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Practice Q's 3

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Which action by the nurse is the most appropriate when initiating guided imagery with a patient as a method to control pain? 1) Suggesting a place where the patient will find peace 2) Guiding the patient toward a most beautiful or peaceful place 3) Asking the patient to use progressive muscle relaxation exercises 4) Asking the patient to take slow, full diaphragmatic/abdominal breaths

1. ANS: 4 Chapter number and title: 11, Pain Management Chapter learning objective: Incorporating both pharmacologic and nonpharmacologic evidence-based interventions into a plan of care for patients with pain Chapter page reference: 179-196 Heading: Pain Management Options Integrated Processes: Nursing Process - Implementation Client Need: Physiological Integrity - Basic Care and Comfort Cognitive level: Application [Applying] Concept: Comfort Difficulty: Moderate Feedback 1 The nurse should never suggest a peaceful place, but should allow the patient to choose the place where he finds peace. 2 The nurse should never suggest a peaceful place, but should allow the patient to choose the place where he finds peace. 3 After deep breathing, the patient may be asked to use progressive muscle relaxation exercises, and then the nurse will guide the patient toward a peaceful place. 4 The nurse begins by helping the patient to relax using slow breaths.

A patient, who rates abdominal pain as a 10 on a 1 to 10 numeric scale is experiencing nausea, vomiting, and restlessness. Which conclusion is appropriate by the nurse based on the current data? 1) Acute pain 2) Chronic pain 3) End-of-life pain 4) Fibromyalgia pain

2. ANS: 1 Chapter number and title: 11, Pain Management Chapter learning objective: Defining types of pain Chapter page reference: 174-177 Heading: Comprehensive Assessment Strategies for Acute and Chronic Pain Integrated Processes: Nursing Process - Assessment Client Need: Physiological Integrity - Basic Care and Comfort Cognitive level: Comprehension [Understanding] Concept: Comfort Difficulty: Easy Feedback 1 Acute pain is pain of varying severity, location, and etiology that lasts fewer than 6 months. Acute pain is often manifested by nausea, vomiting, and restlessness. 2 Chronic pain lasts longer than 6 months and persists beyond the expected period of healing. 3 End-of-life pain is pain that is associated with the process of dying. 4 Fibromyalgia pain is widespread muscular and joint pain.

The nurse is caring for a patient who is experiencing acute chest pain that is rated as a 9 on a 0 to 10 pain scale. Based on this data, which medication does the nurse plan to administer? 1) Morphine 2) Ibuprofen 3) Naproxen 4) Acetaminophen

3. ANS: 1 Chapter number and title: 11, Pain Management Chapter learning objective: Incorporating both pharmacologic and nonpharmacologic evidence-based interventions into a plan of care for patients with pain Chapter page reference: 179-196 Heading: Pain Management Options Integrated Processes: Nursing Process - Implementation Client Need: Physiological Integrity - Pharmacological and Parenteral Therapies Cognitive level: Application [Applying] Concept: Comfort Difficulty: Moderate Feedback 1 Acute pain is often treated with an opioid such as morphine. Morphine is often used to treat chest pain that is associated with a myocardial infarction. 2 Acetaminophen, ibuprofen, and naproxen are more appropriate for other types of pain, not acute chest pain. 3 Acetaminophen, ibuprofen, and naproxen are more appropriate for other types of pain, not acute chest pain. 4 Acetaminophen, ibuprofen, and naproxen are more appropriate for other types of pain, not acute chest pain.

The nurse is teaching a class on the perception of pain. What will the nurse teach as being the second step in processing pain stimuli? 1) Thalamus 2) Limbic system 3) Cerebral cortex 4) Reticular system

4. ANS: 3 Chapter number and title: 11, Pain Management Chapter learning objective: Explaining the pathophysiologic processes that underlie the pain process Chapter page reference: 169-172 Heading: Processing Pain Messages Integrated Processes: Teaching and Learning Client Need: Physiological Integrity - Basic Care and Comfort Cognitive level: Application [Applying] Concept: Comfort Difficulty: Moderate Feedback 1 The thalamus is the main relay station for sensory information. 2 The transmission of pain moves through the limbic system after the thalamus. 3 The cerebral cortex is the second step in processing pain stimuli. 4 Transmission of pain impulses occurs in the reticular system after traveling though the thalamus as the main relay station.

Place the steps the nurse will take to don sterile gloves using the close procedure. (Enter the number of each step in the proper sequence; do not use punctuation or spaces. Example: 1234) 1. With the dominant hand, pick up the opposite glove with the thumb and index finger, handling it through the sleeve. 2. Open the sterile glove wrapper while the hands are still covered by the sleeves. 3. Use the nondominant hand to grasp the cuff of the glove through the gown cuff, and firmly anchor it. 4. Extend the fingers into the glove as you pull the glove up over the cuff. 5. Place the fingers of the gloved hand under the cuff of the remaining glove.

ANS: 21354 Chapter number and title: 16, Priorities for the Intraoperative Patient Chapter learning objective: Explaining priority assessments and procedures in the OR Chapter page reference: 290-291 Heading: Overview of the Surgical Experience Integrated Processes: Nursing Process - Implementation Client Need: Safe and Effective Care Environment - Safety and Infection Control Cognitive level: Application [Applying] Concept: Perioperative Difficulty: Moderate Feedback: The first step of the process is to open the sterile glove wrapper while the hands are covered by the sleeves of the gown. Next, with the dominant hand, pick up the opposite glove with the thumb and index finger, handling it through the sleeve. The third step is to use the nondominant hand to grasp the cuff of the glove through the gown cuff, and firmly anchor it. The fourth step is to place the fingers of the gloved hand under the cuff of the remaining glove. Finally, the nurse will extend the fingers into the glove and pull the glove up over the cuff.

