workplace.
b
An operating room (OR) nurse is teaching a nursing student about the principles of surgical asepsis as a requirement in the restricted zone of the operating suite. Which personal protective equipment should the nurse wear at all times in the restricted zone of the OR? a. Bubble mask b. Mask covering the nose & mouth c. Goggles d. Gloves
b - Masks are worn at all times in the restricted zone of the OR. In hospitals where numerous total joint procedures are performed, a complete bubble mask may be used. This mask provides full-barrier protection from bone fragments & splashes. Goggles & gloves are worn as required, but not necessarily at all times.
The operating room nurse will be caring for a client who will receive a transsacral block. The use of a transsacral block for pain control would be most appropriate for a client undergoing which procedure? a. Thoracotomy b. Inguinal hernia repair c. Reduction mammoplasty d. Closed reduction of a right humerus fracture
b - a transsacral block produces anesthesia for the perineum and lower abdomen.
The nurse is creating the plan of care for a postoperative client for reduction of a femur fracture. Which goal is the most important short-term goal for this client? a. Relief of pain b. Adequate respiratory function c. Resumption of activities of daily living (ADLs) d. Unimpaired wound healing
b - maintenance of the client's airway and breathing are imperative.
The nurse admits a client to the postanesthesia care unit 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. This client is showing signs of what potential issue? a. Hypothermia b. Hypovolemic shock c. Neurogenic shock d. Malignant hyperthermia
b - neurogenic shock doesn't normally result in tachycardia - malignant hyperthermia would rarely present at this stage in the operative experience - hypothermia doesn't cause hypotension & tachycardia
The nurse is caring for a client who is postoperative day 2 following a colon resection. While turning the client, wound dehiscence with evisceration occurs. What should be the nurse's first response? a. Return the client to the previous position & call the health care provider. b. Place saline-soaked sterile dressings on the wound. c. Assess the client's blood pressure & pulse. d. Pull the dehiscence closed using gloved hands.
b - place saline-soaked sterile dressings on the open wound to prevent tissue drying & possible infection. - then call the health care provider & take the client's vital signs.
The postanesthesia care unit nurse is caring for a client who has arrived from the operating room. 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. Which intervention is the priority? a. Check the client's oxygen saturation level, & monitor for apnea. b. Tilt the head back & push forward on the angle of the lower jaw. c. Assess the arterial pulses, and place the client in the Trendelenburg position. d. Reintubate the client, and perform a focused assessment.
b - when a nurse finds a client who is not breathing, the priority intervention is to open the airway & treat a possible hypopharyngeal obstruction. - reintubation & resuscitation would begin after rapidly ruling out a hypopharyngeal obstruction.
A surgical nurse is preparing to enter the restricted zone of the operating room. Which surgical attire should this nurse wear? Select all that apply. a. Street clothes b. Cap c. Mask d. Shoe covers e. Scrub clothes
b, c, d, e
A client is scheduled for a bowel resection in the morning and the client's orders are for a cleansing enema to be administered tonight. The client wants to know why this is necessary. The nurse should explain that the cleansing enema will have what therapeutic effect? a. Preventing aspiration of gastric contents b. Preventing the accumulation of abdominal gas postoperatively c. Preventing potential contamination of the peritoneum d. Facilitating better absorption of medications
c
A client will be undergoing a total hip arthroplasty later in the day and it is anticipated that the client may require blood transfusion during surgery. How can the nurse best ensure the client's safety if a blood transfusion is required? a. Prime IV tubing with a unit of blood & keep it on hold. b. Check that the client's electrolyte levels have been assessed preoperatively. c. Ensure that the client has had a current cross-match. d. Keep the blood on standby & warmed to body temperature.
c
An older adult client is scheduled for a bilateral mastectomy. The OR nurse has come out to the holding area to meet the client and quickly realizes that the client is profoundly anxious. What is the most appropriate intervention for the nurse to apply? a. Reassure the client that modern surgery is free of significant risks. b. Describe the surgery to the client in as much detail as possible. c. Clearly explain any information that the client seeks. d. Remind the client that the anesthetic will render the client unconscious.
