The Surgical Client
A nurse is assisting with teaching a newly licensed nurse about preoperative teaching. Which of the following statements should the nurse include?
"Preoperative teaching can reduce the length of the client's hospital stay."
A nurse is preparing a client for surgery and needs to scrub the surgical site. Identify the sequence the nurse should follow. (Move the steps into the box on the right, placing them in the order of performance. Use all the steps.)
1. Scrub the surgical site in a circular fashion with an antiseptic 2. Start at the center and move to the area away from the site 3. Scrub the outer edge and discard the sponge 4. Repeat with a new sponge 5. Drape the client
A nurse is caring for a client who is postoperative following a femur fracture repair. The client suddenly reports chest pain and is experiencing shortness of breath. Which of the following conditions should the nurse suspect?
A pulmonary embolism
A nurse is collecting data from a client who is preoperative for a surgical procedure. Which of the following information should the nurse document in the client's medical record? (Select all that apply.)
Allergies Alcohol use Spiritual beliefs
A nurse is caring for a client who is 2 days postoperative following abdominal surgery and reports discomfort and nausea. The nurse notes minimal bowel sounds on auscultation. The nurse should anticipate that the client may have which of the following conditions?
An ileus
A nurse is assisting in developing a plan to manage a client's perioperative pain. Which of the following interventions should the nurse include in the plan? (Select all that apply.)
Ask the client what interventions they prefer Determine how the client has responded to analgesics in the past Include nonpharmacological methods to reduce pain
A nurse is reinforcing teaching provided to a client about postoperative complications. Which of the following should the nurse identify as creating a risk for the client to develop pneumonia?
Aspiration
A nurse is assisting a postsurgical client who has had previous trouble swallowing prepare for a meal. Which of the following actions should the nurse take?
Assist the client to sit upright to eat.
A nurse is caring for a client who is preoperative and reports a history of regular tobacco use. The nurse should identify that the client is at the greatest risk for which of the following postoperative complications?
Blood clots
A nurse is collecting data on a client who is postoperative following a hip arthroplasty. Which of the following findings is a possible manifestation of bleeding?
Blood pressure 88/60 mm Hg
Surgical attire for the surgical suite consists of which of the following items? (Select all that apply.)
Cap Shoe covers Gown Mask Gloves
Which of the following members of the surgical team is responsible for ensuring that the necessary tools are sterile and ready to use?
Certified surgical technologist
A nurse is planning care for a client who has a distended bladder and has not voided 8 hr after surgery. Which of the following interventions should the nurse plan to take?
Insert a straight urinary catheter into the client.
A nurse is planning postoperative care for a client. Which of the following actions should be the nurse's priority?
Monitor the client's oxygen saturation.
A nurse is monitoring a postsurgical client for dysphagia. Which of the following factors puts the client at risk?
Parkinson's disease
A nurse is caring for a client who has dementia and is scheduled for surgery. Which of the following creates a risk for the client to develop a postoperative complication?
Prescribed anticholinergics
A nurse is collecting data on a client who is postoperative following abdominal surgery. Which of the following findings is a manifestation of an infection?
Redness around the incision site
A client is having surgery on their hand and tells the nurse that they understand that anesthesia will be administered so that they will have a temporary loss of feeling in their arm. Which of the following types of anesthesia is the client describing?
Regional
A nurse is assisting in planning postoperative care for a client who is scheduled for surgery. Which of the following interventions should the nurse include in the plan?
Reposition the client every hour.
A nurse is caring for a client who is scheduled for surgery and is at risk for postoperative venous thromboembolism (VTE). Which of the following prescriptions should the nurse anticipate to reduce the risk of VTE?
Sequential compression devices
A nurse is discussing the time-out procedure with a newly licensed nurse. The nurse should include that a time-out is performed at which of the following times?
Several times throughout the procedure
A nurse is assessing the surgical wound of a postoperative client. Which of the following information should the nurse include in the documentation of the wound? (Select all that apply.)
The client states the wound is painful. The edges of the wound are red is correct. The client has a fever.
A nurse is collecting data on a client who is preparing for discharge following surgery. Which of the following findings should be the nurse's priority concern?
The client takes medications that cause dizziness.
A nurse is reviewing the medical record of a postoperative client. Which of the following findings in the client's history are risk factors for poor wound healing? (Select all that apply.)
Type 2 diabetes mellitus Current smoker Corticosteroid use 68 years old
A nurse is reinforcing teaching with a newly licensed nurse about informed consent. The nurse should include that which of the following is the nurse's responsibility when obtaining informed consent from a client? (Select all that apply.)
Verify the client has signed the consent. Check that the client is of legal age to provide consent. Confirm the client is competent.