211 Preoperative
The nurse is caring for a patient in the operating suite who is experiencing hypercarbia, tachypnea, tachycardia, premature ventricular contractions, and muscle rigidity. Which condition does the nurse suspect the patient is experiencing? a.Malignant hyperthermia b.Fluid imbalance c.Hemorrhage d.Hypoxia
A
A client who collapsed during dinner in a restaurant arrives in the emergency department. The client is going to surgery to repair an abdominal aortic aneurysm. What medication does the nurse prepare to administer as a priority for this client? a. Hydroxyzine (Atarax) b. Lorazepam (Ativan) c. Metoclopramide (Reglan) d. Morphine sulfate
C
A postoperative client has respiratory depression after receiving midazolam (Versed) for sedation. Which IV-push medication and dose does the nurse prepare to administer? a. Flumazenil (Romazicon) 0.2 to 1 mg b. Flumazenil (Romazicon) 2 to 10 mg c. Naloxone (Narcan) 0.4 to 2 mg d. Naloxone (Narcan) 4 to 20 mg
A
A postoperative nurse is caring for a client whose oxygen saturation dropped from 98% to 95%. What action by the nurse is most appropriate? a. Assess other indicators of oxygenation. b. Call the Rapid Response Team. c. Notify the anesthesia provider. d. Prepare to intubate the client.
A
An older client is hospitalized after an operation. When assessing the client for postoperative infection, the nurse places priority on which assessment? a. Change in behavior b. Daily white blood cell count c. Presence of fever and chills d. Tolerance of increasing activity
A
A nurse answers a call light on the postoperative nursing unit. The client states there was a sudden gush of blood from the incision, and the nurse sees a blood spot on the sheet. What action should the nurse take first? a. Assess the clients blood pressure. b. Perform hand hygiene and apply gloves. c. Reinforce the dressing with a clean one. d. Remove the dressing to assess the wound.
B
A nurse is caring for a postoperative client who reports discomfort, but denies serious pain and does not want medication. What action by the nurse is best to promote comfort? a. Assess the clients pain on a 0-to-10 scale. b. Assist the client into a position of comfort. c. Have the client sit up in a recliner. d. Tell the client when pain medication is due.
B
A nurse is giving a client instructions for showering with special antimicrobial soap the night before surgery. What instruction is most appropriate? a. After you wash the surgical site, shave that area with your own razor. b. Be sure to wash the area where you will have surgery very thoroughly. c. Use a washcloth to wash the surgical site; do not take a full shower or bath. d. Wash the surgical site first, then shampoo and wash the rest of your body.
B
A postoperative client has an abdominal drain. What assessment by the nurse indicates that goals for the priority client problems related to the drain are being met? a. Drainage from the surgical site is 30 mL less than yesterday. b. There is no redness, warmth, or drainage at the insertion site. c. The client reports adequate pain control with medications. d. Urine is clear yellow and urine output is greater than 40 mL/hr.
B
An older adult has been transferred to the postoperative inpatient unit after surgery. The family is concerned that the client is not waking up quickly and states She needs to get back to her old self! What response by the nurse is best? a. Everyone comes out of surgery differently. b. Lets just give her some more time, okay? c. She may have had a stroke during surgery. d. Sometimes older people take longer to wake up.
D
The nurse is encouraging the postoperative patient to utilize diaphragmatic breathing. Which priority goal is the nurse trying to achieve? a.Manage pain b.Prevent atelectasis c.Reduce healing time d.Decrease thrombus formation
B
The operating room environment is deliberately kept cool. When the nurse assesses the patient in the post anesthesia care unit, the patient is shivering. The nurse needs to understand that shivering may do which of the following? a.Be a side effect of anesthesia. b.Indicate a problem of the hypothalamus. c.Indicate the beginning of the infectious process. d.Be a normal response to stabilize blood pressure.
A
A nurse is giving a preoperative client a dose of ranitidine (Zantac). The client asks why the nurse is giving this drug when the client has no history of ulcers. What response by the nurse is best? a. All preoperative clients get this medication. b. It helps prevent ulcers from the stress of the surgery. c. Since you don't have ulcers, I will have to ask. d. The physician prescribed this medication for you.
B
A nurse working in an ambulatory care surgery center is preparing to discharge a postoperative patient. The nurse knows that the convalescence period will occur: a.1 to 2 hours after surgery. b.at home. c.once the patient has been monitored overnight in the hospital. d.2 to 4 hours after surgery.
B
A patient asks a nurse to explain the differences between general anesthesia and regional anesthesia. What is the correct response relating to general anesthesia? a.General anesthesia inhibits peripheral nerve conduction. b.Under general anesthesia all sensation and consciousness is lost. c.Under general anesthesia there is a loss of sensation in a specific area of the body. d.General anesthesia is routinely used for procedures that only require a decreased level of consciousness.
B
A postoperative client vomited. After cleaning and comforting the client, which action by the nurse is most important? a. Allow the client to rest. b. Auscultate lung sounds. c. Document the episode. d. Encourage the client to eat dry toast.
