ATI- The Surgical Client Test

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? A. An Ileus B. Dehiscence C. Irritable Bowel Syndrome D. Hemorrhoids

A. An ileus Rationale: Minimal Peristalsis, nausea, and mild discomfort are an indication that the client may have developed an ileus.

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? A. A report of pain as a 2 on a 0 to 10 pain scale B. Redness around the incision site C. Constipation D. Serosanguinous drainage on the dressing

B. Redness around the incision site Rationale: Redness around the incision site is a manifestation of an infection. Other manifestations of an infection can include, fever, pain, and purulent drainage. Incorrect A. A report of pain as a 2 on a 0 to 10 pain scale. Rationale: A report of pain as a 2 on a 0 to 10 pain scale is an expected finding following abdominal surgery. Persistent pain could be a manifestation of an infection. C. Constipation Rationale: Constipation is an expected finding following abdominal surgery due to limited mobility, anesthesia, and opioid analgesics. It is not a manifestation of an infection. D. Serosanguinous drainage on the dressing Rationale: Serosanguinous drainage is an expected finding following abdominal surgery. Purulent drainage is a manifestation of an infection.

A nurse is planning postoperative care for a client. Which of the following actions should be the nurse's priority? A. Monitor the client's oxygen saturation. B. Check the client's bowel sounds. C. Administer analgesics to the client. D. Measure the client's intake and output.

A. Monitor the client's oxygen saturation. Rationale: When using the airway, breathing, circulation approach to client care, the nurse should determine that the priority action is to monitor the client's oxygen saturation because the client is at risk for hypoxia. Incorrect B. Check the client's bowel sounds. Rationale: The nurse should check the client's bowel sounds to determine bowel function; however, there is another action the nurse should take first. C. Administer analgesics to the client. Rationale: The nurse should administer analgesics to the client to promote comfort and relieve pain; however, there is another action the nurse should take first. D. Measure the client's intake and output. Rationale: The nurse should measure the client's intake and output to monitor the client's hydration status; however, there is another action the nurse should take first.

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? A. Instruct the client to perform pelvic muscle exercises. B. Restrict the client's fluid intake. C. Insert a straight urinary catheter into the client. D. Administer an anticholinergic medication to the client.

C. Insert a straight urinary catheter into the client. Rationale: The nurse should plan to insert a straight urinary catheter into the client to relieve the client's distended bladder and assist with voiding. Incorrect A. Instruct the client to perform pelvic muscle exercises. Rationale: Pelvic muscle exercises are used to treat urinary stress incontinence and will not treat urinary retention. B. Restrict the client's fluid intake. Rationale: The nurse should monitor the client's hydration status and maintain the client's fluid intake to reduce the risk for dehydration. D. Administer an anticholinergic medication to the client. Rationale: The nurse should not plan to administer an anticholinergic medication to the client as this can cause an increase in urinary retention.

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? A. Use of probiotics B. Prescribed antibiotics C. Prescribed anticholinergics D. Use of antiseptic skin cleanser

C. Prescribed anticholinergics Rationale: Anticholinergics are given to decrease secretions in the upper airway, but they can cause delirium, which poses a risk for a client who has dementia. Incorrect A. Use of probiotics Rationale: Probiotics help keep the body healthy. They do not pose a risk to a client who has dementia. B. Prescribed antibiotics Rationale: Antibiotics are used to prevent bacterial infections and are not expected to create a risk for a postoperative complication. D. Use of antiseptic skin cleanser Rationale: Antiseptics slow the growth of micro-organisms on external surfaces and do not pose a risk for a client who has dementia.

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? A. Reposition the client every hour. B. Have the client cough and deep breathe every 4 hr. C. Instruct the client to perform ankle pump exercises once a day. D. Reinforce with the client that they should use an incentive spirometer every 2 hr.

A. Reposition the client every hour. Rationale: The nurse should reposition the client every hour to promote lung expansion and decrease the risk of muscle weakness, blood clots, and pneumonia. Incorrect B. Have the client cough and deep breathe every 4 hr. Rationale: The nurse should instruct the client to cough and deep breathe every 2 hr to promote lung expansion and clear secretions. C. Instruct the client to perform ankle pump exercises once a day. Rationale: The nurse should instruct the client to perform ankle pump exercises every hour while awake to promote venous return and decrease the risk for a thrombus formation. D. Reinforce with the client that they should use an incentive spirometer every 2 hr. Rationale: The nurse should instruct the client to perform 10 repetitions of an incentive spirometer every hour to promote lung expansion and clear secretions.

