Practice Quiz

The patient is to take nothing by mouth after 0400. The nurse recognizes that the patient has deficient knowledge when he states that he: brushed his teeth at 0400 but did not swallow. ate a gelatin dessert at 0330. held a cold wash cloth against his lips. smoked a cigarette at 0600.

smoked a cigarette at 0600.

Three days after surgery, a patient continues to take hydrocodone 7.5mg and acetaminophen 500mg for postoperative pain. What should the nurse ask the patient before administering the pain medication? "Is your pain better than before you had surgery?" "Have you emptied your bladder?" "When did you last have a bowel movement?" "How long has it been since your last dose?"

"When did you last have a bowel movement?" The nurse should ask the patient about having a bowel movement because acetaminophen with hydrocodone is an opioid, which can be constipating. By the 3rd day, many clients become constipated and are feeling distended, with sharp cramping pain due to gas, which is treated with ambulation, not more opioids.

A patient arrives from surgery to the postanesthesia care unit. Which respiratory assessment should the nurse complete first? Airway flow. Respiratory rate. Oxygen saturation. Breath sounds.

Airflow

Which patient is most at risk for potential complications from the surgical experience? A 50-year old patient. A 15-year old patient. An 80-year old patient. A 30-year old patient.

An 80-year old patient.

After surgery your patient starts to shiver uncontrollably. What nursing intervention would you do first? Take the patient's rectal temperature. Page the doctor for further orders. Apply warm blankets & continue oxygen as prescribed. Adjust the thermostat in the room.

Apply warm blankets & continue oxygen as prescribed.

The patient had undergone thyroidectomy. Which of the following are the earliest signs of poor tissue perfusion and poor respiratory function?\ Faintness and pallor. Apprehension, anxiousness, and restlessness. Cyanosis, lethargy. Fast thready pulse, bradypnea.

Apprehension, anxiousness, and restlessness.

When the patient vomits, the most important nursing objective is to prevent: Metabolic alkalosis. Aspiration. Rupture of suture line. Dehydration

Aspiration

The nurse receives a telephone call from the postanesthesia care unit stating that a client is being transferred to the surgical unit. The nurse plans to take which action first on arrival of the client? Check the dressing to assess for bleeding. Assess the patency of the airway. Assess the vital signs to compare with preoperative measurements. Check tubes or drains for patency.

Assess the patency of the airway. The first action of the nurse is to assess the patency of the airway and respiratory function. If the airway is not patent, the nurse must take immediate measures for the survival of the client. The nurse then takes vital signs followed by checking the dressing and the tubes or drains. The other nursing actions should be performed after a patent airway has been established.

A patient has accidentally received twice the normal dose of a medication that was administered on the previous shift. What should the nurse who discovers the error do first? Call the healthcare provider (HCP) to obtain a prescription for additional IV fluids to dilute the drug. Administer a drug antidote per standing prescription. Call the person who made the error, and request that an incident report be completed. Assess the patient, and note any changes in condition.

Assess the patient, and note any changes in condition.

Which activity takes priority in the patient's nursing care? Providing oral care after meals. Assisting with ambulation post-operatively. Reviewing health care provider orders. Assessing respiratory status.

Assessing respiratory status.

On the first postoperative day, a patient develops a fever. The nurse auscultates crackles bilaterally in the lower lobes. The nurse understands which complication of surgery is probably developing? Pulmonary embolism. Heart failure. Atelectasis. Thrombophlebitis.

Atelectasis Atelectasis is the most probable cause for the crackles; with atelectasis, secretions block the bronchioles and the alveoli collapse causing hypoventilation.

A pediatric nurse is preparing a child for cleft palate repair surgery. The nurse recognizes that this type of surgery is categorized as which of the following? Transplantation surgery. Constructive surgery. Palliative surgery. Reconstructive surgery.

Constructive surgery.

A patient who is scheduled for an open cholecystectomy has been smoking a pack of cigarettes a day for 20 years. For which postoperative complication is the patient most at risk? Prolonged immobility. Hyperemesis. Delayed wound healing. Atelectasis.

Atelectasis. The patient who has a significant cigarette smoking history and an operative manipulation close to the diaphragm (the gallbladder is against the liver) is at increased risk for atelectasis and pneumonia. Postoperatively, this patient will be reluctant to deep breathe because of pain, in addition to having residual lung damage from smoking. Therefore, the patient is at greater than average risk for pulmonary complications. The patient does not have an increased risk of prolonged immobility (unless slowed by respiratory problem) or delayed wound healing (as long as the patient maintains appropriate nutrition).