The patient with a sprained ankle is complaining of pain in the injured area. Which term will the nurse use when documenting this patient's pain? 1) Somatic pain 2) Visceral pain 3) Neuropathic pain 4) Physiological pain

ANS: 1 Chapter number and title: 11, Pain Management Chapter learning objective: Developing a comprehensive plan of nursing care for patients with pain Chapter page reference: 177-179 Heading: Nursing Management of Pain Integrated Processes: Nursing Process - Planning Client Need: Physiological Integrity - Basic Care and Comfort Cognitive level: Application [Applying] Concept: Comfort Difficulty: Moderate Feedback 1 Anticipating a patient's pain will ensure a more manageable pain experience than waiting until the patient complains of pain. 2 If the patient is asleep, she should not be awakened simply to assess the pain every 4 hours unless there are other significant nonverbal signs during sleep that indicate that the patient is in pain. These can include grimacing, moaning, thrashing, or guarding of a surgical site. 3 Pain management needs to be implemented prior to the patient's describing specific postoperative pain, or "sleeping off" anesthesia. 4 Pain management needs to be implemented prior to the patient's describing specific postoperative pain, or "sleeping off" anesthesia.

The nurse is providing care to a patient who had an abdominal nevus removed who is reporting intense pain. Which action by the nurse is appropriate? 1) Administer the stronger analgesic ordered by the primary care provider. 2) Administer a nonnarcotic analgesic because the patient had minor surgery. 3) Notify the health-care provider that the patient's pain is excessive for the minor surgery performed. 4) Attempt to divert the patient without administering an analgesic because the surgery was so minor.

ANS: 1 Chapter number and title: 11, Pain Management Chapter learning objective: Incorporating both pharmacologic and nonpharmacologic evidence-based interventions into a plan of care for patients with pain Chapter page reference: 177-179 Heading: Nursing Management of Pain Integrated Processes: Nursing Process - Implementation Client Need: Physiological Integrity - Pharmacological and Parenteral Therapies Cognitive level: Application [Applying] Concept: Comfort Difficulty: Moderate Feedback 1 Pain perception is what the patient says it is, and the nurse should medicate the patient based on the patient's description of the pain, not what the nurse anticipates. If the patient reports severe pain, the nurse should administer strong analgesics. 2 Patients who have minor surgery can still experience severe pain, and administering weaker analgesics when the patient reports severe pain would not be responsible practice. 3 There is no need to notify the health-care provider unless the nurse's assessment indicates there is something unusual occurring. 4 Diverting the patient most likely will not be effective alone, although diversion might be possible after administering the analgesic.

The nurse is using a nonpharmacologic method to manage a patient's pain, and applies a unit that applies low-voltage electrical stimulation directly over the pain area. When documenting this intervention, which term is the most appropriate for the nurse to use? 1) TENS unit 2) Nerve block 3) Functional restoration 4) Cutaneous stimulation

ANS: 1 Chapter number and title: 11, Pain Management Chapter learning objective: Incorporating both pharmacologic and nonpharmacologic evidence-based interventions into a plan of care for patients with pain Chapter page reference: 179-196 Heading: Pain Management Options Integrated Processes: Communication and Documentation Client Need: Physiological Integrity - Basic Care and Comfort Cognitive level: Application [Applying] Concept: Comfort Difficulty: Moderate Feedback 1 The unit described is a TENS unit, or transcutaneous electrical nerve stimulator, which is a form of cutaneous stimulation. 2 Nerve block is a pharmacologic treatment injecting an analgesic or steroid into the site of pain. 3 Functional restoration is a form of social therapy. 4 TENS would be the specific name of this treatment, whereas cutaneous stimulation would be a more general term.

The patient reports difficulty sleeping related to anxiety. Which nonpharmacologic pain management intervention might the nurse consider performing in order to relax the patient? 1) Massage 2) Distraction 3) Acupressure 4) Acupuncture

ANS: 1 Chapter number and title: 11, Pain Management Chapter learning objective: Incorporating both pharmacologic and nonpharmacologic evidence-based interventions into a plan of care for patients with pain Chapter page reference: 179-196 Heading: Pain Management Options Integrated Processes: Nursing Process - Planning Client Need: Physiological Integrity - Basic Care and Comfort Cognitive level: Comprehension [Understanding] Concept: Comfort Difficulty: Easy Feedback 1 Massage is used for relaxation, and can be effective in helping the client who is anxious. 2 Distraction, acupressure, and acupuncture are not used for relaxation, although they can be effective in helping the patient cope with pain. 3 Distraction, acupressure, and acupuncture are not used for relaxation, although they can be effective in helping the patient cope with pain. 4 Distraction, acupressure, and acupuncture are not used for relaxation, although they can be effective in helping the patient cope with pain.

The nurse is conducting a medication assessment for a preoperative patient. Which action by the nurse is appropriate for the patient who is prescribed amiodarone? 1) Obtaining a baseline ECG 2) Monitoring blood pressure 3) Assessing for hyperglycemia 4) Tapering the drug two days prior to surgery

ANS: 1 Chapter number and title: 15, Priorities for the Preoperative Patient Chapter learning objective: Explaining the priority assessments for the surgical patient Chapter page reference: 280-284 Heading: Patient Assessment Integrated Processes: Nursing Process - Assessment Client Need: Physiological Integrity - Physiological Adaptation Cognitive level: Application [Applying] Concept: Perioperative Difficulty: Moderate Feedback 1 The prescribed drug is an antiarrhythmic; therefore, the most appropriate nursing action is to obtain a baseline ECG. 2 This nursing action is appropriate for a patient who is prescribed an antihypertensive drug. 3 This nursing action is appropriate for a patient who is prescribed a corticosteroid drug. 4 The nursing action is appropriate for a patient who is prescribed an anticoagulant drug.

