perioperative nursing prepu

What is the highest priority nursing intervention for a client in the immediate postoperative phase? a. maintaining a patent airway b. assessing urinary output every hour c. Assessing for hemorrhage d. Monitoring vital signs at least every 15 minutes

a. maintaining a patent airway

A perioperative nurse is conducting an in-service education program about maintaining surgical asepsis during the intraoperative period. Which of the following would the nurse emphasize? a. The edges of a sterile package, once opened, are considered unsterile. b. If a tear occurs in a sterile drape, a new sterile drape is applied on top of it. c. A distance of 3 feet must be maintained when moving around a sterile field. d. Circulating nurses may come in contact with the sterile field without contaminating it.

a. the edges of a sterile package, once opened, are considered unsterile.

The nurse documents the presence of granulation tissue in a healing wound. How should the nurse describe the tissue? a. White with long, thin areas of scar tissue b. Pink to red and soft, bleeding easily c. Pale yet able to blanch with digital pressure d. Necrotic and hard

b. pink to red and soft, bleeding easily.

Which zone of the surgical area only requires attire in the form of scrub clothes and caps? a. operative zone b. semi restricted zone c. unrestricted zone d. restricted zone

b. semi restricted zone

Which of the following is the appropriate response to the statement, "I'm so nervous about my surgery"? a. "Stop worrying. It only makes you more nervous." b. "You needn't worry. Your doctor has done this surgery many times before." c. "Relax. Your recovery period will be shorter if you're less nervous." d. "You seem nervous about your surgery."

d. you seem nervous about your surgery

During a procedure, a client's temperature begins to rise rapidly. This is likely the result of which complication? a. malignant hyperthermia b. infection c. hypothermia d. fluid volum excess

a. malignant hyperthermia

The nurse is caring for the postoperative client in the postanesthesia care unit. Which of the following is the priority nursing action? a. Position the client to maintain a patent airway. b. Administer antiemetics to prevent nausea and vomiting. c. Monitor vital signs for early detection of shock. d. Assess the incisional dressing to detect hemorrhage.

a. position the client to maintain a patent airway

A client at risk for malignant hyperthermia returns to the surgical unit. For what time period will the nurse monitor the client for development of malignant hyperthermia? a. The client will need to be discharged with special instructions. b. The client can develop malignant hyperthermia up to 24 hours after surgery c. A client can develop malignant hyperthermia only with intravenous anesthesia after surgery. d. Malignant hyperthermia occurs in the operating room only.

b. the client can develop malignant hyperthermia up to 24 hours after surgery

The nurse recognizes older adults require lower doses of anesthetic agents due to: a. increased liver mass. b. decreased bone mass. c. decreased lean tissue mass. d. increased tissue elasticity.

c. decreased lean tissue mass

A client has undergone a colon resection. While turning him, wound dehiscence with evisceration occurs. The nurse's first response is to: a. call the physician. b. take a blood pressure and pulse. c. place saline-soaked sterile dressings on the wound. d. pull the dehiscence closed.

c. place saline soaked dressings on the wound

The nurse observes that a postsurgical client has hemorrhaged and is in hypovolemic shock. Which nursing intervention will manage and minimize hemorrhage and shock? a. Elevating the head of the bed b. Encouraging the client to breathe deeply c. Reinforcing dressings or applying pressure if bleeding is frank d. Rubbing the back

c. reinforcing dressings or applying pressure if bleeding is frank

A physician calls the nurse for an update on his client who underwent abdominal surgery 5 hours ago. The physician asks the nurse for the total amount of drainage collected in the Hemovac since surgery. The nurse reports that according to documentation, no drainage has been recorded. When the nurse finishes on the telephone, she goes to assess the client. Which assessment finding explains the absence of drainage? a. There is a moderate amount of dry drainage on the outside of the dressing. b. The client has been lying on his side for 2 hours with the drain positioned upward. c. The client has a nasogastric (NG) tube in place that drained 400 ml d. The Hemovac drain isn't compressed; instead it's fully expanded.