Which of the following drugs is administered to minimize respiratory secretions preoperatively? Demerol (meperidine) Valium (diazepam). Atropine Sulfate. Phenergan (promethazine).

Atropine Sulfate. Atropine sulfate, an anticholinergic, minimizes respiratory secretions preoperatively. It helps aspiration of secretions.

A postoperative patient vomited. After cleaning and comforting the patient, which action by the nurse is most important? Auscultate lung sounds. Encourage the patient to eat dry toast. Document the episode. Allow the patient to rest.

Auscultate lung sounds. Vomiting after surgery has several complications, including aspiration. The nurse should listen to the patient's lung sounds. The patient should be allowed to rest after an assessment. Documenting is important, but the nurse needs to be able to document fully, including an assessment. The patient should not eat until nausea has subsided.

The nurse is precepting a student nurse and explains that perioperative nursing care occurs: During the surgical procedure. In the post anesthesia care unit. In preadmission testing. Before, during, and after surgery.

Before, during, and after surgery.

As the nurse you are getting the patient ready for surgery. You are completing the preoperative checklist. Which of the following is not part of the preoperative checklist? Informed consent is signed. Conducting the Time Out. Ensuring that the history and physical examination has been completed. Assess for allergies.

Conducting the Time Out. The time out is conducted by the OR nurse in the intraoperative phase prior to surgery. All of the other options are conducted by the nurse getting the patient ready for surgery during the preoperative phase.

The nurse is admitting a patient to the operating room. Which of the following nursing actions should be given highest priority by the nurse? Assessing the patient's level of consciousness. Positioning and performing skin preparation to the patient. Checking the patient's identification and correct operative permit (informed consent form). Checking the patient's vital signs.

Checking the patient's identification and correct operative permit (informed consent form).

The nurse is removing the patient's staples from an abdominal incision when the patient sneezes and the incision splits open, exposing the intestines. What should the nurse do first? Have all visitors and family leave the room. Call the surgeon to come to the patient's room immediately? Cover the abdominal organs with sterile dressings moistened with sterile normal saline. Press the emergency alarm to call the resuscitation team.

Cover the abdominal organs with sterile dressings moistened with sterile normal saline.

Which nursing intervention is most important in preventing postoperative complications? Pain management. Bowel and elimination monitoring. Early ambulation. Progressive diet planning.

Early ambulation.

The nurse is caring for a patient in the post anesthesia care unit. The patient has developed profuse bleeding from the surgical site, and the surgeon has determined the need to return to the operative area. This procedure would be classified as: Urgent. Emergency. Major. Elective.

Emergency

A patient reports he hasn't had a bowel movement or passed gas since surgery. On assessment, the nurse notes the abdomen is distended and no bowel sounds are noted in the four quadrants. The nurse notifies the surgeon. What non-invasive nursing intervention (s) can the nurse perform without a physician's order? Insert a nasogastric attached to intermittent suction. Encourage ambulation, maintain NPO status, and monitor intake and output. Administer IV fluids. Encourage at least 3000 ml of fluids per day.

Encourage ambulation, maintain NPO status, and monitor intake and output.

To prevent complications of immobility, which activities would the nurse plan for the first postoperative day after a colon resection? Turn, cough, and deep breathe every 30 minutes around the clock Get the client out of bed and ambulate to a bedside chair It is not necessary to worry about complications of immobility on the first postoperative day. Provide passive range of motion three times a day

Get the client out of bed and ambulate to a bedside chair

The nurse is preparing to administer a preoperative medication that includes a sedative to a patient who is having abdominal surgery. The nurse should first: Ensure that the operative area has been shaved. Have the patient empty the bladder. Have the family present. Maker sure the patient is covered with a warm blanket.

Have the patient empty the bladder.

To prevent pulmonary emboli (PE) in a patient who has had abdominal surgery, the nurse should: Have the patient perform leg exercises every hour while awake. Have the patient wear antiembolism stockings when out of bed. Encourage the patient to cough and deep breathe. Massage the patient's calves.

Have the patient perform leg exercises every hour while awake. Performing leg exercises, including ankle pumping and ankle rotation, will help prevent stasis of blood in the lower extremities which can lead to blood clot formation. Encouraging the patient to cough and deep breathe is an important postoperative intervention; however, it is directed at preventing pneumonia, not pulmonary emboli. The nurse should NOT massage the calves because a deep vein thrombus could dislodge and travel to the pulmonary vasculature. Antiembolism stockings should be worn continuously during the postoperative period.