Which identifier should the nurse use during the initial time-out to determine the right patient? 1) Date of birth 2) Maiden name 3) Medical record number 4) Photo placed in the medical record

ANS: 1 Chapter number and title: 15, Priorities for the Preoperative Patient Chapter learning objective: Identifying the vital preoperative preparation for the patient Chapter page reference: 279-280 Heading: Time Outs/Cause for Pause Integrated Processes: Nursing Process - Assessment Client Need: Safe and Effective Care Environment - Management of Care Cognitive level: Application [Applying] Concept: Legal; Perioperative Difficulty: Moderate Feedback 1 Date of birth is an identifier the nurse should use to determine the right patient during the initial time-out conducted during the preoperative period. 2 The patient's first and last name, not maiden name, are identifiers the nurse should use to determine the right patient during the initial time-out conducted during the preoperative period. 3 The patient's social security number, not medical record number, is an identifier the nurse should use to determine the right patient during the initial time-out conducted during the preoperative period. 4 A photo placed on the patient's identification band, not medical record, is an identifier the nurse should use to determine the right patient during the initial time-out conducted during the preoperative period.

Which gauge catheter should the nurse use when initiating intravenous (IV) access for a preoperative patient? 1) 18 2) 20 3) 22 4) 24

ANS: 1 Chapter number and title: 15, Priorities for the Preoperative Patient Chapter learning objective: Identifying the vital preoperative preparation for the patient Chapter page reference: 284-286 Heading: Patient Preparation for Surgical Experience Integrated Processes: Nursing Process - Implementation Client Need: Physiological Integrity - Pharmacological and Parenteral Therapies Cognitive level: Knowledge [Remembering] Concept: Perioperative; Fluid and Electrolyte Maintenance Difficulty: Easy Feedback 1 An 18-gauge catheter is used when initiating IV access for a perioperative patient as this is the gauge preferred for the administration of blood products. 2 This is not an appropriate gauge for the nurse to use when initiating IV access for a perioperative patient. 3 This is not an appropriate gauge for the nurse to use when initiating IV access for a perioperative patient. 4 This is not an appropriate gauge for the nurse to use when initiating IV access for a perioperative patient.

Which action should the circulating nurse anticipate when the patient is intubated with the administration of general anesthesia? 1) Securing the patient's airway 2) Administering oxygen to the patient by face mask 3) Maintaining the patient using balanced anesthesia 4) Suctioning the patient to decrease incidence of aspiration

ANS: 1 Chapter number and title: 16, Priorities for the Intraoperative Patient Chapter learning objective: Analyzing the importance of airway management in the OR Chapter page reference: 301-303 Heading: Airway Management Integrated Processes: Nursing Process - Implementation Client Need: Safe and Effective Care Environment - Management of Care Cognitive level: Application [Applying] Concept: Perioperative Difficulty: Moderate Feedback 1 The patient's airway is secured during the intubation phase of general anesthesia. 2 Oxygen is administered to the patient by face mask during the induction of general anesthesia. 3 The patient is maintained with balanced anesthesia during maintenance of general anesthesia. 4 The patient is suctioned to decrease the incidence of aspiration during emergence phase of general anesthesia.

The circulating nurse is assisting the anesthesiologist with patient monitoring during a surgical procedure. When documenting the administration of morphine sulfate, which terminology should the nurse use? 1) A narcotic analgesic 2) An intravenous anesthetic 3) A depolarizing muscle relaxant 4) A nondepolarizing muscle relaxant

ANS: 1 Chapter number and title: 16, Priorities for the Intraoperative Patient Chapter learning objective: Discussing types of anesthesia utilized in the OR Chapter page reference: 295-301 Heading: Anesthesia Integrated Processes: Communication and Documentation Client Need: Physiological Integrity - Pharmacological and Parenteral Therapies Cognitive level: Application [Applying] Concept: Perioperative; Medication Difficulty: Moderate Feedback 1 Morphine sulfate is a narcotic analgesic. 2 Propofol is an intravenous anesthetic. 3 Succinylcholine is a depolarizing muscle relaxant. 4 Cisatracurium is a nondepolarizing muscle relaxant.

Which classification should the nurse document, according to the American Society of Anesthesiologists, for a patient who is diagnosed with a mild systemic disease? 1) 2 2) 3 3) 4 4) 5

ANS: 1 Chapter number and title: 16, Priorities for the Intraoperative Patient Chapter learning objective: Discussing types of anesthesia utilized in the OR Chapter page reference: 295-301 Heading: Anesthesia Integrated Processes: Communication and Documentation Client Need: Safe and Effective Care Environment - Management of Care Cognitive level: Application [Applying] Concept: Communication; Perioperative Difficulty: Moderate Feedback 1 This is the appropriate classification for a patient with mild systemic disease. 2 This is the appropriate classification for a patient with severe systemic disease. 3 This is the appropriate classification for a patient with severe systemic disease that is a constant threat to life. 4 This is the appropriate classification for a moribund patient who is not expected to survive without the operation.