d. the hemovac drain isn't compressed; instead it's fully expanded

A nurse assesses a postoperative client as having abdominal organs protruding through the surgical incision. Which term best describes this assessment finding? a. evisceration b. hernia c. dehiscence d. erythema

a. evisceration

The nurse is educating a community group about 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. tumor excision b. a biopsy c. placement of gastrostomy tube d. a face lift

a. tumor excision

The anesthesiologist will use moderate (conscious) sedation during the client's surgical procedure. The circulating nurse will expect the client to: a. Respond verbally during the procedure b. Need an endotracheal tube c. Need pain control throughout the procedure d. Be anxious throughout the procedure

a. respond verbally during the procedure

Which client would the nurse recognize as having the greatest risk for complications during the intraoperative or postoperative period? a. The 35-year-old client with non-insulin dependent diabetes. b. The 28-year-old client who occasionally smoked marijuana in high school. c. The 47-year-old client who stopped smoking 2 years ago. d. The 72-year-old client who takes no routine medications

a. the 35 year old client with no insulin dependent diabetes

The nurse is caring for a client 6 hours post surgery. The nurse observes that the client voids urine frequently and in small amounts. The nurse knows that this most probably indicates what? a. urine retention b. urinary infection c. requirement of intermittent catheterization d. calculus formation

a. urine retention

A client with an abdominal surgical wound sneezes and then states, "Something doesn't feel right with my wound." The nurse asses the upper half of the wound edges, noticing that they are no longer approximated and the lower half remains well approximated. The nurse would document that following a sneeze, the wound a. pustulated b. hemorrhaged c. dehisced d. eviscerated

c. dehisced

The nurse is teaching the client about usual side effects associated with spinal anesthesia. Which of the following should the nurse include when teaching? a. seizures b. sore throat c. headache d. itching

c. headache

The primary objective in the immediate postoperative period is a. relieving pain b. controlling nausea and vomiting. c. maintaining pulmonary ventilation. d. monitoring for hypotension.

c. maintaining pulmonary ventilation

The nurse is preparing to discharge a client from the PACU using a PACU room scoring guide. With what score can the client be transferred out of the recovery room? a. 6 b. 4 c. 5 d. 7

d. 7

When the indication for surgery is without delay, the nurse recognizes that the surgery will be classified as a. urgent b. required c. elective d. emergency

d. emergency

A student nurse is scheduled to observe a surgical procedure. The nurse provides the student nurse with education on the dress policy and provides all attire needed to enter a restricted surgical zone. Which observation by the nurse requires immediate intervention? a. Hair is pulled back and covered by a cap. b. Scrub top and drawstring are tucked into pants. c. Shoe covers are used. d. Mask is placed over nose and extends to bottom lip.

d. mask is placed over nose and extends to bottom lip

Once the operating team has assembled in the room, the circulating nurse calls for a "time out." What action should the nurse take during the time out? a. Check that all surgical personnel are properly attired. b. Confirm that informed consent has been obtained. c. Ensure that sufficient surgical supplies are available. d. Review the scheduled procedure, site, and client.

d. review the scheduled procedure, site, and client.

A client undergoing coronary artery bypass surgery is subjected to intentional hypothermia. The client is ready for rewarming procedures. Which action by the nurse is appropriate? a. Apply a warm air blanket, gradually increasing body temperature. b. Place warm damp drapes on the client, replacing them every 5 minutes. c. Administer IV fluids warmed to room temperature. d. Temporarily set the OR temperature to 30°C.

