NCLEX CH. 17
A patient continuously states, "I know all will go well." What cognitive coping strategy should the nurse document? a)Optimistic self-recitation b)Imagery c)Music therapy d)Distraction
a)Optimistic self-recitation Explanation: When that patient verbalizes this statement, it is an optimistic response. Imagery occurs when the patient concentrates on a pleasant experience or restful scene. Distraction occurs when the patient thinks of an enjoyable story or recites a favorite poem or song. Music therapy would be an incorrect answer. Reset
The nurse would identify which of the following vitamin deficiencies to prevent the complication of hemorrhaging during surgery? a)Vitamin A b)Zinc c)Vitamin K d)Magnesium
c)Vitamin K Explanation: Vitamin K is important for normal blood clotting. Vitamin A and zinc deficiencies would affect the immune system, whereas a magnesium deficiency would delay wound healing.
A patient asks about the purpose of withholding food and fluid before surgery. Which response by the nurse is appropriate? a)It decreases urine output so that a catheter would not be needed. b)It prevents overhydration and hypertension. c)It decreases the risk of elevated blood sugars and slow wound healing. d)It prevents aspiration and respiratory complications.
d)It prevents aspiration and respiratory complications. Explanation: The major purpose of withholding food and fluid before surgery is to prevent aspiration, which can lead to respiratory complications. Preventing overhydration, decreasing urine output, and decreasing blood sugar levels are not major purposes of withholding food and fluid before surgery.
The nurse is educating a community group regarding types of surgery. A member of the group asks the nurse to describe a type of surgery that is curative. What response by the nurse is true? a)The excision of a tumor b)A face-lift c)A biopsy d)The placement of gastrostomy tube
a)The excision of a tumor Explanation: An example of a curative surgical procedure is the excision of a tumor. A biopsy, a face-lift, and the placement of a gastrostomy tube are not examples of curative surgical procedures.
A patient is scheduled to have a cholecystectomy. Which of the nurse's finding is least likely to contribute to surgical complications? a)Diabetes b)Osteoporosis c)Urinary tract infection d)Pregnancy
b)Osteoporosis Explanation: Osteoporosis is most likely not going to contribute to complications related to a cholecystectomy. Pregnancy decreases maternal reserves. Diabetes increases wound-healing problems and risks for infection. Urinary tract infection decreases the immune system, increasing the chance for infections.
The nurse is educating a patient scheduled for elective surgery. The patient currently takes aspirin daily. What education should the nurse provide in regard to the medication? a)Take half doses of the aspirin until 1 week after surgery. b)Aspirin should be increased until 3 days before surgery, and then it should be discontinued until 3 days after surgery. c)Continue to take the aspirin as ordered. d)Stop taking the aspirin 7 days before the surgery, unless otherwise directed by your physician.
d)Stop taking the aspirin 7 days before the surgery, unless otherwise directed by your physician. Explanation: Aspirin should be stopped at least 7 to 10 days before surgery. The other directions provided are incorrect.
A parent of a 16-year-old patient asks the nurse, "How could the surgeon operate without my consent?" What is the best response given by the nurse? a)"Your child had life-threatening injuries that required immediate surgery." b)"We obtained consent from your child after your child requested the surgery." c)"The surgical procedure being performed does not require consent." d)"Two doctors decided your child needed the surgery, therefore we did not need to get consent."
a)"Your child had life-threatening injuries that required immediate surgery." Explanation: In an emergency, it may be necessary for the surgeon to operate as a lifesaving measure without the patient's or parent's informed consent. Informed consent must be obtained before any invasive procedure. A minor cannot consent for a surgical procedure. Two doctors' opinions do not overrule the need to obtain informed consent.
The nurse has administered the preanesthetic medication. What action should the nurse take next? a)Place the patient on bed rest with the side rails up. b)Review the patient's list of home medications. c)Obtain the patient's signature on the consent form. d)Educate the patient on discharge instructions.
a)Place the patient on bed rest with the side rails up. Explanation: The preanesthetic medication can make the patient lightheaded and dizzy. Safety is a priority. The consent form should be signed before the patient is medicated. Consents signed after the patient is medicated are not legal. Reviewing the home medications and educating the patient should take place before the patient is medicated.