Which laboratory test should the postanesthesia care nurse monitor for a patient who is having difficulty regaining consciousness after a surgical procedure? 1) Serum glucose 2) Serum potassium 3) Prothrombin (PT) time 4) Blood urea nitrogen (BUN)

ANS: 1 Chapter number and title: 17, Priorities for the Postoperative Patient Chapter learning objective: Explaining the priority assessments for the postsurgical patient Chapter page reference: 312-314 Heading: Patient Care in the Post-Anesthesia Care Unit (PACU) Integrated Processes: Nursing Process - Assessment Client Need: Physiological Integrity - Reduction of Risk Potential Cognitive level: Application [Applying] Concept: Perioperative Difficulty: Moderate Feedback 1 Serum glucose is monitored for a patient who is having difficult regaining consciousness in the postoperative period. 2 Serum potassium is monitored for patients who experienced abnormal fluid or blood losses and for patients who may have been overhydrated. 3 A PT time is monitored closely for any patient who is prescribed warfarin. Warfarin is often stopped for several days prior to a surgical procedure. However, this patient will continue to be at an increased risk for bleeding. 4 A BUN is monitored for any patient who may have experienced abnormal fluid or blood losses during surgery. A BUN should also be monitored for older adult patients and for those with renal disease.

Which nursing action is appropriate when providing care to a patient who is exhibiting low oxygen saturation levels in the postanesthesia care unit (PACU). 1) Monitor breath sounds 2) Administer prescribed heparin 3) Hold prescribed opioid analgesics 4) Assess for malignant hyperthermia

ANS: 1 Chapter number and title: 17, Priorities for the Postoperative Patient Chapter learning objective: Explaining the priority assessments for the postsurgical patient Chapter page reference: 315-317 Heading: Nursing Interventions Integrated Processes: Nursing Process - Assessment Client Need: Physiological Integrity - Physiological Adaptation Cognitive level: Application [Applying] Concept: Perioperative Difficulty: Moderate Feedback 1 The nurse would monitor breath sounds for a patient experiencing inadequate oxygenation. 2 The nurse would administer a prescribed anticoagulant, such as heparin, for a patient who is experiencing venous thromboembolism (VTE). 3 A patient who is difficult to arouse should have prescribed analgesics held until the patient stabilizes. 4 The nurse would assess a patient for malignant hyperthermia for a patient who is experiencing an increased temperature in the PACU.

Which nursing action is appropriate when providing care to a patient who is exhibiting symptoms of a venous thromboembolism (VTE)? 1) Monitor breath sounds 2) Administer prescribed heparin 3) Hold prescribed opioid analgesics 4) Assess for malignant hyperthermia

ANS: 1 Chapter number and title: 17, Priorities for the Postoperative Patient Chapter learning objective: Explaining the priority assessments for the postsurgical patient Chapter page reference: 315-317 Heading: Nursing Interventions Integrated Processes: Nursing Process - Assessment Client Need: Physiological Integrity - Physiological Adaptation Cognitive level: Application [Applying] Concept: Perioperative Difficulty: Moderate Feedback 1 The nurse would monitor breath sounds for a patient experiencing inadequate oxygenation. 2 The nurse would administer a prescribed anticoagulant, such as heparin, for a patient who is experiencing venous thromboembolism (VTE). 3 A patient who is difficult to arouse should have prescribed analgesics held until the patient stabilizes. 4 The nurse would assess a patient for malignant hyperthermia for a patient who is experiencing an increased temperature in the PACU.

The nurse works in a facility whose policy requires an antiseptic hand rub instead of a surgical scrub when performing surgical hand asepsis. Which are known advantages of the hand rub over the scrub? Select all that apply. 1) Less harmful to the skin 2) Does not require the use of a brush 3) Contains ingredients that help to protect the skin 4) Takes longer to perform 5) Contains alcohol, which could dry the skin

ANS: 1, 2, 3 Chapter number and title: 16, Priorities for the Intraoperative Patient Chapter learning objective: Explaining priority assessments and procedures in the OR Chapter page reference: 293-295 Heading: Priority Assessments and Procedures Integrated Processes: Nursing Process - Planning Client Need: Safe and Effective Care Environment - Safety and Infection Control Cognitive level: Comprehension [Understanding] Concept: Perioperative Difficulty: Easy Feedback 1. This is correct. The antiseptic rub was implemented because it is less harmful to the skin, does not require the use of a brush, and contains ingredients that actually protect the skin. As a result, the nurse is less likely to develop abrasions or dermatitis when using a hand rub instead of the older method of scrubbing the hands using a brush and caustic soaps. 2. This is correct. The antiseptic rub was implemented because it is less harmful to the skin, does not require the use of a brush, and contains ingredients that actually protect the skin. As a result, the nurse is less likely to develop abrasions or dermatitis when using a hand rub instead of the older method of scrubbing the hands using a brush and caustic soaps. 3. This is correct. The antiseptic rub was implemented because it is less harmful to the skin, does not require the use of a brush, and contains ingredients that actually protect the skin. As a result, the nurse is less likely to develop abrasions or dermatitis when using a hand rub instead of the older method of scrubbing the hands using a brush and caustic soaps. 4. This is incorrect. The antiseptic hand rub is faster, not longer, to perform. 5. This is incorrect. The antiseptic hand rub does not c

Which should the nurse ask the patient to verify during the initial time-out, the "pause for cause"? 1) "What is the name of your surgeon?" 2) "Which procedure are you having done today?" 3) "Is the information on your identification band correct?" 4) "Which side of the body is your procedure going to be completed on?" 5) "Have you signed your informed consent for the scheduled procedure?"