A nurse is assisting with teaching a newly licensed nurse about preoperative teaching. Which of the following statements should the nurse include? A. "Preoperative teaching can reduce the length of the client's hospital stay." B. "Preoperative teaching results in an increase in client anxiety." C. "Preoperative teaching results in a decrease in clients' participation in their health care plan." D. "Preoperative teaching can cause an increase in the cost of health care."

A: "Preoperative teaching can reduce the length of the client's hospital stay." Rationale: Effective preoperative teaching can reduce the length of the client's hospital stay by decreasing complications such as pneumonia, infection, and thrombophlebitis. Incorrect: B. "Preoperative teaching results in an increase in client anxiety." Rationale: Preoperative teaching can reduce client anxiety by informing the client what to expect before, during, and after the procedure. C. "Preoperative teaching results in a decrease in clients' participation in their health care plan." Rationale: Effective preoperative teaching promotes clients' participation in their health care plan. A client who is educated is empowered to ask questions and actively participate in their health care. D. Rationale: Effective preoperative teaching can reduce the cost of health care by decreasing complications such as pneumonia, infection, and thrombophlebitis.

A nurse is monitoring a postsurgical client for dysphagia. Which of the following factors puts the client at risk? A. History of foot surgery B. Parkinson's disease C. Leukemia D. History of a total abdominal hysterectomy

B. Parkinson's disease Rationale: Parkinson's disease is a risk factor for a client to develop dysphagia.

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? A. Once at the beginning of the procedure B. Several times throughout the procedure C. Once at the end of the procedure D. After anesthesia has been administered

B. Several times throughout the procedure Rationale: A time-out is performed at the beginning of the procedure, prior to any additional procedures performed, and at the completion of the procedure.

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? A. Diarrhea B. Aspiration C. Pain D. Pruritis

B: Aspiration Rationale: Aspiration is a postoperative complication that can increase the risk for pneumonia. Incorrect: A. Diarrhea Rationale: Diarrhea could be a concern, but it is not a postoperative complication that can increase the risk of pneumonia. C. Pain Rationale: Pain could be a concern, but it is not a postoperative complication that can increase the risk for pneumonia. D. Pruritis Rationale: Pruritis is not a postoperative complication that can increase the risk for pneumonia.

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? A. Instruct the client to quickly eat their food. B. Assist the client to sit upright to eat. C. Cut the food into medium-sized pieces. D. Encourage the client to talk during the meal.

B: Assist the client to sit upright to eat. Rationale: The nurse should assist the client to sit upright to eat. Remaining in an upright position for at least 1 hr is also recommended. This can help to prevent aspiration. Incorrect: A. Instruct the client to quickly eat their food. Rationale: Clients should be instructed to eat and drink slowly to prevent aspiration. C. Cut the food into medium-sized pieces. Rationale: The food should be cut into small pieces, and the client should be encouraged to chew completely before swallowing. D. Encourage the client to talk during the meal. Rationale: Clients should be encouraged to avoid watching TV or talking while eating.

Which of the following members of the surgical team is responsible for ensuring that the necessary tools are sterile and ready to use? A. Circulating nurse B. Anesthesiologist C. Certified surgical technologist D. Surgeon

C. Certified surgical technologist Rationale: The certified surgical technologist (CST) is responsible for ensuring that the necessary tools are sterile and ready to use. Incorrect: A. Circulating nurse Rationale: The circulating nurse is not responsible for ensuring that the necessary tools are sterile and ready to use. B. Anesthesiologist Rationale: The anesthesiologist is not responsible for ensuring that the necessary tools are sterile and ready to use. D. Surgeon Rationale: The surgeon is not responsible for ensuring that the necessary tools are sterile and ready to use.

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? A. General B. Local C. Regional D. Epidural

C. Regional Rationale: With regional anesthesia, the client will experience a temporary loss of feeling to an area of the body. Incorrect A. General Rationale: General anesthesia is medications or inhalants used to depress the central nervous system. B. Local Rationale: Local anesthesia affects the moto and sensory nerves at the surgical site. D. Epidural Rationale: Epidural anesthesia is combined with general anesthesia and is generally used for abdominal and thoracic surgeries.

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? A. The client lives alone B. The client cares for a pet C. The client takes medication that causes dizziness D. The client takes medications that cause heartburn

C. The client takes medications that cause dizziness. Rationale: The greatest risk to this client is injury from a fall because the client is taking a medication that can cause dizziness; therefore, this finding is the nurse's priority. Incorrect: A. The client lives alone Rationale: The nurse should collect data regarding whether the client can take care of themselves; however, another finding is the priority. B. The client cares for a pet Rationale: The nurse should collect data about whether the client needs assistance caring for a pet; however, another finding is the priority. D. The client takes medications that cause heartburn Rationale: The nurse should provide instructions to the client about how to reduce heartburn; however, another finding is the priority.