B
All patients undergoing surgery need to have preoperative preparation. When physically preparing the patient, the most appropriate action for the nurse to take is which of the following? a.Leaving all of the patients jewelry in place b.Removing the patients makeup and nail polish c.Providing the patient with sips of water for a dry mouth d.Removing the patients hearing aid before transport to the operating room
B
The circulating nurse and preoperative nurse are reviewing the chart of a client scheduled for minimally invasive surgery (MIS). What information on the chart needs to be reported to the surgeon as a priority? a. Allergies noted and allergy band on b. Consent for MIS procedure only c. No prior anesthesia exposure d. NPO status for the last 8 hours
B
The circulating nurse is caring for a patient intraoperatively. Which primary role of the circulating nurse will be implemented? a.Suturing the surgical incision in the OR suite b.Managing patient care activities in the OR suite c.Assisting with applying sterile drapes in the OR suite d.Handing sterile instruments and supplies to the surgeon in the OR suite
B
The nurse has administered a preoperative medication to the patient going to surgery. Which action will the nurse take next? a.Notify the operating suite that the medication has been given. b.Instruct the patient to call for help to go to the restroom. c.Waste any unused medication according to policy. d.Ask the patient to sign the consent for surgery.
B
The nurse is caring for a patient who is scheduled to undergo a surgical procedure. The nurse is completing an assessment and reviews the patient's laboratory tests and allergies and prepares the patient for surgery. In which perioperative nursing phase is the nurse working? a.Perioperative b.Preoperative c.Intraoperative d.Postoperative
B
The nurse is caring for a patient who will undergo a removal of a lung lobe. Which level of care will the patient require immediately post procedure? a.Acute care—medical-surgical unit b.Acute care—intensive care unit c.Ambulatory surgery d.Ambulatory surgery—extended stay
B
The nurse is caring for a postoperative patient with an abdominal incision. The nurse provides a pillow to use during coughing. Which activity is the nurse promoting? a.Pain relief b.Splinting c.Distraction d.Anxiety reduction
B
A registered nurse (RN) is watching a nursing student change a dressing and perform care around a Penrose drain. What action by the student warrants intervention by the RN? a. Cleaning around the drain per agency protocol b. Placing a new sterile gauze under the drain c. Securing the drains safety pin to the sheets d. Using sterile technique to empty the drain
C
Intraoperatively, the circulating nurse observes a member of the surgical team breach aseptic technique. As a result of this incident the postoperative patient can be at risk for which of the following? a.Paralytic ileus b.Malignant hyperthermia c.Development of infection d.Alteration in pulmonary hygiene
C
The nurse is monitoring a patient in the postanesthesia care unit (PACU) for postoperative fluid and electrolyte imbalance. Which action will be most appropriate for the nurse to take? a.Encourage copious amounts of water. b.Start an additional intravenous (IV) line. c.Measure and record all intake and output. d.Weigh the patient and compare with preoperative weight.
C
The nurse is preparing a patient for a surgical procedure on the right great toe. Which action will be most important to include in this patient's preparation? a.Place the patient in a clean surgical gown. b.Ask the patient to remove all hairpins and cosmetics. c.Ascertain that the surgical site has been correctly marked. d.Determine where the family will be located during the procedure.
C
The perioperative nurse is admitting a patient for an elective surgery. She questions the patient about issues with anesthesia, to assess the patient for malignant hyperthermia. Which of the following is a late sign of malignant hyperthermia? a.High CO2 levels b.Tachycardia c.Elevated temperature d.Tachypnea
C
The postanesthesia care unit (PACU) charge nurse notes vital signs on four postoperative clients. Which client should the nurse assess first? a. Client with a blood pressure of 100/50 mm Hg b. Client with a pulse of 118 beats/min c. Client with a respiratory rate of 6 breaths/min d. Client with a temperature of 96 F (35.6 C)
C
A patient with a ruptured abdominal aortic aneurysm needs to have major surgery. The nurse explains to the family that major surgery: a.is an excision or removal of a diseased body part. b.involves extensive surgery to reconstruct body parts. c.is not necessary but may prevent additional problems. d.is a surgical exploration that allows the physician or health care provider to confirm a diagnosis.
D
A preoperative nurse is assessing a client prior to surgery. Which information would be most important for the nurse to relay to the surgical team? a. Allergy to bee and wasp stings b. History of lactose intolerance c. No previous experience with surgery d. Use of multiple herbs and supplements
D
The nurse is caring for a patient in the postanesthesia 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. How will the nurse classify this procedure? a.Major b.Urgent c.Elective d.Emergency
D
The nurse is caring for a patient in the preoperative holding area of an ambulatory surgery center. Which nursing action will be most appropriate for this area? a.Count the sterile surgical instruments. b.Empty the urinary drainage bag. c.Check the surgical dressing. d.Apply a warm blanket.
D
The nurse is encouraging a reluctant postoperative patient to deep breathe and cough. Which explanation can the nurse provide that may encourage the patient to comply? a."If you don't deep breathe and cough, you will get pneumonia." b."You will need to cough only a few times during this shift." c."Let's try clearing the throat because that will work just as well." d."Deep breathing and coughing will clear out the anesthesia."