ANS: 1, 2, 3, 4 Chapter number and title: 15, Priorities for the Preoperative Patient Chapter learning objective: Explaining the priority assessments for the surgical patient Chapter page reference: 279-280 Heading: Time-Outs/Pause for Cause Integrated Processes: Nursing Process - Assessment Client Need: Safe and Effective Care Environment - Management of Care Cognitive level: Application [Applying] Concept: Perioperative Difficulty: Moderate Feedback 1. This is correct. This question is included in the initial time-out, the "pause for cause." 2. This is correct. This question is included in the initial time-out, the "pause for cause." 3. This is correct. This question is included in the initial time-out, the "pause for cause." 4. This is correct. This question is included in the initial time-out, the "pause for cause." 5. This is incorrect. This question is not included in the initial time-out. This information is included in the preoperative checklist.

Which information should the postanesthesia care unit (PACU) nurse include in the hand-off that occurs with the medical-surgical nurse who will assume care? Select all that apply. 1) Fluid intake and blood loss 2) Placement of intravenous (IV) lines 3) Patient identification using one identifier 4) Information regarding the surgical procedure 5) Over-the-counter (OTC) medications taken at home

ANS: 1, 2, 4 Chapter number and title: 17, Priorities for the Postoperative Patient Chapter learning objective: Applying the vital postoperative interventions for the patient in the immediate postoperative period Chapter page reference: 312-314 Heading: Patient Care in the Post-Anesthesia Care Unit (PACU) Integrated Processes: Communication and Documentation Client Need: Safe and Effective Care Environment - Management of Care Cognitive level: Application [Applying] Concept: Communication; Perioperative Difficulty: Moderate Feedback 1. This is correct. Fluid intake and blood loss is included in the hand-off communication process between the PACU and medical-surgical nurses. 2. This is correct. Information regarding the placement of IV lines is included in the hand-off communication process between the PACU and medical-surgical nurses. 3. This is incorrect. Patient identification during the hand-off process should include two patient identifiers, not one. 4. This is correct. Information regarding the surgical procedure is included in the hand-off communication process between the PACU and medical-surgical nurses. 5. This is incorrect. Important medications taken by the patient at home, not OTC medications, should be included in the hand-off process.

The nurse is working on the orthopedic unit, and is caring for a patient who reports back pain. Which responses by the nurse would be appropriate when caring for this patient? Select all that apply. 1) "Does anything other than your back hurt?" 2) "I'm sorry you're hurting. I want to make you feel better." 3) "Why don't you try another position until it's time for more pain medication?" 4) "You had medication for your pain at 4 p.m., so I can't give you any more until 8 p.m." 5) "People with back pain experience very different symptoms. Tell me more about your back pain."

ANS: 1, 2, 5 Chapter number and title: 11, Pain Management Chapter learning objective: Developing a comprehensive plan of nursing care for patients with pain Chapter page reference: 177-179 Heading: Nursing Management of Pain Integrated Processes: Nursing Process - Implementation Client Need: Physiological Integrity - Basic Care and Comfort Cognitive level: Application [Applying] Concept: Comfort Difficulty: Moderate Feedback 1. This is correct. The nurse should inform the patient that it is the job of the nurse to work to make the patient feel better, seek more information about the type of pain the patient is experiencing, and question any other discomforts the patient may be experiencing. 2. This is correct. The nurse should inform the patient that it is the job of the nurse to work to make the patient feel better, seek more information about the type of pain the patient is experiencing, and question any other discomforts the patient may be experiencing. 3. This is incorrect. Allowing the patient to remain in pain would not be prudent practice, and would be lacking in caring. 4. This is incorrect. Allowing the patient to remain in pain would not be prudent practice, and would be lacking in caring. 5. This is correct. The nurse should inform the patient that it is the job of the nurse to work to make the patient feel better, seek more information about the type of pain the patient is experiencing, and question any other discomforts the patient may be experiencing.

Which patient populations are at risk for complications due to positioning that is required during surgical procedures? Select all that apply. 1) Pediatric patients 2) Older adult patients 3) Young adult patients 4) Patients diagnosed with bipolar disorder 5) Patients diagnosed with diabetes mellitus

ANS: 1, 2, 5 Chapter number and title: 16, Priorities for the Intraoperative Patient Chapter learning objective: Examining risks and complications for the surgical patient Chapter page reference: 303-307 Heading: Positioning the Patient in the OR Integrated Processes: Nursing Process - Assessment Client Need: Physiological Integrity - Physiological Adaptation Cognitive level: Comprehension [Understanding] Concept: Perioperative Difficulty: Easy Feedback 1. This is correct. Pediatric patients are at an increased risk for complications during surgical procedures due to required positioning. 2. This is correct. Older adult patients are at an increased risk for complications during surgical procedures due to required positioning. 3. This is incorrect. A young adult patient is not at risk for complications due to positioning during surgical procedures. 4. This is incorrect. A patient diagnosed with bipolar disorder is not at risk for complications due to positioning during surgical procedures. 5. This is correct. Any patient diagnosed with a disease process affecting circulation, such as diabetes mellitus, is at an increased risk for complications during surgical procedures due to required positioning. PTS: 1 CON: Perioperative

Which members of the surgical team are considered sterile? Select all that apply. 1) Surgeon 2) Scrub nurse 3) Anesthesiologist 4) Circulating nurse 5) Surgical assistant

ANS: 1, 2, 5 Chapter number and title: 16, Priorities for the Intraoperative Patient Chapter learning objective: Identifying the roles and responsibilities of operating room (OR) team members Chapter page reference: 291-293 Heading: Overview of Surgical Team Members Integrated Processes: Caring Client Need: Safe and Effective Care Environment - Safety and Infection Control Cognitive level: Comprehension [Understanding] Concept: Perioperative Difficulty: Easy Feedback 1. This is correct. The surgeon is considered sterile during a surgical procedure. 2. This is correct. The scrub nurse is considered sterile during a surgical procedure. 3. This is incorrect. The anesthesiologist is not considered sterile during the surgical procedure. 4. This is incorrect. The circulating nurse is not considered sterile during the surgical procedure. 5. This is correct. The surgical assistant is considered sterile during a surgical procedure.