A patient is undergoing thoracic surgery. What priority education should the nurse provide to assist in preventing respiratory complications? a)Splint the incision site using a pillow during deep breathing and coughing exercises. b)Deep breathing and coughing exercises should be completed every 8 hours. c)Deep breathing and coughing exercises may be used as relaxation techniques. d)Pain medication should be taken before completing deep breathing and coughing exercises.
a)Splint the incision site using a pillow during deep breathing and coughing exercises. Explanation: Splinting the incision site will help decrease pain and support the incision. This will increase compliance with the deep breathing and coughing exercises that assist with the prevention of respiratory complications. Pain medication should be taken regularly and not only before deep breathing and coughing exercises. Deep breathing and coughing exercises should be done at least every 2 hours, more frequently if possible. While some patients will find the exercises relaxing, most patients find it painful to complete the exercises.
The nurse is completing a preoperative assessment. The nurse notices the patient is tearful and constantly wringing hands. The patient states, "I'm really nervous about this surgery. Do you think it will be ok?" What is the nurse's best response? a)"What family support do you have after the surgery?" b)"What are your concerns?" c)"You have nothing to worry about; you have the best surgical team." d)"No one has ever died from the procedure you are having."
b)"What are your concerns?" Explanation: Asking the patient about their concerns is an open-ended therapeutic technique. It allows the patient to guide the conversation and address their emotional state. Asking about family support is changing the subject and is nontherapeutic. Discussing the surgical team and the low death rate associated with a procedure is minimizing the patient's feelings and is nontherapeutic.
During the preoperative assessment, the patient states he is allergic to avocados, bananas, and hydrocodone (Vicodin). What is the priority action by the nurse? a)Notify the nurse manager to follow up on the procedure. b)Notify the dietary department. c)Notify the surgical team to remove all latex-based items. d)Notify the physician regarding postoperative pain medications.
c)Notify the surgical team to remove all latex-based items. Explanation: Allergies to avocados and bananas may indicate an allergy to latex. Although it is necessary to notify the dietary department and physician, it is not an immediate threat, as the patient is NPO (nothing by mouth) and pain medication will be ordered postoperatively. The nurse manager does not need to be notified of the patient's allergies.
The nurse is educating patients requiring surgery for various ailments on the perioperative experience. What education provided by the nurse is most appropriate? a)Expected pain levels and narcotic pain medication used to treat the pain b)Intraoperative techniques used to perform the surgery c)Risks and benefits of the surgical procedures d)Three phases of surgery and safety measures for each phase
d) Three phases of surgery and safety measures for each phase Explanation: The perioperative period includes the preoperative, intraoperative, and postoperative phases. Specific safety guidelines are followed for all surgical patients. The information provided should be general enough to be informative about surgery and should not focus on individual surgeries, as all the patients are having different surgeries. Intraoperative techniques, expected pain levels, and pain medication are specific to the patient and type of surgery. The risks and benefits of the surgical procedure should be discussed by the physician.
A patient with a history of alcoholism and scheduled for an urgent surgery asks the nurse, "Why is everyone so concerned about how much I drink?" What is the best response by the nurse? a)"It is a required screening question for all patients having surgery." b)"We can have counselors available after surgery; if it is determined you need help for your drinking." c)"The amount of alcohol you drink will determine the amount of pain medication you will need postoperatively." d)"It is important for us to know how much and how often you drink to help prevent surgical complications."
d)"It is important for us to know how much and how often you drink to help prevent surgical complications." Explanation: Alcohol use and alcoholism can contribute to serious postoperative complications. If the medical and nursing staff is aware of the use or abuse, measures can be implemented proactively to prevent complications. Although alcohol may interfere with a medication's effectiveness, it does not determine the amount of pain medications that are prescribed following surgery. Even though this is a required screening question and counselors can be made available for those who want help, those are not the best responses to answer the patient's question.