D
The preoperative nurse who is providing patient teaching to a 49-year-old patient who is scheduled to undergo a right-side inguinal surgery repair. The nurse informs the patient that the American Society of Anesthesiologists recommend that patients undergoing surgery with a general anesthesia fast from meat and fried foods for how many hours before surgery? a.2 b.4 c.6 d.8
D
A client has developed malignant hyperthermia. The client weighs 136 pounds. What is the safe dose range for one dose of dantrolene sodium (Dantrium)? (Enter your answer using whole numbers, separated by a hyphen with no spaces.) _____ mg
124-186 mg
A postoperative client has the following orders: IV lactated Ringers 125 mL/hr NG tube to low continuous suction Replace NG output every 4 hours with normal saline over 4 hours Morphine sulfate 2 mg IV push every hour as needed for pain NPO Up in chair tonight At 1600 (4:00 PM), the nurse measures the nasogastric (NG) output from noon to be 200 mL. What is the clients total IV rate for the next 4 hours? (Record your answer using a whole number.) _____ mL/hr
175 mL/hr
A 57-year-old patient who is being admitted for an appendectomy. The patient is a 2-pack-a-day smoker, has a history of diabetes, and is 20 pounds overweight. Which of the following potential postoperative complications should be the nurses highest concern for prevention? a.Atelectasis b.Negative nitrogen balance c.Delayed wound healing d.Hyperthermia
A
A circulating nurse has transferred an older client to the operating room. What action by the nurse is most important for this client? a. Allow the client to keep hearing aids in until anesthesia begins. b. Pad the table as appropriate for the surgical procedure. c. Position the client for maximum visualization of the site. d. Stay with the client, providing emotional comfort and support.
A
A client in the operating room has developed malignant hyperthermia. The clients potassium is 6.5 mEq/L. What action by the nurse takes priority? a. Administer 10 units of regular insulin. b. Administer nifedipine (Procardia). c. Assess urine for myoglobin or blood. d. Monitor the client for dysrhythmias.
A
A client is scheduled for a below-the-knee amputation. The circulating nurse ensures the proper side is marked prior to the start of surgery. What action by the nurse is most appropriate? a. Facilitate marking the site with the client and surgeon. b. Have the client mark the operative site. c. Mark the operative site with a waterproof marker. d. Tell the surgeon it is time to mark the surgical site.
A
A clinic nurse is teaching a client prior to surgery. The client does not seem to comprehend the teaching, forgets a lot of what is said, and asks the same questions again and again. What action by the nurse is best? a. Assess the client for anxiety. b. Break the information into smaller bits. c. Give the client written information. d. Review the information again.
A
A postoperative client has just been admitted to the postanesthesia care unit (PACU). What assessment by the PACU nurse takes priority? a. Airway b. Bleeding c. Breathing d. Cardiac rhythm
A
The nurse demonstrates postoperative exercises for a patient. In which order will the nurse instruct the patient to perform the exercises? 1. Turning 2. Breathing 3. Coughing 4. Leg exercises a.4, 1, 2, 3 b.1, 2, 3, 4 c.2, 3, 4, 1 d.3, 1, 4, 2
A
Which nursing assessment will indicate the patient is performing diaphragmatic breathing correctly? a.Hands placed on the border of the rib cage with fingers extended will touch as the chest wall contracts. b.Hands placed on the chest wall with fingers extended will separate as the chest wall contracts. c.The patient will feel upward movement of the diaphragm during inspiration. d.The patient will feel downward movement of the diaphragm during expiration.
A
Which of the following patients is most at risk for hypovolemic shock after emergency surgery? a.14-year-old adolescent with gastroenteritis b.59-year-old patient with pneumonia c.12-year-old patient with H1N1 flu d.28-year-old patient with a fractured ankle
A
The nurse is participating in a "time-out." In which activities will the nurse be involved? (Select all that apply.) a.Verify the correct site. b.Verify the correct patient. c.Verify the correct procedure. d.Perform "time-out" after surgery. e.Perform the actual marking of the operative site.
A,B,C
A client is experiencing pain after leg surgery but cannot yet have more pain medication. What comfort interventions can the nurse provide? (Select all that apply.) a. Apply stimulation to the contralateral leg. b. Assess the clients willingness to try meditation. c. Elevate the clients operative leg and apply ice. d. Reduce the noise level in the clients environment. e. Turn the TV on loudly to distract the client.
A,B,C,D
A student nurse asks why older adults are at higher risk for complications after surgery. What reasons does the registered nurse give? (Select all that apply.) a. Decreased cardiac output b. Decreased oxygenation c. Frequent nocturia d. Mobility alterations e. Inability to adapt to changes
A,B,C,D
What actions by the circulating nurse are important to promote client comfort? (Select all that apply.) a. Correct positioning b. Introducing ones self c. Providing warmth d. Remaining present e. Removing hearing aids
A,B,C,D
A nurse is admitting an older client for surgery to the inpatient surgical unit. The client relates a prior history of acute confusion after a previous operation. What interventions does the nurse include on the clients plan of care to minimize the potential for this occurring? (Select all that apply.) a. Allow family and friends to visit as the client desires. b. Ask the client about coping techniques frequently used. c. Instruct the nursing assistant to ensure the client is bathed. d. Place the client in a room secluded at the end of the hall. e. Provide the client with uninterrupted periods of sleep.
A,B,C,E
A client is having shoulder surgery with regional anesthesia. What actions by the nurse are most important to enhance client safety related to this anesthesia? (Select all that apply.) a. Assessing distal circulation to the operative arm after positioning b. Keeping the client warm during the operative procedure c. Padding the clients shoulder and arm on the operating table d. Preparing to suction the clients airway if the client vomits e. Speaking in a low, quiet voice as anesthesia is administered
A,C
A student nurse has been assigned to a 67-year-old patient who is undergoing thoracic surgery to remove a tumor. As part of the preoperative teaching, the student nurse discusses the importance of coughing. Which of the following statements is true regarding why postoperative coughing is important? (Select all that apply.) a.Coughing assists in removing retained mucus in the airways. b.It wont hurt to cough with adequate pain control. c.You can splint your incision when coughing to minimize pain. d.Deep breathing and coughing will remove anesthesia gases from your lungs. e.Deep breathing involves fast, shallow, breaths and then one big breath. f.Coughing is not encouraged because of the potential or dehiscence at the surgical site.