The postoperative nurse is planning care for a patient recovering from major thoracic surgery. Which nursing diagnoses should the nurse select to plan for this patient's immediate care needs? Select all that apply. 1) Risk for Impaired Gas Exchange 2) Risk for Decreased Cardiac Output 3) Risk for Ineffective Airway Clearance 4) Risk for Imbalanced Nutrition: Less than Body Requirements 5) Risk for Imbalanced Fluid Volume

ANS: 1, 2, 5 Chapter number and title: 17, Priorities for the Postoperative Patient Chapter learning objective: Applying the vital postoperative interventions for the patient in the immediate postoperative period Chapter page reference: 315-317 Heading: Nursing Interventions Integrated Processes: Nursing Process - Diagnosis Client Need: Physiological Integrity - Physiological Adaptation Cognitive level: Analysis [Analyzing] Concept: Perioperative Difficulty: Difficult Feedback 1. This is correct. Nursing diagnoses appropriate for the immediate postoperative phase include the Risk for Impaired Gas Exchange because of anesthesia medications and hypothermia, the Risk for Decreased Cardiac Output because of anesthesia, and the Risk for Imbalanced Fluid Volume because of blood loss and nothing by mouth status. 2. This is correct. Nursing diagnoses appropriate for the immediate postoperative phase include the Risk for Impaired Gas Exchange because of anesthesia medications and hypothermia, the Risk for Decreased Cardiac Output because of anesthesia, and the Risk for Imbalanced Fluid Volume because of blood loss and nothing by mouth status. 3. This is incorrect. The Risk for Ineffective Airway Clearance might be appropriate later as the patient recovers from surgery. 4. This is incorrect. There is no Risk for Imbalanced Nutrition: Less than Body Requirements during the immediate postoperative phase. 5. This is correct. Nursing diagnoses appropriate for the immediate postoperative phase include the Risk for Impaired Gas Exchange because of anesthesia medications and hypothermia, the Risk for Decreased Cardiac Output because of anesthesia, and the Risk for Imbalanced Fluid Volume because of blood loss and nothing by mouth status.

Which individuals should the nurse emphasize when discussing providers who take part in providing patient care during the intraoperative period of the surgical process? Select all that apply. 1) Surgeon 2) Postoperative nurse 3) Circulating nurse 4) Anesthesiologist 5) Social worker

ANS: 1, 3, 4 Chapter number and title: 16, Priorities for the Intraoperative Patient Chapter learning objective: Identifying the roles and responsibilities of operating room (OR) team members Chapter page reference: 291-293 Heading: Overview of the Surgical Team Members Integrated Processes: Caring Client Need: Safe and Effective Care Environment - Management of Care Cognitive level: Knowledge [Remembering] Concept: Perioperative Difficulty: Easy Feedback 1. This is correct. The surgeon performs the procedure. 2. This is incorrect. The postoperative nurse will provide care to the patient after the surgery is completed. 3. This is correct. The circulating nurse is a perioperative registered nurse who cares for the patient during the surgical procedure. 4. This is correct. The anesthesiologist provides the anesthesia during the surgery and continually monitors the patient's physiologic status. 5. This is incorrect. The social worker will not be in attendance during the procedure but may become involved in the patient's care during the preoperative and postoperative phases.

When providing preoperative teaching for the patient who is scheduled for coronary artery bypass surgery in the morning, the nurse would include which topics? Select all that apply. 1) Location of incisions 2) Discharge information 3) Postoperative drains to expect 4) Postoperative pain management 5) Coughing and deep breathing exercises

ANS: 1, 3, 4, 5 Feedback 1. This is correct. The location of incisions is included in the preoperative teaching session. 2. This is incorrect. Discharge information is not included in the preoperative teaching session. 3. This is correct. Drains to expect after the surgical procedure is information included in the preoperative teaching session. 4. This is correct. Postoperative pain management is information included in the preoperative teaching session. 5. This is correct. Coughing and deep breathing exercises is information included in the preoperative teaching session. Chapter number and title: 15, Priorities for the Preoperative Patient Chapter learning objective: Developing teaching and support strategies for the surgical patient and his or her family Chapter page reference: 284-286 Heading: Patient Preparation for the Surgical Experience Integrated Processes: Teaching and Learning Client Need: Safe and Effective Care Environment - Management of Care Cognitive level: Application [Applying] Concept: Perioperative Difficulty: Moderate

The nurse performs preoperative teaching for a patient requiring a surgical intervention. Which actions by the patient indicate appropriate understanding of the information provided? Select all that apply. 1) Demonstrating how to turn and get out of bed 2) Having no anxiety about the impending surgery 3) Demonstrating proper performance of leg exercises 4) Demonstrating proper coughing and deep breathing 5) Asking questions about and voicing understanding of information provided

ANS: 1, 3, 4, 5 Chapter number and title: 15, Priorities for the Preoperative Patient Chapter learning objective: Developing teaching and support strategies for the surgical patient and his or her family Chapter page reference: 284-286 Heading: Patient Preparation for the Surgical Experience Integrated Processes: Teaching and Learning Client Need: Safe and Effective Care Environment - Management of Care Cognitive level: Analysis [Analyzing] Concept: Perioperative Difficulty: Difficult Feedback 1. This is incorrect. The nurse evaluates the patient's understanding through the questions asked and the return demonstration of skills performed. 2. This is incorrect. Although preoperative teaching can help to reduce anxiety, it is unlikely to completely eliminate fear. 3. This is correct. The nurse evaluates the patient's understanding through the questions asked and the return demonstration of skills performed. 4. This is correct. The nurse evaluates the patient's understanding through the questions asked and the return demonstration of skills performed. 5. This is correct. The nurse evaluates the patient's understanding through the questions asked and the return demonstration of skills performed.