The nurse recognizes the value of leg exercises in the prevention of postoperative thrombophlebtitis. When should the nurse teach the correct technique for leg exercises to a patient? When early signs of venous stasis are evident. While the patient is recovering in the post anesthesia care unit. In the preoperative phase. Upon transfer from the post anesthesia care unit to the post surgical unit.

In the preoperative phase.

The anesthesiologist is coming to the unit to see a patient prior to surgery that is scheduled for tomorrow morning. What information, obtained during the admission assessment, should be given to the anesthesiologist during the visit? Latex allergy. Number of pregnancies. Last bowel movement. Difficulty falling asleep.

Latex allergy

Headache after spinal anesthesia is due to: Loss of cerebral spinal fluid through a dural hole. Traction placed on structures within abdomen. Paralysis of vasomotor nerves. Administration of large amounts and heavy concentration of anesthetic agents.

Loss of cerebral spinal fluid through a dural hole.

The nurse assesses a patient who has just received morphine sulfate. The patient's blood pressure is 90/50 mm Hg, pulse rate, 58 bpm: and respiration rate, 4 breaths/min. The nurse should prepare to administer: Doxacurium. Naloxone hydrochloride (Narcan). Flumazenil. Remifentanil.

Naloxone hydrochloride (Narcan).

A patient who is to receive general anesthesia has a serum potassium level of 5.8 mEq/L. What should be the nurse's first response? Make a note on the patient's record. Call the operating room to cancel the surgery. Send the patient to surgery. Notify the anesthesiologist.

Notify the anesthesiologist. The nurse should notify the anesthesiologist because a serum potassium level of 5.8 mEq/L places the patient at risk for arrhythmias when under general anesthesia. It is not the role of the nurse to cancel surgery. The nurse should not automatically send a patient with abnormal laboratory findings to surgery because the procedure may be canceled. The nurse should call ahead of time to communicate the abnormal laboratory result instead of noting the finding on the patient's record.

When the nurse asks the patient who is having abdominal surgery today if the patient understands the procedure, the patient replies, "NO, not really; I talked about several different things with my surgeon, and I am just not sure." The nurse should: Notify the surgeon of the patient's expressed lack of understanding. Administer the prescribed preoperative narcotics and/or sedatives. Utilize a second witness when the patient signs for consent. Teach the patient all the details of the planned procedure.

Notify the surgeon of the patient's expressed lack of understanding.

You're performing an abdominal assessment on Brent who is 52 y.o. In which order do you proceed? Observation, auscultation, percussion, palpation. Palpation, percussion, observation, auscultation. Observation, percussion, palpation, auscultation. Percussion, palpation, auscultation, observation.

Observation, auscultation, percussion, palpation.

A patientt with a perforated gastric ulcer is scheduled for surgery. The patient cannot sign the operative consent form because of sedation from opioid analgesics that have been administered. The nurse should take which most appropriate action in the care of this patient? Have the charge nurse sign the informed consent immediately. Send the patient to surgery without the consent form being signed. Obtain a court order for the surgery. Obtain a telephone consent from a family member, following agency policy.

Obtain a telephone consent from a family member, following agency policy.

How does palliative surgery differ from any other type of surgery? Palliative surgery is performed to provide temporary relief of distressing symptoms rather than to cure a problem or condition. The outcomes of palliative surgery cannot be ensured to produce the desired effect or restoration of functional ability. The main purpose is cosmetic in nature rather than functional repair or comfort. There are fewer risks associated with palliative surgery than with any other type of surgery.

Palliative surgery is performed to provide temporary relief of distressing symptoms rather than to cure a problem or condition.

A postoperative patient asks the nurse why it is so important to deep-breathe and cough after surgery. When formulating a response, the nurse incorporates the understanding that retained pulmonary secretions in a postoperative patient can lead to which condition? Pneumonia. Hypoxemia. Fluid imbalance. Pulmonary embolism.

Pneumonia

Which laboratory result would require immediate intervention by the nurse for the client scheduled for surgery? Hemoglobin 15 g/dL. Bleeding time 2 minutes. Calcium 9.2 mg/dL. Potassium 2.4 mEq/L.

Potassium 2.4 mEq/L. This potassium level is low and should be reported to the health-care provider because potassium is important for muscle function, including the cardiac muscle.

You are the circulating nurse caring for a 78-year-old patient who is scheduled for a total hip replacement. Which of the factors should you consider during the preparation of the patient in the operating room? The patient should be placed in Trendelenburg position. The patient must be firmly restrained at all times. The preoperative shave should be done by the circulating nurse. Pressure points should be assessed and well padded.