c
In anticipation of a client's scheduled surgery, the nurse is teaching the client to perform deep breathing and coughing to use postoperatively. What action should the nurse teach the client? a. The client should take three deep breaths and cough hard three times, at least every 15 minutes for the immediate postoperative period. b. The client should take three deep breaths and exhale forcefully and then take a quick short breath and cough from deep in the lungs. c. 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. d. The client should rapidly inhale, hold for 30 seconds or as long as possible, and exhale slowly
c
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? a. 2 feet (60 cm) b. 18 inches (45 cm) c. 1 foot (30 cm) d. 6 inches (15 cm)
c
The ED nurse is caring for an 11-year-old brought in by ambulance after having been hit by a car. The child's parents are thought to be en route to the hospital but have not yet arrived. No other family members are present, and attempts to contact the parents have been unsuccessful. The child needs emergency surgery to survive. How should the need for informed consent be addressed? a. A social worker should temporarily sign the informed consent. b. Consent should be obtained from the hospital's ethics committee. c. Surgery should be done without informed consent. d. Surgery should be delayed until the parents arrive.
c
The circulating nurse will be participating in a 78-year-old client's total hip replacement. Which consideration should the nurse prioritize during the preparation of the client in the operating room? a. The client should be placed in Trendelenburg position. b. The client must be firmly restrained at all times. c. Pressure points should be assessed and well padded. d. The preoperative shave should be done by the circulating nurse.
c
The clinic nurse is doing a preoperative assessment of a client who will be undergoing outpatient cataract surgery with lens implantation in 1 week. While taking the client's medical history, the nurse notes that this client had a kidney transplant 8 years ago and that the client is taking immunosuppressive drugs. For what is this client at increased risk when having surgery? a. Rejection of the kidney b. Rejection of the implanted lens c. Injection d. Adrenal storm
c
The intraoperative nurse advocates for each client who receives care in the surgical setting. How can the nurse best exemplify the principles of client advocacy? a. By encouraging the client to perform deep breathing preoperatively. b. By limiting the client's contact with family members preoperatively. c. By maintaining the privacy of each client d. By eliciting informed consent from clients
c
The intraoperative nurse is transferring a client from the OR to the PACU after replacement of the right knee. The client is an older adult. The nurse should prioritize which of the following actions? a. Keeping the client sterile b. Keeping the client restrained c. Keeping the client warm d. Keeping the client hydrated
c
The intraoperative nurse knows that the client's emotional state can influence the outcome of the surgical procedure. How should the nurse best address this? a. Teach the client strategies for distraction. b. Pair the client with another client who has better coping strategies. c. Incorporate cultural and religious considerations, as appropriate. d. Give the client antianxiety medication.
c
The nurse in the preoperative area places a warmed blanket on a client. Which reason does the nurse give the client for this action? a. Hypothermia assists in the induction of anesthesia. b. Warming reduces the risk of postoperative infection. c. The risk of bleeding is increased with hypothermia. d. The length of hospital stay is increased with warming.
c
The nurse is caring for a 78-year-old client who has had an outpatient cholecystectomy. The nurse is getting the client up for the first walk postoperatively. To decrease the potential for orthostatic hypotension and consequent falls, what should the nurse have the client do? a. Sit in a chair for 10 minutes prior to ambulating. b. Drink plenty of fluids to increase circulating blood volume. c. Stand upright for 2 to 3 minutes prior to ambulating. d. Perform range-of-motion exercises for each joint.
c
The nurse is caring for a client in the postanesthesia care unit after abdominal surgery. The client's blood pressure has increased, and the client is restless. The client's oxygen saturation is 97%. Which factor should the nurse first suspect as the cause for this change in status? a. Hypothermia B. Shock c. Pain d. Hypoxia
c
The nurse is caring for a client on the medical-surgical unit postoperative day 5. During each client assessment, the nurse evaluates the client for infection. Which of the following would be most indicative of infection? a. Presence of an indwelling urinary catheter. b. Oral temperature of 99.5 F c. Red, warm, tender incision d. White blood cell (WBC) count of 8,000/mL
c
The nurse is caring for a client who anticipates pain and anxiety following surgery. Which intervention should the nurse implement in the postoperative period to reduce the client's pain and anxiety? a. Administer NSAIDs for mild-to-moderate pain. b. Encourage the client to increase activity. c. Use guided imagery along with pain medication. d. Teach deep breathing and coughing exercises.