The nurse is preparing an older adult patient for surgery. Which topics should the nurse focus on when preparing this patient's preoperative teaching? Select all that apply. 1) Level of hearing 2) Transportation needs of the patient after discharge 3) Teaching on deep breathing and coughing 4) Plans for discharge care 5) Actions to prevent pressure ulcers

ANS: 1, 3, 4, 5 Chapter number and title: 15, Priorities for the Preoperative Patient Chapter learning objective: Developing teaching and support strategies for the surgical patient and his or her family Chapter page reference: 284-286 Heading: Patient Preparation for the Surgical Experience Integrated Processes: Teaching and Learning Client Need: Safe and Effective Care Environment - Management of Care Cognitive level: Application [Applying] Concept: Perioperative Difficulty: Moderate Feedback 1. This is correct. For the older patient, make sure the patient can hear the information to be presented or provide information through alternative means. 2. This is incorrect. Transportation needs of the patient after discharge would not be part of the preoperative teaching plan. 3. This is correct. Older adults are at greater risk for pneumonia and other postoperative complications and should have teaching related to deep breathing and coughing. 4. This is correct. The older patient is going to need assistance once discharged and should have the necessary medical equipment such as walkers and raised toilet seats, assistance with transportation, or extended care. 5. This is correct. The older patient is at risk for pressure ulcer formation because of poor nutritional status, diabetes, cardiovascular illness, or history of steroid use.

Which actions by the nurse are appropriate when preparing a patient for a surgical procedure that requires supine positioning? Select all that apply. 1) Placing the patient on his or her back 2) Supporting the patient's head in a headrest 3) Placing the patient's feet on a padded footboard 4) Placing the patient's arms at the sides with palms down 5) Lowering the foot of the bed flexing the patient's knees

ANS: 1, 4 Chapter number and title: 16, Priorities for the Intraoperative Patient Chapter learning objective: Developing support strategies for the surgical patient and his or her family Chapter page reference: 303-307 Heading: Positioning the Patient in the OR Integrated Processes: Nursing Process - Implementation Client Need: Safe and Effective Care Environment - Management of Care Cognitive level: Application [Applying] Concept: Perioperative Difficulty: Moderate Feedback 1. This is correct. This is an appropriate nursing action when using the supine position during a surgical procedure. 2. This is incorrect. This nursing action is appropriate for Fowler's position during a surgical procedure. 3. This is incorrect. This nursing action is appropriate for Fowler's position during a surgical procedure. 4. This is correct. This is an appropriate nursing action when using the supine position during a surgical procedure. 5. This is incorrect. This nursing action is appropriate for Fowler's position during a surgical procedure.

According to the World Health Organization Three-Step Approach, if the nurse is caring for a patient reporting mild pain that persists after using full doses of step 1 medications, which medications can the nurse administer? Select all that apply. 1) Codeine 2) Fentanyl 3) Morphine 4) Hydrocodone with ibuprofen 5) Oxycodone with acetaminophen

ANS: 1, 4, 5 Chapter number and title: 11, Pain Management Chapter learning objective: Incorporating both pharmacologic and nonpharmacologic evidence-based interventions into a plan of care for patients with pain Chapter page reference: 179-196 Heading: Pain Management Options Integrated Processes: Nursing Process - Implementation Client Need: Physiological Integrity - Pharmacological and Parenteral Therapies Cognitive level: Application [Applying] Concept: Comfort Difficulty: Moderate Feedback 1. This is correct. If the pain persists or the pain is moderate, the second step is a weak opioid, or a combination of opioid and nonopioid medicine can be used. Codeine is a weak opioid. 2. This is incorrect. Fentanyl is a strong opioid that is not administered until step 3. 3. This is incorrect. Morphine is a strong opioid that is not administered until step 3. 4. This is correct. If the pain persists or the pain is moderate, the second step is a weak opioid, or a combination of opioid and nonopioid medicine can be used. Hydrocodone with ibuprofen is an opioid/nonopioid medicine. 5. This is correct. If the pain persists or the pain is moderate, the second step is a weak opioid, or a combination of opioid and nonopioid medicine can be used. Oxycodone with acetaminophen is an opioid/nonopioid medicine.

The pain management team individualizes the analgesic regimen by guiding the adjustment of medication, dose, time intervals, and route of administration. When discussing this method of treating pain, which term is the most appropriate for the nurse to use? 1) Analgesia 2) Equianalgesia 3) Polypharmacy 4) Dose-reduction pharmacology

ANS: 2 Chapter number and title: 11, Pain Management Chapter learning objective: Defining types of pain Chapter page reference: 166-169 Heading: Definitions of Pain Integrated Processes: Communication and Documentation Client Need: Physiological Integrity - Basic Care and Comfort Cognitive level: Comprehension [Understanding] Concept: Comfort Difficulty: Easy Feedback 1 Analgesia is a classification of medication used for pain control. 2 The term equianalgesia refers to the relative potency of various opioid analgesics compared to a standard dose of parenteral morphine (gold standard opioid). This tool helps professionals individualize the analgesic regimen by guiding the adjustment of medication, dose, time interval, and route of administration. 3 Polypharmacy is a generic term for multiple medication administration, often used with elders who are on many medications. 4 Dose-reduction pharmacology is not terminology associated with pain management.