A patient is scheduled for elective surgery. To prevent the complication of hypotension and cardiovascular collapse, the nurse should report the use of what medication? a)Warfarin (Coumadin) b)Hydrochlorothiazide (HydroDIURIL) c)Erythromycin (Ery-Tab) d)Prednisone (Deltasone)
d)Prednisone (Deltasone) Explanation: Patients who have received corticosteroids are at risk of adrenal insufficiency. Insufficiency related to corticosteroids can cause circulatory collapse and hypotension. Hydrochlorothiazide and erythromycin can cause respiratory complications. Warfarin will increase the risk of bleeding.
What action by the nurse best encompasses the preoperative phase? a)Shaving the patient using a straight razor b)Monitoring vital signs every 15 minutes c)Documenting the application of sequential compression devices (SCD) d)Educating the patients on signs and symptoms of infection
d)Educating the patients on signs and symptoms of infection Explanation: Educating the patient on prevention or recognition of complications begins in the preoperative phase. Applying SCD and frequent vital sign monitoring happens after the preoperative phase. Only electric clippers should be used to remove hair.
A patient with fractured skull after falling from a ladder requires surgery. The nurse should anticipate transporting the patient to surgery during what time frame? a)In 1 week b)In 48-72 hours c)In 1 day d)Immediately
d)Immediately Explanation: Emergent surgery occurs when the patient requires immediate attention. A fractured skull is an indication for emergent surgery. An urgent surgery occurs when the patient requires prompt attention, usually within 24-30 hours. Any surgery scheduled beyond 30 hours is classified as required or elective and a fractured skull does not meet the requirements for elective or required surgery.
A nurse is witnessing a patient sign the consent form for surgery. After the patient signs the consent form, the patient starts asking questions regarding the risks and benefits of a surgical procedure. What action by the nurse is most appropriate? a)Place the consent form in the patient's medical record. b)Notify the nurse manager of the patient's questions. c)Request that the surgeon come and answer the questions. d)Answer the patient's questions.
:c)Request that the surgeon come and answer the questions. Explanation: It is the physician's responsibility to provide information pertaining to risks and benefits of surgery. It is not the responsibility of the nurse or nurse manager to discuss risks and benefits. The consent form should not be placed in the medical record until all questions are answered fully for the patient.
A surgical patient has been transferred to the holding area. What nursing intervention(s) promote safe and effective nursing care? Select all that apply. a)Identify the patient using two identifiers. b)Provide oral fluids to the patient. c)Apply grounding devices to the patient. d)Review the medical records. e)Verify the surgical site and mark it appropriately. f)Maintain an aseptic environment.
a)Identify the patient using two identifiers. e)Verify the surgical site and mark it appropriately. d)Review the medical records. Explanation: Identifying the patient, verifying and marking the surgical site, and reviewing the medical records all promote safe and effective care while the patient is in the holding area. Maintaining an aseptic environment and applying grounding devices are part of the intraoperative phase. Oral fluids should not be provided while the patient is in the holding area.
An anxious preoperative surgical patient is encouraged to concentrate on a pleasant experience or restful scene. What cognitive coping strategy would the nurse document as being used? a)Imagery b)Progressive muscular relaxation c)Distraction d)Optimistic self-recitation
a)Imagery Explanation: Imagery has proven effective for anxiety in surgical patients. Optimistic self-recitation is practiced when the patient is encouraged to recite optimistic thoughts such as, "I know all will go well." Distraction is employed when the patient is encouraged to think of an enjoyable story or recite a favorite poem. Progressive muscular relaxation requires contracting and relaxing muscle groups and is a physical coping strategy as opposed to a cognitive strategy.