A,C,D
A nurse is caring for several clients prior to surgery. Which medications taken by the clients require the nurse to consult with the physician about their administration? (Select all that apply.) a. Metformin (Glucophage) b. Omega-3 fatty acids (Sea Omega 30) c. Phenytoin (Dilantin) d. Pilocarpine hydrochloride (Isopto Carpine) e. Warfarin (Coumadin)
A,C,D,E
A student nurse is caring for clients on the postoperative unit. The student asks the registered nurse why malnutrition can lead to poor surgical outcomes. What responses by the nurse are best? (Select all that apply.) a. A malnourished client will have fragile skin. b. Malnourished clients always have other problems. c. Many drugs are bound to protein in the body. d. Protein stores are needed for wound healing. e. Weakness and fatigue are common in malnutrition.
A,C,D,E
The nurse is preparing for a patient who will be going to surgery. The nurse screens for risk factors that can increase a person's risks in surgery. What risk factors are included in the nurse's screening? (Select all that apply.) a.Age b.Race c.Obesity d.Nutrition e.Pregnancy f.Ambulatory surgery
A,C,D,E
A student nurse observing in the operating room notes that the functions of the Certified Registered Nurse First Assistant (CRNFA) include which activities? (Select all that apply.) a. Dressing the surgical wound b. Grafting new or synthetic skin c. Reattaching severed nerves d. Suctioning the surgical site e. Suturing the surgical wound
A,D,E
The nurse is caring for a postoperative patient with an incision. Which actions will the nurse take to decrease wound infections? (Select all that apply.) a.Maintain normoglycemia. b.Use a straight razor to remove hair. c.Provide bath and linen change daily. d.Perform first dressing change 2 days postoperatively. e.Perform hand hygiene before and after contact with the patient. f.Administer antibiotics within 60 minutes before surgical incision.
A,E
A patient with a ruptured abdominal aortic aneurysm needs to have major surgery. The family asks the nurse what type of anesthesia the patient will receive. The best response is which of the following? a.Local anesthesia b.Regional anesthesia c.Moderate sedation d.General anesthesia
D
. The nurse explains the pain relief measures available after surgery during preoperative teaching for a surgical patient. Which comment from the patient indicates the need for additional education on this topic? a."I will be asked to rate my pain on a pain scale." b."I will have minimal pain because of the anesthesia." c."I will take the pain medication as the provider prescribes it." d."I will take my pain medications before doing postoperative exercises."
B
A 44-year-old patient with breast cancer who is scheduled to undergo a right-side mastectomy. Ideally when should preoperative teaching begin? a.As soon as she is diagnosed with breast cancer b.One week before surgery c.The day before surgery d.The day of surgery
B
A 56-year-old non-diabetic patient is undergoing orthopedic surgery. The perioperative nurse is monitoring the blood glucose level. What is the main rationale for monitoring his blood glucose level during surgery? a.She does not want the patient to develop an embolism. b.Research shows a strong relationship between wound infections and hyperglycemia. c.She knows that normal glucose levels promote platelet production. d.She is monitoring to prevent embolism.
B
A client has a great deal of pain when coughing and deep breathing after abdominal surgery despite having pain medication. What action by the nurse is best? a. Call the provider to request more analgesia. b. Demonstrate how to splint the incision. c. Have the client take shallower breaths. d. Tell the client a little pain is expected.
B
An inpatient nurse brings an informed consent form to a client for an operation scheduled for tomorrow. The client asks about possible complications from the operation. What response by the nurse is best? a. Answer the questions and document that teaching was done. b. Do not have the client sign the consent and call the surgeon. c. Have the client sign the consent, then call the surgeon. d. Remind the client of what teaching the surgeon has done.
B
The nurse instructs the postoperative patient to perform leg exercises every hour in order to do which of the following? a.Maintain muscle tone. b.Increase venous return. c.Exercise fatigued muscles. d.Assess range of joint motion.
B
The nurse is providing preoperative education and reviews with the patient what it will be like to be in the surgical environment. Which points should the nurse include in the teaching session? (Select all that apply.) a.The operative suite will be very dark. b.The family is not allowed in the operating suite. c.The operating table or bed will be comfortable and soft. d.The nurses will be there to assist you through this process. e.The surgical staff will be dressed in special clothing with hats and masks.
B,D,E
The nurse is using a forced air warmer for a surgical patient preoperatively. Which goals is the nurse trying to achieve? (Select all that apply.) a.Induce shivering. b.Reduce blood loss. c.Induce pressure ulcers. d.Reduce cardiac arrests. e.Reduce surgical site infection.
B,D,E
A nursing instructor is teaching students about different surgical procedures and their classifications. Which examples does the instructor include? (Select all that apply.) a. Hemicolectomy: diagnostic b. Liver biopsy: diagnostic c. Mastectomy: restorative d. Spinal cord decompression: palliative e. Total shoulder replacement: restorative
B,E
A postanesthesia care unit (PACU) nurse is assessing a postoperative client with a nasogastric (NG) tube. What laboratory values would warrant intervention by the nurse? (Select all that apply.) a. Blood glucose: 120 mg/dL b. Hemoglobin: 7.8 mg/dL c. pH: 7.68 d. Potassium: 2.9 mEq/L e. Sodium: 142 mEq/L
B,C,D
A nurse recently hired to the preoperative area learns that certain clients are at higher risk for venous thromboembolism (VTE). Which clients are considered at high risk? (Select all that apply.) a. Client with a humerus fracture b. Morbidly obese client c. Client who underwent a prolonged surgical procedure d. Client with severe heart failure e. Wheelchair-bound client
B,C,D,E
A nurse working in the preoperative holding area performs which functions to ensure client safety? (Select all that apply.) a. Allow small sips of plain water. b. Check that consent is on the chart. c. Ensure the client has an armband on. d. Have the client help mark the surgical site. e. Allow the client to use the toilet before giving sedation.