c
The nurse is caring for a client who has returned to the postsurgical unit following abdominal surgery. The client is unable to ambulate and is now refusing to wear external pneumatic compression stockings. The nurse should explain that refusing to wear external pneumatic compression stockings increases the risk of which postsurgical complication? a. Sepsis b. Infection c. Pulmonary embolism d. Hematoma
c
The nurse is caring for a client who is admitted to the ER with the diagnosis of acute appendicitis. The nurse notes during the assessment that the client's ribs and xiphoid process are prominent. The client reports exercising two to three times daily, and the client's parent indicates that the client is being treated for anorexia nervosa. How should the nurse best follow up on these assessment data? a. Inform the postoperative team about the client's risk for wound dehiscence. b. Evaluate the client's ability to manage pain level. c. Facilitate a detailed analysis of the client's electrolyte levels. d. Instruct the client on the need for a high-sodium diet to promote healing.
c
The nurse is caring for a trauma victim in the ED who will require emergency surgery due to injuries. Before the client leaves the ED for the OR, the client goes into cardiac arrest. The nurse assists in a successful resuscitation and proceeds to release the client to the OR staff. When can the ED nurse perform the preoperative assessment? a. When the nurse has the opportunity to review the client's electronic health records b. When the client arrives in the OR c. When assisting with the resuscitation d. Preoperative assessment is not necessary in this case
c
The nurse is caring for an older adult client in the postanesthesia care unit. The client begins to awaken and responds to their name, but is confused, restless, and agitated. Which principle should guide the nurse's subsequent assessment? a. Postoperative confusion in older adults is an indication of impaired oxygenation or possibly a stroke during surgery. b. Confusion, restlessness, and agitation are expected postoperative findings in older adults, and they will diminish in time. c. Postoperative confusion is common in the older adult client, but it could also indicate a significant blood loss. d. Confusion, restlessness, and agitation indicate an underlying cognitive deficit such as dementia.
c
The nurse is performing wound care on a postsurgical client. Which practice violates the principles of surgical asepsis? a. Holding sterile objects at chest level b. Allowing a sterile instrument to touch a sterile drape c. A circulating nurse touching a sterile drape d. Considering an unopened sterile package to be sterile
c
The nurse is preparing a client for surgery prior to her hysterectomy without oophorectomy. The nurse is witnessing the client's signature on a consent form. Which comment by the client would best indicate informed consent? a. "I know I'll be fine because the health care provider has done this procedure hundreds of times." b. "I know I'll have pain after the surgery but they'll do their best to keep it to a minimum." c. "The health care provider is going to remove my uterus and told me about the risk of bleeding." d. "Because the health care provider isn't taking my ovaries, I'll still be able to have children."
c
The operating room nurse is providing care for a major trauma client who has been involved in a motorcycle accident. Which intraoperative change may suggest the presence of anesthesia awareness? a. Respiratory depression b. Sudden hypothermia & diaphoresis c. Vital sign changes & client movement d. Bleeding beyond what is anticipated
c
The nurse is checking the informed consent for an older adult who requires surgery and who has recently been diagnosed with Alzheimer disease. When obtaining informed consent, who is legally responsible for signing? a. The client's next of kin b. The client's spouse c. The client D. The surgeon
c - Just because a client has been diagnosed with Alzheimer disease doesn't mean the client is not competent to provide informed consent. - Because there is no evidence that this client is legally incompetent, the client would be required to personally provide informed consent.
A client is admitted to the ED reporting severe abdominal pain & vomiting "coffee-ground" like emesis. The client is diagnosed with a perforated gastric ulcer and is informed that they need surgery. When can the client most likely anticipate that the surgery will be scheduled? a. Within 24 hours b. Within the next week c. Without delay d. As soon as all the day's elective surgeries have been completed
c - an active bleed, which is indicated by the "coffee-ground" emesis, is considered an emergency, and the client requires immediate attention because the disorder may be life threatening.