A patient is scheduled for an invasive procedure. What is the priority documentation needed regarding the procedure? a)The medication reconciliation form b)A signed consent form from the patient c)Prescriptions for postoperative medications d)A health history obtained by the primary physician
b)A signed consent form from the patient Explanation: A signed consent is required and is important for initiating invasive procedures. The nurse should therefore check for the patient's signed consent form. A health history, medication reconciliation, and postoperative prescriptions are good items to have, but are not required documentation before performing an invasive procedure.
A patient refuses to remove her wedding band when preparing for surgery. What is the best action for the nurse to take? a)Remove the ring once the patient is sedated. b)Allow the ring to stay on the patient and cover it with tape. c)Discuss the risk for infection caused by wearing the ring. d)Notify the surgeon to cancel surgery.
b)Allow the ring to stay on the patient and cover it with tape. Explanation: Most facilities will allow a wedding band to remain on the patient during the surgical procedure. The nurse must secure the ring with tape. Although it is appropriate to discuss the risk for infection, the patient has already refused removal of the ring. The surgery should not be canceled and the ring should not be removed without permission.
A patient has been transported to the operating room for emergent surgery. Which statement by the nurse best supports the need for emergent surgery? a)"The patient was tachycardic, had progressive weight loss, and bouts of insomnia as a result of hyperthyroidism." b)"The patient had epigastric abdominal pain, an elevated white blood count, and vomiting for 1 day." c)"The patient was unresponsive, had a distended abdomen, and unstable vital signs following a motor vehicle accident." d)"The patient had severe pain and a laceration to the face with minimal bleeding after being attacked by a dog 1 hour ago." Show Answer
c)"The patient was unresponsive, had a distended abdomen, and unstable vital signs following a motor vehicle accident." Explanation: Emergency surgery means that the patient requires immediate attention and the disorder may be life threatening. The patient with unstable vital signs and a distended abdomen following a motor vehicle accident requires immediate attention. The patient with left sided abdominal pain may not need surgery. Epigastric pain with vomiting for 1 day is usually not an indication for emergent surgery. Lacerations to the face require sutures, not emergent surgery. A thyroidectomy to treat hyperthyroidism is a required surgery, not an emergent one.
The nurse is triaging the surgical patients. Which patient would the nurse document as urgent for surgical care? a)A patient needing cataract surgery b)A patient scheduled for cosmetic surgery c)A patient with an acute gallbladder infection d)A patient with severe bleeding
c)A patient with an acute gallbladder infection Explanation: An acute gallbladder infection is considered an urgent surgical procedure. Cosmetic surgery and cataract surgery are not considered urgent surgical procedures. Severe bleeding could be considered an emergent surgical procedure.
The nurse is conducting a preoperative assessment on a patient scheduled for gallbladder surgery. The patient reports having a frequent cough producing green sputum for 3 days and denies fever. Upon auscultation, the nurse notes rhonchi throughout the right lung with an occasional expiratory wheeze. Respiratory rate is 20, temperature is 99.8 taken orally, heart rate is 87, and blood pressure is 124/70. What is the nurse's best action? a)Notify the primary physician about the assessment findings. b)Wait 1 hour and complete the assessment again. c)Document the findings and continue the patient through the preoperative phase. d)Notify the surgeon to possibly delay the surgery.
d)Notify the surgeon to possibly delay the surgery. Explanation: A respiratory infection can delay a nonemergent surgical procedure because the infection can increase the risk for respiratory complications. Therefore, the nurse should notify the surgeon about delaying the surgery. The primary physician may be called to care for the assessment findings but that should be done only after the surgeon has been notified. Continuing through the preoperative phase without notifying the surgeon and waiting 1 hour is not appropriate.
An obese patient is scheduled for open abdominal surgery. What priority education should the nurse provide this patient? a)Wound care and infection prevention b)Prevention of wound dehiscence c)Venous thromboembolism prevention d)Prevention of respiratory complications
d)Prevention of respiratory complications Explanation: All answers are correct but the obese patient has an increased susceptibility to respiratory complications, and maintaining a patent airway would be the priority.