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.) A. Type 2 diabetes mellitus B. BMI 28 C. Married D. Current smoker E. Corticosteroid use F. 68 years old

Correct A. Type 2 diabetes mellitus Rationale: Clients who have type 1 or type 2 diabetes are at an increased risk for poor wound healing. D. Current smoker Rationale: Clients who smoke are at risk for poor wound healing. E. Corticosteroid use Rationale: Clients who use corticosteroids on a regular basis are at an increased risk for poor wound healing. F. 68 years old Rationale: Clients who are older than 65 years of age are at an increased risk for poor wound healing. Incorrect: B. BMI 28 Rationale: Clients who are obese with a BMI greater than 30 are at an increased risk for poor wound healing. C. Married Rationale: Marital status is not a risk factor for poor wound healing.

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.) A. Ask the client what interventions they prefer B. Limit medications to one type of analgesic C. Determine how the client has responded to analgesics in the past D. Include the use of a placebo for pain management E. Include nonpharmacological methods to reduce pain

Correct: A. Ask the client what interventions they prefer. Rationale: the nurse should ask the client about what interventions they prefer when planning perioperative pain management. C. Determine how the client has responded to analgesics in the past. Rationale: The nurse should ask the client how they have responded to analgesics in the past to provide safe and effective pain management. E. Include nonpharmacological methods to reduce pain. Rationale: The nurse should include nonpharmacological methods, such as massage, in the plan to promote pain control. Incorrect B. Limit medications to one type of analgesic Rationale: The nurse should include a variety of analgesics to reduce the client's pain in order to limit adverse effects of high-dose pain medications. D. Include the use of a placebo for pain management Rationale: The nurse should not plan to use a placebo for pain management as this can result in client distrust and might not effectively decrease the client's pain.

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. Deep vein thrombosis B. Thrombotic stroke C. Hypovolemic shock D. A pulmonary embolism

D. A pulmonary embolism Rationale: Chest pain, shortness of breath, tachycardia, and hypoxia is indicative of a pulmonary embolism and is a medical emergency. The nurse should immediately activate the emergency response team and notify the client's provider. Incorrect: A. Deep vein thrombosis Rationale: A client who is experiencing a deep vein thrombosis will experience pain, redness, and swelling within the lower extremity. B. Thrombotic stroke Rationale: A client who is experiencing a thrombotic stroke will have neurological deficits such as confusion, impaired speech or understanding, dizziness, or numbness or weakness on one side of the body. C. Hypovolemic shock Rationale: A client who is experiencing hypovolemic shock following surgery will have a major loss of intravascular fluid and will have manifestations of hypotension, confusion, tachycardia, and oliguria.

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? A. Urinary Retention B. Constipation C. Nausea D. Blood Clots

D. Blood clots Rationale: According to evidence-based practice, the nurse should identify that a history of regular tobacco use places the client at an increased risk for blood clots. The nurse should monitor the client for areas of swelling and redness, and implement measures to promote venous return, such as graded compression stockings and early ambulation. Incorrect A. Urinary Retention Rationale: The nurse should monitor the client for urinary retention, which can occur as a result of taking opioid analgesics. However, evidence-based practice indicates the client is at an increased risk for another complication. B. Constipation Rationale: The nurse should monitor the client for constipation, which can occur as a result of taking opioid analgesics. However, evidence-based practice indicates the client is at an increased risk for another complication. C. Nausea Rationale: The nurse should monitor the client for nausea, which can occur as a result of taking opioid analgesics. However, evidence-based practice indicates the client is at an increased risk for another complication.

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? A. Incentive spirometer B. Antibiotic therapy C. Antihypertensive medication D. Sequential compression devices

D. Sequential compression devices Rationale: Sequential compression devices are prescribed for clients postoperatively to decrease the risk of VTE. Clients should wear the devices while in bed and sitting in a chair. Incorrect: A. Incentive spirometer Rationale: An incentive spirometer is prescribed for a postoperative client to assist with deep breathing to reduce the risk of atelectasis and pneumonia. It is not therapy for VTE. B. Antibiotic therapy Rationale: Antibiotic therapy is prescribed postoperatively as treatment for an infection or as prophylaxis against infection occurring. It is not therapy for VTE. C. Antihypertensive medication Rationale: Antihypertensive medication prescribed postoperatively is for treatment of hypertension that can occur following surgery. It is not therapy for VTE.