The nurse is caring for a postoperative client with a history of congestive heart failure and peptic ulcer disease. The client is highly reluctant to ambulate and will not drink fluids except for hot tea with meals. The client's vital signs are slightly elevated, and the client has a nonproductive cough. The nurse auscultates crackles at the base of the lungs. Which complication should the nurse first suspect? a. Pulmonary embolism b. Hypervolemia c. Hypostatic pulmonary congestion d. Malignant hyperthermia
c - hypostatic pulmonary congestion, caused by a weakened cardiovascular system, that permits stagnation of secretions at lung base, may develop. - symptoms are vague; slight elevation of temperature, pulse, and respiratory rate, as well as a cough.
The nurse just received a postoperative client from the postanesthesia care unit to the medical-surgical unit. The client had surgery for a left hip replacement. Which concern should the nurse prioritize for this client in the first few hours on the unit? a. Beginning early ambulation b. Maintaining clean dressings on the surgical site c. Closely monitoring neurologic status d. Resuming normal oral intake
c - in the initial hours after admission to the clinical unit, adequate ventilation, hemodynamic stability, incisional pain, surgical site integrity, nausea & vomiting, neurologic status, and spontaneous voiding are primary concerns.
The nurse is caring for a client who has had spinal anesthesia. The client is under a health care provider's order to lie flat postoperatively. When the client asks to go to the bathroom, the nurse encourages the client to adhere to the health care provider's order. Prevention of which outcome should the nurse include in the rationale for complying with this order? a. Hypotension b. Respiratory depression c. Headache d. Pain at the lumbar injection site
c - lying flat reduces the risk of headache after spinal anesthesia.
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? a. Increased temperature b. Oliguria c. Tachycardia d. Hypotension
c - the initial symptoms of malignant hyperthermia are related to cardiovascular & musculoskeletal activity. - tachycardia (HR >150 bpm) is often the earliest sign.
A 90-year-old client is scheduled to undergo surgery. Prevention of which potential complication should the nurse prioritize when planning this client's postoperative care? a. Reduced concentration related to stress b. Delayed growth and development due to a prolonged hospitalization c. Decision conflict related to discharge planning d. Pneumonia due to reduced respiratory reserve
d
A nurse is caring for a client following knee surgery that was performed under a spinal anesthetic. What intervention should the nurse implement to prevent a spinal headache? a. Seat the client in a chair and have them perform deep breathing exercises. b. Ambulate the client as early as possible. c. Limit the client's fluid intake for the first 24 hrs postoperatively. d. Keep the client positioned supine.
d
Prior to a client's scheduled surgery, the nurse has described the way that members of diverse health disciplines will collaborate in the client's care. What is the main rationale for organizing perioperative care in this collaborative manner? a. Historical precedent b. Client requests c. Health care providers' needs d. Evidence-based practice
d
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? a. Wait for the client to initiate dialogue. b. Avoid making eye contact. c. Give preoperative medications prior to discussion. d. Use a tone that decreases the client's anxiety.
d
The nurse is admitting a client who is insulin dependent to the same-day surgical suite for carpal tunnel surgery. How should this client's diagnosis of type I diabetes affect the care that the nurse plans? a. The nurse should administer a bolus of dextrose IV solution preoperatively. b. The nurse should keep the client NPO for at least 8 hours preoperatively. c. The nurse should initiate a subcutaneous infusion of long-acting insulin. d. The nurse should assess the client's blood glucose levels frequently.