B,C,D,E
A new perioperative nurse is receiving orientation to the surgical area and learns about the Surgical Care Improvement Project (SCIP) goals. What major areas do these measures focus on preventing? (Select all that apply.) a. Hemorrhage b. Infection c. Serious cardiac events d. Stroke e. Thromboembolism
B,C,E
A nurse on the postoperative nursing unit provides care to reduce the incidence of surgical wound infection. What actions are best to achieve this goal? (Select all that apply.) a. Administering antibiotics for 72 hours b. Disposing of dressings properly c. Leaving draining wounds open to air d. Performing proper hand hygiene e. Removing and replacing wet dressings
B,D,E
A client had a surgical procedure with spinal anesthesia. The nurse raises the head of the clients bed. The clients blood pressure changes from 122/78 mm Hg to 102/50 mm Hg. What action by the nurse is best? a. Call the Rapid Response Team. b. Increase the IV fluid rate. c. Lower the head of the bed. d. Nothing; this is expected.
C
A client in the preoperative holding room has received sedation and now needs to urinate. What action by the nurse is best? a. Allow the client to walk to the bathroom. b. Delegate assisting the client to the nurses aide. c. Give the client a bedpan or urinal to use. d. Insert a urinary catheter now instead of waiting.
C
A nurse is monitoring a client after moderate sedation. The nurse documents the clients Ramsay Sedation Scale (RSS) score at 3. What action by the nurse is best? a. Assess the clients gag reflex. b. Begin providing discharge instructions c. Document findings and continue to monitor. d. Increase oxygen and notify the provider.
C
A nurse works on the postoperative floor and has four clients who are being discharged tomorrow. Which one has the greatest need for the nurse to consult other members of the health care team for post-discharge care? a. Married young adult who is the primary caregiver for children b. Middle-aged client who is post knee replacement, needs physical therapy c. Older adult who lives at home despite some memory loss d. Young client who lives alone, has family and friends nearby
C
A patient is awaiting surgery. The nurses best rationale for assessing vital signs is to do which of the following? a.Assess the patients anxiety level. b.Determine the patients basal temperature. c.Establish a baseline for vital signs comparisons. d.Assess for any changes that may indicate infection.
C
The circulating nurse is in the operating room and sees the surgeon don gown and gloves using appropriate sterile procedure. The surgeon then folds the hands together and places them down below the hips. What action by the nurse is most appropriate? a. Ask the surgeon to change the sterile gown. b. Do nothing; this is acceptable sterile procedure. c. Inform the surgeon that the sterile field has been broken. d. Obtain a new pair of sterile gloves for the surgeon to put on.
C
The circulating nurse is plugging in a piece of equipment and notes that the cord is frayed. What action by the nurse is best? a. Call maintenance for repair. b. Check the machine before using. c. Get another piece of equipment. d. Notify the charge nurse.
C
The nurse is caring for a patient in preadmission testing. The patient has been assigned a physical status classification by the American Society of Anesthesiologists of ASA III. Which assessment will support this classification? a.Normal, healthy patient b.Denial of any major illnesses or conditions c.Poorly controlled hypertension with implanted pacemaker d.Moribund patient not expected to survive without the operation
C
The nurse is caring for a postoperative patient on the medical-surgical floor. Which activity will the nurse encourage to prevent venous stasis and the formation of thrombus? a.Diaphragmatic breathing b.Incentive spirometry c.Leg exercises d.Coughing
C
The nurse is caring for a surgical patient, when the family member asks what perioperative nursing means. How should the nurse respond? a.Perioperative nursing occurs in preadmission testing. b. Perioperative nursing occurs primarily in the postanesthesia care unit. c. Perioperative nursing includes activities before, during, and after surgery. d. Perioperative nursing includes activities only during the surgical procedure.
C
The nurse is making a preoperative education appointment with a patient. The patient asks if a family member should come to the appointment. Which is the best response by the nurse? a."There is no need for an additional person at the appointment." b."Your family can come and wait with you in the waiting room." c."We recommend including family members at this appointment." d."It is required that you have a family member at this appointment."
C
A nurse is preparing a client for discharge after surgery. The client needs to change a large dressing and manage a drain at home. What instruction by the nurse is most important? a. Be sure you keep all your postoperative appointments. b. Call your surgeon if you have any questions at home. c. Eat a diet high in protein, iron, zinc, and vitamin C. d. Wash your hands before touching the drain or dressing.
D
A 45-year-old woman has been admitted for surgery to remove a cancerous abdominal tumor. She has been on chemotherapy and recently radiotherapy to shrink the tumor without success. To best facilitate wound healing, when is the best time for her to undergo surgery? a.During the radiotherapy treatments b.Immediately after the radiotherapy treatments c.2 to 3 weeks after radiotherapy treatments d.4 to 6 weeks after radiotherapy treatments
D
A circulating nurse wishes to provide emotional support to a client who was just transferred to the operating room. What action by the nurse would be best? a. Administer anxiolytics. b. Give the client warm blankets. c. Introduce the surgical staff. d. Remain with the client.