Pressure points should be assessed and well padded.

A continuous intravenous infusion of heparin is administered to a patient. It is most important for the nurse to have which of the following medications available? Vitamin K. Protamine Sulfate. Digitalis. Magnesium Sulfate.

Protamine Sulfate.

A patient is to receive Lovenox (enoxaparin) 6 hours before the scheduled time of a laparoscopic assisted vaginal hysterectomy. Which effect does the nurse recognize as an intended therapeutic action of the enoxaparin? Decrease in postoperative bleeding. Reduction of postoperative thrombi. Promotion of tissue healing. Increase in red blood cell production.

Reduction of postoperative thrombi.

A nurse is developing a care plan for a patient who is at risk for developing pneumonia after surgery. Which of the following is not an appropriate nursing intervention? Encourage early ambulation and patient to eat meals in beside chair. Encourage patient to use the incentive spirometry device 10 times every 1-2 hours while awake. Encourage patient intake of 3000 ml/day of fluids if not contraindicated. Repositioning every 3-4 hours.

Repositioning every 3-4 hours.

The nurse is assessing a patient recovering from anesthesia. Which is an early indicator of hypoxemia? Somnolence. Restlessness. Chills. Urgency.

Restlessness. One of the earliest signs of hypoxia is restlessness and agitation. Decreased level of consciousness and somnolence are later signs of hypoxia. Chills can be related to the anesthetic agent used but are not indicative of hypoxia. Urgency is not related to hypoxia.

The patient gave her consent for the surgery. To ensure the legality of the consent the following conditions must be met except: She gave her consent freely. She must understand the nature of the surgery. The consent must be signed by a witness. Signing should be done after the administration of pre-anesthesia meds

Signing should be done after the administration of pre-anesthesia meds

Prior to going to surgery, the patient tells the nurse that she cannot hear without her hearing aid and asks to wear it to surgery and recovery. What is the nurse's best response? Explain to the patient that she will have a premedication that will make her sleepy before she goes to surgery and she will not need to hear. Explain to the patient that it is policy not to take personal items to surgery because they may be lost or broken. Call the surgery unit to explain the patient's concern, and ask if she can wear her hearing aid to surgery. Tell the patient that a nurse will bring the hearing aid to the postanesthesia care unit so that she can have it as soon as she wakes up.

Tell the patient that a nurse will bring the hearing aid to the postanesthesia care unit so that she can have it as soon as she wakes up.

A patient is eligible for patient-controlled analgesia (PCA) when: A family member is able to assist with self-dosing. There is a nurse to assist with self-administration. There are advanced directives in place. The patient has the ability to self-administer.

The patient has the ability to self-administer.

Which of the following is experienced by the patient who is under general anesthesia? The patient experiences slight pain. The patient experiences loss of sensation in the lower half of the body. The patient is unconscious. The patient is awake

The patient is unconscious.

When the nurse is conducting a preoperative interview with a patient who is having a vaginal hysterectomy, the patient states that she forgot to tell her surgeon that she had a total hip replacement 3 years ago. The nurse communicates this information to the perioperative nurse because: There is not enough time to notify the surgeon and note this finding on the history and physical information before the procedure. The patient should not have her hip externally rotated when she is positioned for the procedure. The perioperative nurse can inform the rest of the team about the total hip replacement. The prosthesis may cause a problem with the electrosurgica (cautery)l unit used to control bleeding.

The patient should not have her hip externally rotated when she is positioned for the procedure.

The nurse is caring for a patient who had undergone exploratory laparotomy. Which of the following postop findings should the nurse report to the physician? The patient's vital signs are as follows: BP= 102/78 mmHg, PR= 95bpm, RR=9, T= 36.8 C. The patient's urine output is 20 mL/hour for the past 2 hours. The patient pushes out the oral airway with his tongue. The patient's wound drainage.

The patient's urine output is 20 mL/hour for the past 2 hours.

Which of the following is the primary purpose of maintaining NPO for 6 to 8 hours before surgery? To prevent electrolyte imbalance. To prevent intestinal obstruction. To prevent aspiration pneumonia. To prevent malnutrition.

To prevent aspiration pneumonia.

The nurse is transferring the patient from the postanesthesia care unit to the surgical unit. Which of the following is the primary reason for gradual change of position of the patient? To prevent respiratory distress. To prevent muscle injury. To promote comfort. To prevent sudden drop of blood pressure.

To prevent sudden drop of blood pressure. Gradual change of the patient's position during transfer primarily prevents sudden drop of blood pressure.