d
The nurse is caring for a client who is scheduled to have a needle biopsy of the pleura. The client has had a consultation with the anesthesiologist, and a conduction block will be used. Which local conduction block can be used to block the nerves leading to the chest? a. Transsacral block b. Brachial plexus block c. Pudendal block d. Paravertebral block
d
The nurse is caring for a hospice client who is scheduled for a surgical procedure to reduce the size of a spinal tumor in an effort to relieve pain. The nurse should plan this client care with the knowledge that this surgical procedure is classified as which of the following? a. Diagnostic b. Laparoscopic c. Curative d. Palliative
d
The nurse is creating the care plan for a 70-year-old obese client who has been admitted to the post-surgical unit following a colon resection. This client's age and body mass index increases the risk for what complication in the postoperative period? a. Hyperglycemia b. Azotemia c. Falls d. Infection
d
The nurse is doing preoperative client education with a client who has a 40 pack-year history of cigarette smoking. The client will undergo an elective bunionectomy at a time that fits his work schedule in a few months. What would be the best instruction to give to this client? a. Reduce smoking by 50% to prevent the development of pneumonia. b. Continue smoking so as to help manage stress levels before and after surgical. c. Aim to quit smoking in the postoperative period to reduce the chance of surgical smplications. d. Stop smoking as soon as possible before the scheduled surgery to enhance pulmonary function and decrease infection.
d
The nurse is packing a client's abdominal wound with sterile, half-inch Iodoform gauze. During the procedure, the nurse drops some of the gauze onto the client's abdomen 2 inches (5 cm) away from the wound. What should the nurse do? a. Apply povidone-iodine (Betadine) to that section of the gauze & continue packing the wound. b. Pick up the gauze & continue packing the wound after irrigating the abdominal wound with Betadine solution. c. Continue packing the wound & inform the health care provider that an antibiotic is needed. d. Discard the gauze packing & repack the wound with new Iodoform gauze.
d
The nurse is planning 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? a. Upon the client's admission to the post anesthesia care unit (PACU) b. When the client returns from the PACU c. During the intraoperative period d. As soon as possible, and before the surgical procedure
d
The postanesthesia care unit nurse is caring for a client who had a hernia repair. The client's blood pressure is now 164/92 mm Hg; the client has no history of hypertension prior to surgery and preoperative blood pressure was 112/68 mm Hg. The nurse should assess for which potential causes of hypertension following surgery? a. Dysrhythmias, blood loss, & hyperthermia b. Electrolyte imbalances & neurologic changes c. A parasympathetic reaction & low blood volumes d. Pain, hypoxia, & bladder distention
d
The recovery room nurse is admitting a client from the OR following the client's successful splenectomy. What is the first assessment that the nurse should perform on this newly admitted client? a. Heart rate & rhythm b. Skin integrity c. Core body temperature d. Airway patency
d
The perioperative nurse knows that the National Client Safety Goals have the potential to improve client outcomes in a wide variety of health care settings. Which of these goals has the most direct relevance to the OR? a. Improve safety related to medication use. b. Reduce the risk of client harm resulting from falls. c. Reduce the incidence of health care-associated infections. d. Reduce the risk of fires.
d - The National Client Safety Goals all pertain to the perioperative areas, but the one with the most direct relevance to the OR is the reduction of the risk of surgical fires.
The nurse's aide notifies the nurse that a client has decreased oxygen saturation levels. The nurse assesses the client and finds that the client is tachypneic, has crackles on auscultation, and has frothy and pink sputum. The nurse should suspect which complication? a. Pulmonary embolism b. Atelectasis c. Laryngospasm d. Flash pulmonary edema
d - flash pulmonary edema occurs when protein & fluid accumulate in the alveoli unrelated to elevated pulmonary artery occlusive pressure. - s/s: agitation, tachypnea, tachycardia, decreased pulse oximetry readings, frothy, pink sputum, & crackles on auscultation.
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? a. Dorsal recumbent position b. Trendelenburg position c. Sims position d. Lithotomy position
d - the lithotomy position is used for nearly all perineal, rectal, and vaginal surgical procedures.
A client is in the recovery room following a nephrectomy performed for the treatment of renal cell carcinoma. The client's vital signs and level of consciousness have stabilized, but the client then reports severe nausea and begins to vomit. What should the nurse do next? a. Administer a dose of intravenous analgesic. b. Apply a cool cloth to the client's forehead. c. Offer the client a small amount of ice chips. d. Turn the client to one side.
d - turning the client to one side allows collected fluid to escape from the side of the mouth if the client vomits. - after turning the client to the side, the nurse can offer a cool cloth to the client's forehead.