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.) -Start at the center and move to the area away from the site is the second step. -Drape the client. -Scrub the surgical site in a circular fashion with an antiseptic -Repeat with a new sponge -Scrub the outer edge and discard the sponge

Correct Order: 1 - Scrub the surgical site in a circular fashion with an antiseptic Rationale: The nurse should first 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 Rationale: When scrubbing, the nurse should start at the center and move to the area away from the site. 3 - Scrub the outer edge and discard the sponge Rationale: Once the nurse reaches the outer edge, the sponge is considered to be contaminated and the nurse must discard it. 4 - Repeat with a new sponge Rationale: Next, the nurse repeats the scrubbing process with a new sponge. 5 - Drape the client Rationale: After scrubbing the site, the nurse should drape the client.

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.) A. Allergies B. Discontinued medications C. Alcohol use D. Spiritual beliefs E. Financial status

Correct: A. Allergies Rationale: The nurse should identify any allergies to medications, foods, and other substances the client might have, and then place an allergy band on the client. C. Alcohol use Rationale: The nurse should identify and document the client's history of alcohol and tobacco use. D. Spiritual beliefs Rationale: The nurse should document the client's spiritual beliefs to provide empathy and emotional support to the client. Incorrect B. Discontinued medications Rationale: The nurse should identify and document any current medications or supplements the client is taking. E. Financial status Rationale: The nurse should not document the client's financial status in the client's medical record.

A nurse is collecting data on 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.) A. The client states the wound is painful. B. The client's blood pressure is 115/72 mm Hg. C. The edges of the wound are red. D. The client is ambulating frequently. E. The client has a fever.

Correct: A. The client states the wound is painful Rationale: The nurse should record the client's level of pain in the documentation, as well as actions taken to alleviate the pain. C. The edges of the wound are red Rationale: The nurse should include in the documentation that the edges of the wound are red. E. The client has a fever Rationale: The nurse should include in the documentation that the client is experiencing a fever, along with actions taken to treat the fever. Incorrect B. The client's blood pressure is 115/72 mm Hg. Rationale: The client's blood pressure is within the expected reference range and is not pertinent to the appearance of the surgical wound. D. The client is ambulating frequently. Rationale: The nurse should record the client's mobility in the activity section of the documentation, but this is not pertinent to the description of the wound.

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.) A. Verify the client has signed the consent. B. Describe the procedure to the client. C. Check that the client is of legal age to provide consent. D. Explain alternatives to the procedure to the client. E. Confirm the client is competent.

Correct: A. Verify the client has signed the consent. Rationale: The nurse is responsible for verifying the client has signed the consent. C. Check that the client is of legal age to provide consent. Rationale: The nurse is responsible for verifying the client is of legal age to provide consent. E. Confirm the client is competent. Rationale: The nurse is responsible for verifying the client is competent. Incorrect: B. Describe the procedure to the client. Rationale: The provider is responsible for explaining the procedure to the client. It is not the responsibility of the nurse. D. Explain alternatives to the procedure to the client. Rationale: The provider is responsible for explaining any alternatives to the procedure to the client.

Surgical attire for the surgical suite consists of which of the following items? (Select all that apply.) A. Belt B. Cap C. Shoe covers D. Gown E. Mask F. Gloves

Correct: B. Cap Rationale: A surgical cap is part of the surgical attire for the surgical suite C. Shoe covers Rationale: Surgical shoe covers are part of the surgical attire for the surgical suite D. Gown Rationale: A surgical gown is part of the surgical attire for the surgical suite. E. Mask Rationale: A surgical mask is part of the surgical attire for the surgical suite F. Gloves Rationale: Surgical gloves are part of the surgical attire for the surgical suite. Incorrect A. Belt Rationale: A surgical belt is not part of the surgical attire for the surgical suite.

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? A. Oxygen saturation 97% on room air B. Respiratory rate 14/min C. Heart rate 72/min D. Blood pressure 88/60 mm Hg

D: Blood pressure 88/60 mm Hg Rationale: A blood pressure of less than 90 mm Hg systolic is considered hypotension and is a manifestation of bleeding. The nurse should notify the provider and monitor the client for other manifestations of bleeding, such as tachycardia and tachypnea. Incorrect: A. Oxygen saturation 97% on room air Rationale: Oxygen saturation of 97% on room air is within the expected reference range of greater that 95%. A decrease in oxygen saturation is a possible manifestation of bleeding. C. Heart rate 72/min Rationale: A respiratory rate of 14/min is within the expected reference range of 12 to 20/min. Tachypnea is a possible manifestation of bleeding. D. Blood pressure 88/60 mm Hg Rationale: A heart rate of 72/min is within the expected reference range of 60 to 100/min. Tachycardia is a manifestation of bleeding.