a. apply a warm blanket, gradually increasing body temperature

A nurse is teaching a client with chronic bronchitis about breathing exercises. Which instruction should the nurse include in the teaching? a. use diaphragmatic breathing. b. Exhale through an open mouth. c. Make inhalation longer than exhalation d. Use chest breathing

a. Use diaphragmatic breathing

An obese client is undergoing abdominal surgery. During the procedure a surgical resident states, "The amount of fat we have to cut through is disgusting." What is the best response by the nurse? a. Inform the resident that all communication needs to remain professional. b. Ignore the comment. c. Report the resident to the attending surgeon. d. Discuss concerns regarding the comments with the charge nurse.

a. inform the resident that all communication needs to remain professional

A client 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. Pain medication should be taken before completing deep breathing and coughing exercises. c. Deep breathing and coughing exercises may be used as relaxation techniques. d. Deep breathing and coughing exercises should be completed every 8 hours.

a. splint the incision site using a pillow during deep breathing and coughing exercises.

A client vomits postoperatively. What is the most important nursing intervention? a. Turn the client's head completely to one side to prevent aspiration of vomitus into the lungs. b. Measure the amount of vomitus to estimate fluid loss, in order to accurately monitor fluid balance. c. Support the wound area so that unnecessary strain will not disrupt the integrity of the incision. d. Offer tepid water and juices to replace lost fluids and electrolytes.

a. turn the client's head completely to one side to prevent aspiration of vomitus into the lungs

A fractured skull would be classified under which category of surgery based on urgency? a. Elective b. emergent c. urgent d. required

b. emergent

A client is undergoing a perineal surgical procedure. The nurse should place the client in which position? a. trendelenburg b. lithotomy c. dorsal recumbent d. sims

b. lithotomy

Which statement by the client indicates further teaching about epidural anesthesia is necessary? a. "I will lose the ability to move my legs." b. "I will be able to hear the surgeon during the surgery." c. "I will become unconscious." d. "A needle will deliver the anesthetic into the area around my spinal cord."

c. "i will become unconscious"

To prevent pneumonia and promote the integrity of the pulmonary system, an essential postoperative nursing intervention includes: a. Assisting with incentive spirometry every 6 hours b. Positioning the client in a supine position c. Ambulating the client as soon as possible d. Assessing breath sounds at least every 2 hours

c. ambulating the client as soon as possible

What are the circulating nurse's responsibilities, in contrast to the scrub nurse's responsibilities? a. setting up the sterile tables b. assisting the surgeon c. coordinating the surgical team d. passing instruments

c. coordinating the surgical team

A nurse is witnessing a client sign the consent form for surgery. After signing the consent form, the client 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 client's medical record. b. Answer the client's questions. c. Request that the surgeon come and answer the questions. d. Notify the nurse manager of the client's questions.

c. request that the surgeon come and answer the questions

A client is having a surgical procedure that requires the client to be in the prone position. What is an expected client outcome? a. The client will not experience signs of an allergic reaction. b. The client will not experience anxiety during the preoperative phase. c. The client remains free of perioperative positioning injury. d. The client will not experience signs and symptoms of infection.

c. the client remains free of perioperative positioning injury

A client at risk for malignant hyperthermia returns to the surgical unit. For what time period will the nurse monitor the client for development of malignant hyperthermia? a. A client can develop malignant hyperthermia only with intravenous anesthesia after surgery. b. The client will need to be discharged with special instructions. c. The client can develop malignant hyperthermia up to 24 hours after surgery. d. Malignant hyperthermia occurs in the operating room only.

c. the. client can develop malignant hyperthermia up to 24 hours after surgery

A nurse is teaching a client about pain management after surgery. Which client statement indicates the teaching was effective? a. "I will need to learn how to give myself pain medication by injection for when I go home." b. "The pain from my incision will be very similar to my arthritis pain." c. "I will ask for pain medication when the pain becomes unbearable." d. "I will support my incision with my hands when I cough and do my deep breathing exercises."

d. " i will support my incision with my hands when I cough and do my deep breathing exercises."

Clients who have received corticosteroids preoperatively are at risk for which type of insufficiency? a. parathyroid b. pituitary c. thyroid d. adrenal

d. adrenal