D
A client has arrived in the postoperative unit. What action by the circulating nurse takes priority? a. Assessing fluid and blood output b. Checking the surgical dressings c. Ensuring the client is warm d. Participating in hand-off report
D
A client on the postoperative nursing unit has a blood pressure of 156/98 mm Hg, pulse 140 beats/min, and respirations of 24 breaths/min. The client denies pain, has normal hemoglobin, hematocrit, and oxygen saturation, and shows no signs of infection. What should the nurse assess next? a. Cognitive status b. Family stress c. Nutrition status d. Psychosocial status
D
Ten hours after surgery, a postoperative client reports that the antiembolism stockings and sequential compression devices itch and are too hot. The client asks the nurse to remove them. What response by the nurse is best? a. Let me call the surgeon to see if you really need them. b. No, you have to use those for 24 hours after surgery. c. OK, we can remove them since you are stable now. d. To prevent blood clots you need them a few more hours.
D
The nurse and the nursing assistive personnel (NAP) are caring for a group of postoperative patients who need turning, coughing, deep breathing, incentive spirometer, and leg exercises. Which task will the nurse assign to the NAP? a.Teach postoperative exercises. b.Do nothing associated with postoperative exercises. c.Document in the medical record when exercises are completed. d.Inform the nurse if the patient is unwilling to perform exercises.
D
The nurse and the nursing assistive personnel are assisting a postoperative patient to turn in bed. To assist in minimizing discomfort, which instruction should the nurse provide to the patient? a."Close your eyes and think about something pleasant." b."Hold your breath and count to three." c."Grab my shoulders with your hands." d."Place your hand over your incision."
D
The nurse is caring for a group of postoperative patients on the surgical unit. Which patient assessments indicate the nurse needs to follow up? (Select all that apply.) a.Patient with abdominal surgery has patent airway. b.Patient with knee surgery has approximated incision. c.Patient with femoral artery surgery has strong pedal pulse. d.Patient with lung surgery has 20 mL/hr of urine output via catheter. e.Patient with bladder surgery has bloody urine within the first 12 hours. f.Patient with appendix surgery has thready pulse and blood pressure is 90/60.
D,F
A client is having surgery. The circulating nurse notes the clients oxygen saturation is 90% and the heart rate is 110 beats/min. What action by the nurse is best? a. Assess the clients end-tidal carbon dioxide level. b. Document the findings in the clients chart. c. Inform the anesthesia provider of these values. d. Prepare to administer dantrolene sodium (Dantrium).
A
A client is on the phone when the nurse brings a preoperative antibiotic before scheduled surgery. The circulating nurse has requested the antibiotic be started. The client wants the nurse to wait before starting it. What response by the nurse is most appropriate? a. Explain the rationale for giving the medicine now. b. Leave the room and come back in 15 minutes. c. Provide holistic client care and come back later. d. Tell the client you must start the medication now.
A
A nurse assesses a client in the preoperative holding area and finds brittle nails and hair, dry skin turgor, and muscle wasting. What action by the nurse is best?a. Consult the surgeon about a postoperative dietitian referral.b. Document the findings thoroughly in the clients chart.c. Encourage the client to eat more after recovering from surgery.d. Refer the client to Meals on Wheels after discharge.
A
A nurse is concerned that a preoperative client has a great deal of anxiety about the upcoming procedure. What action by the nurse is best? a. Ask the client to describe current feelings. b. Determine if the client wants a chaplain. c. Reassure the client this surgery is common. d. Tell the client there is no need to be anxious.
A
A student is caring for clients in the preoperative area. The nurse contacts the surgeon about a client whose heart rate is 120 beats/min. After consulting with the surgeon, the nurse administers a beta blocker to the client. The student asks why this was needed. What response by the nurse is best? a. A rapid heart rate requires more effort by the heart. b. Anesthesia has bad effects if the client is tachycardic. c. The client may have an undiagnosed heart condition. d. When the heart rate goes up, the blood pressure does too.
A
During preoperative assessment for a 7:30 AM (0730) surgery, the nurse finds the patient drank a cup of coffee this morning. The nurse reports this information to the anesthesia provider. Which action does the nurse anticipate next? a.A delay in or cancellation of surgery b.Questions regarding components of the coffee c.Additional questions about why the patient had coffee d.Instructions to determine what education was provided in the preoperative visit
A
The nurse has completed a preoperative assessment for a patient going to surgery and gathers assessment data. Which will be the most important next step for the nurse to take? a.Notify the operating suite that the patient has a latex allergy. b.Document that the patient had a bath at home this morning. c.Administer the ordered preoperative intravenous antibiotic. d.Ask the nursing assistive personnel to obtain vital signs.
A
The nurse is assessing a postoperative patient with a history of obstructive sleep apnea for airway obstruction. Which assessment finding will best alert the nurse to this complication? a.Drop in pulse oximetry readings b.Moaning with reports of pain c.Shallow respirations d.Disorientation
A
The nurse is caring for a group of patients. Which patient will the nurse see first? a.A patient who had cataract surgery is coughing. b.A patient who had vascular repair of the right leg is not doing right leg exercises. c.A patient after knee surgery is wearing intermittent pneumatic compression devices and receiving heparin. d.A patient after surgery has vital signs taken every 15 minutes twice, every 30 minutes twice, hourly for 2 hours then every 4 hours.
A
The nurse is caring for a patient in the operating suite. Which outcome will be most appropriate for this patient at the end of the intraoperative phase? a.The patient will be free of burns at the grounding pad. b.The patient will be free of nausea and vomiting. c.The patient will be free of infection. d.The patient will be free of pain.
A
The nurse is caring for a patient in the postanesthesia care unit who has undergone a left total knee arthroplasty. The anesthesia provider has indicated that the patient received a left femoral peripheral nerve block. Which assessment will be an expected finding for this patient? a.Sensation decreased in the left leg b.Patient report of pain in the left foot c.Pulse decreased at the left posterior tibia d.Left toes cool to touch and slightly cyanotic
A
The nurse is caring for a patient in the postanesthesia care unit. The patient asks for a bedpan and states to the nurse, "I feel like I need to go to the bathroom, but I can't." Which nursing intervention will be most appropriate initially? a.Assess the patient for bladder distention. b.Encourage the patient to wait a minute and try again. c.Inform the patient that everyone feels this way after surgery. d.Call the health care provider to obtain an order for catheterization.
A
The nurse is caring for a postoperative patient who has had a minimally invasive carpel tunnel repair. The patient has a temperature of 97° F and is shivering. Which reason will the nurse most likely consider as the primary cause when planning care? a.Anesthesia lowers metabolism. b.Surgical suites have air currents. c.The patient is dressed only in a gown. d.The large open body cavity contributed to heat loss.
A
The nurse is completing a medication history for the surgical patient in preadmission testing. Which medication should the nurse instruct the patient to hold (discontinue) in preparation for surgery according to protocol? a.Warfarin b.Vitamin C c.Prednisone d.Acetaminophen
A
The nurse is preparing to assist the patient in using the incentive spirometer. Which nursing intervention should the nurse provide first? a.Perform hand hygiene. b.Explain use of the mouthpiece. c.Instruct the patient to inhale slowly. d.Place in the reverse Trendelenburg position.
A
The nurse is providing preoperative teaching for the ambulatory surgery patient who will be having a cyst removed from the right arm. Which will be the best explanation for diet progression after surgery? a."Start with clear liquids, soup, and crackers. Advance to a normal diet as tolerated." b."Stay with ice chips for several hours. After that, you can have whatever you want." c."Stay on clear liquids for 24 hours. Then you can progress to a normal diet." d."Start with clear liquids for 2 hours and then full liquids for 2 hours. Then progress to a normal diet."
A
The nurse is reviewing the surgical consent with the patient during preoperative education and finds the patient does not understand what procedure will be completed. What is the nurse's best next step? a.Notify the health care provider about the patient's question. b.Explain the procedure that will be completed. c.Continue with preoperative education. d.Ask the patient to sign the form.
A
The nurse working on a medical/surgical floor knows that pulmonary embolisms can be a deadly complication after surgery. Which of the following patients is most likely to develop a pulmonary embolism? a.45-year-old patient after bariatric surgery b.23-year-old patient with pneumonia c.13-year-old patient after appendectomy d.57-year-old patient after cholecystectomy
A
The perioperative nurse manager and the postoperative unit manager are concerned about the increasing number of surgical infections in their hospital. What action by the managers is best? a. Audit charts to see if the Surgical Care Improvement Project (SCIP) outcomes were met. b. Encourage staff on both units to provide peer pressure to adhere to hand hygiene policy. c. Hold educational meetings with the nursing and surgical staff on infection prevention. d. Monitor staff on both units for consistent adherence to established hand hygiene practices.
A
A postoperative client is being discharged with a prescription for oxycodone hydrochloride with acetaminophen (Percocet). What instructions does the nurse give the client? (Select all that apply.) a. Check all over-the-counter medications for acetaminophen. b. Do not take more pills each day than you are prescribed. c. Eat a diet that is high in fiber and drink lots of water. d. If this gives you diarrhea, loperamide (Imodium) can help. e. You shouldn't drive while you are taking this medication.
A,B,C,E
The circulating nurse reviews the days schedule and notes clients who are at higher risk of anesthetic overdose and other anesthesia-related complications. Which clients does this include? (Select all that apply.) a. A 75-year-old client scheduled for an elective procedure b. Client who drinks a 6-pack of beer each day c. Client with a serum creatinine of 3.8 mg/dL d. Client who is taking birth control pills e. Young male client with a RYR1 gene mutation
A,B,C,E
The nurse is providing preoperative teaching for a patient regarding pain control after surgery. Which of the following statements is/are true regarding the use of postoperative analgesia? (Select all that apply.) a.Analgesics will not provide adequate relief if you wait until the pain becomes excruciating before using them. b.Pain control will help you recover from surgery quicker. c.You shouldn't be concerned about becoming addicted to your pain medications immediately after surgery. d.You will remain pain-free as long as you take your pain medications as prescribed. e.A PCA pump is commonly used to help patients control their pain. f.Take pain medication carefully as it will lengthen your recovery period.
A,B,C,E
When is it appropriate to ask a surgeon to clarify information for a patient who is undergoing surgery? (Select all that apply.) a.Before the informed consent has been signed b.When a patient is confused about the reason for the procedure c.When a patient understands the risks involved in a procedure d.If there is confusion about the procedure after the informed consent is signed e.After the surgery has been performed
A,B,D
A client is clearly uncomfortable and anxious in the preoperative holding room waiting for emergent abdominal surgery. What actions can the nurse perform to increase comfort? (Select all that apply.) a. Allow the client to assume a position of comfort. b. Allow the clients family to remain at the bedside. c. Give the client a warm, non-caffeinated drink. d. Provide warm blankets or cool washcloths as desired. e. Pull the curtains around the bed to provide privacy.
A,B,D,E
The operating room nurse is providing a hand-off report to the postanesthesia care unit (PACU) nurse. Which components will the operating room nurse include? (Select all that apply.) a.IV fluids b.Vital signs c.Insurance data d.Family location e.Anesthesia provided f.Estimated blood loss
A,B,E,F
The nursing student observing in the perioperative area notes the unique functions of the circulating nurse, which include which roles? (Select all that apply.) a. Ensuring the clients safety b. Accounting for all sharps c. Documenting all care given d. Maintaining the sterile field e. Monitoring traffic in the room
A,E
A client waiting for surgery is very anxious. What intervention can the nurse delegate to the unlicensed assistive personnel (UAP)? a. Assess the clients anxiety. b. Give the client a back rub. c. Remind the client to turn. d. Teach about postoperative care.
B
A client has been given hydroxyzine (Atarax) in the preoperative holding area. What action by the nurse is most important for this client? a. Document giving the drug. b. Raise the siderails on the bed. c. Record the clients vital signs. d. Teach relaxation techniques.
B
A client has received intravenous anesthesia during an operation. What action by the postanesthesia care nurse is most important? a. Assist with administering muscle relaxants to the client. b. Place the client on a cardiac monitor and pulse oximeter. c. Prepare to administer intravenous antiemetics to the client. d. Prevent the client from experiencing postoperative shivering.
B
A client is having robotic surgery. The circulating nurse observes the instruments being inserted, then the surgeon appears to break scrub when going to the console and sitting down. What action by the nurse is best? a. Call a time-out to discuss sterile procedure and scrub technique. b. Document the time the robotic portion of the procedure begins. c. Inform the surgeon that the scrub preparation has been compromised. d. Report the surgeons actions to the charge nurse and unit manager
B
A client is in stage 2 of general anesthesia. What action by the nurse is most important? a. Keeping the room quiet and calm b. Being prepared to suction the airway c. Positioning the client correctly d. Warming the client with blankets
B
The nurse is caring for a preoperative patient. The nurse teaches the principles and demonstrates leg exercises for the patient. The patient is unable to perform leg exercises correctly. What is the nurse's best next step? a.Encourage the patient to practice at a later date. b.Assess for the presence of anxiety, pain, or fatigue. c.Ask the patient why exercises are not being done. d.Evaluate the educational methods used to educate the patient.
B
The nurse is concerned about the skin integrity of the patient in the intraoperative phase of surgery. Which action will the nurse take to minimize skin breakdown? a.Encouraging the patient to bathe before surgery b.Securing attachments to the operating table with foam padding c.Periodically adjusting the patient during the surgical procedure d.Measuring the time a patient is in one position during surgery
B
The nurse is conducting preoperative teaching with the patient and family. The nurse teaches the patient the proper use of the incentive spirometer. The nurse knows that the patient understands the need for this intervention when the patient states, I use this device to: a.help my cough reflex. b.expand my lungs after surgery. c.increase my lung circulation. d.keep me from coughing.
B
The nurse is preparing a patient for surgery. Which goal is a priority for assessing the patient before surgery? a.Plan for care after the procedure. b.Establish a patient's baseline of normal function. c.Educate the patient and family about the procedure. d.Gather appropriate equipment for the patient's needs
B
The nurse is prescreening a surgical patient in the preadmission testing unit. The medication history indicates that the patient is currently taking an anticoagulant. Which action should the nurse take when consulting with the health care provider? a.Ask for a radiological examination of the chest. b.Ask for an international normalized ratio (INR). c.Ask for a blood urea nitrogen (BUN). d.Ask for a serum sodium (Na).
B
The patient has presented to the ambulatory surgery center to have a colonoscopy. The patient is scheduled to receive moderate sedation (conscious sedation) during the procedure. How will the nurse interpret this information? a.The procedure results in loss of sensation in an area of the body. b.The procedure requires a depressed level of consciousness. c.The procedure will be performed on an outpatient basis. d.The procedure necessitates the patient to be immobile.
B
The postanesthesia care unit (PACU) nurse transports the inpatient surgical patient to the medical-surgical floor. Before leaving the floor, the medical-surgical nurse obtains a complete set of vital signs. What is the rationale for this nursing action? a.This is done to complete the first action in a head-to-toe assessment. b.This is done to compare and monitor for vital sign variation during transport. c.This is done to ensure that the medical-surgical nurse checks on the postoperative patient. d.This is done to follow hospital policy and procedure for care of the surgical patient.
B
A nurse orienting to the postoperative area learns which principles about the postoperative period? (Select all that apply.) a. All phases require the client to be in the hospital. b. Phase I care may last for several days in some clients. c. Phase I requires intensive care unit monitoring. d. Phase II ends when the client is stable and awake. e. Vital signs may be taken only once a day in phase III.
B,D,E
A preoperative nurse is reviewing morning laboratory values on four clients waiting for surgery. Which result warrants immediate communication with the surgical team? a. Creatinine: 1.2 mg/dL b. Hemoglobin: 14.8 mg/dL c. Potassium: 2.9 mEq/L d. Sodium: 134 mEq/L
C