The nurse is caring for a patient who is experiencing acute pain. Which action by the patient, noted by the nurse during the assessment, is considered an associated symptom of pain? 1) Crying 2) Vomiting 3) Grimacing 4) Changing position

ANS: 2 Chapter number and title: 11, Pain Management Chapter learning objective: Describing components that comprise a comprehensive pain assessment Chapter page reference: 166-169 Heading: Definitions of Pain Integrated Processes: Nursing Process - Assessment Client Need: Physiological Integrity - Basic Care and Comfort Cognitive level: Comprehension [Understanding] Concept: Comfort Difficulty: Easy Feedback 1 Changing position, crying, and grimacing are manners of expressing pain. 2 Symptoms that are often associated with pain include nausea, vomiting, and dizziness. 3 Changing position, crying, and grimacing are manners of expressing pain. 4 Changing position, crying, and grimacing are manners of expressing pain.

Which type of pain syndrome should the nurse assess when providing care to a female patient? 1) Back pain 2) Interstitial cystitis 3) Cluster headaches 4) Visceral pain from the heart

ANS: 2 Chapter number and title: 11, Pain Management Chapter learning objective: Describing components that comprise a comprehensive pain assessment Chapter page reference: 174-177 Heading: Comprehensive Assessment Strategies for Acute and Chronic Pain Integrated Processes: Nursing Process - Assessment Client Need: Physiological Integrity - Basic Care and Comfort Cognitive level: Application [Applying] Concept: Comfort Difficulty: Moderate Feedback 1 Back pain syndrome is more common in male, not female, patients. 2 Interstitial cystitis is more common in female patients; therefore, the nurse should assess for this. 3 Cluster headache syndrome is more common in male, not female, patients. 4 Visceral pain syndrome is more common in male, not female, patients.

Which data collected by the nurse is nonessential when conducting a patient pain history? 1) Intensity, quality, and patterns 2) Significant other's assessment of the pain 3) Precipitating factors, alleviating factors, and associated symptoms 4) Effects on activities of daily living, coping resources, and affective responses

ANS: 2 Chapter number and title: 11, Pain Management Chapter learning objective: Describing components that comprise a comprehensive pain assessment Chapter page reference: 174-177 Heading: Comprehensive Assessment Strategies for Acute and Chronic Pain Integrated Processes: Nursing Process - Assessment Client Need: Physiological Integrity - Basic Care and Comfort Cognitive level: Comprehension [Understanding] Concept: Assessment; Comfort Difficulty: Easy Feedback 1 The nurse should determine all of the other factors in order to put a plan of care in place that will help the patient address and treat the pain effectively. 2 During a pain history, it is the patient's description of the pain that is most important, not the significant other's. 3 The nurse should determine all of the other factors in order to put a plan of care in place that will help the patient address and treat the pain effectively. 4 The nurse should determine all of the other factors in order to put a plan of care in place that will help the patient address and treat the pain effectively.

Which classification should the nurse document, according to the American Society of Anesthesiologists, for a patient who is diagnosed with a severe systemic disease? 1) 2 2) 3 3) 4 4) 5

ANS: 2 Chapter number and title: 16, Priorities for the Intraoperative Patient Chapter learning objective: Discussing types of anesthesia utilized in the OR Chapter page reference: 295-301 Heading: Anesthesia Integrated Processes: Communication and Documentation Client Need: Safe and Effective Care Environment - Management of Care Cognitive level: Application [Applying] Concept: Communication; Perioperative Difficulty: Moderate Feedback 1 This is the appropriate classification for a patient with mild systemic disease. 2 This is the appropriate classification for a patient with severe systemic disease. 3 This is the appropriate classification for a patient with severe systemic disease that is a constant threat to life. 4 This is the appropriate classification for a moribund patient who is not expected to survive without the operation.

The nurse administered an oral analgesic to a patient complaining of a mild-to-moderate headache. Which activity would the nurse consider to help relieve the patient's discomfort until the analgesic takes effect? 1) Crossword puzzles 2) Slow rhythmic breathing 3) Reading or watching TV 4) Video or computer games

ANS: 2 Chapter number and title: 11, Pain Management Chapter learning objective: Incorporating both pharmacologic and nonpharmacologic evidence-based interventions into a plan of care for patients with pain Chapter page reference: 179-196 Heading: Pain Management Options Integrated Processes: Nursing Process - Planning Client Need: Physiological Integrity - Basic Care and Comfort Cognitive level: Application [Applying] Concept: Comfort Difficulty: Moderate Feedback 1 Reading, watching TV, video games, and crossword puzzles might exacerbate the symptoms because the patient with a headache is often more comfortable in a dark, low-stimuli environment. 2 Slow rhythmic breathing would be an effective distraction technique for a patient with a headache. 3 Reading, watching TV, video games, and crossword puzzles might exacerbate the symptoms because the patient with a headache is often more comfortable in a dark, low-stimuli environment. 4 Reading, watching TV, video games, and crossword puzzles might exacerbate the symptoms because the patient with a headache is often more comfortable in a dark, low-stimuli environment.

The nurse is completing the preoperative checklist on the night shift in preparation for the patient's surgery, scheduled for 0800. Which tasks could the nurse complete at this time? 1) Documenting the time of last voiding 2) Checking the medical record for the history, physical, and signed informed consent 3) Administering preoperative medication 4) Removing the prosthesis

ANS: 2 Chapter number and title: 15, Priorities for the Preoperative Patient Chapter learning objective: Discussing the essentials of the surgical experience Chapter page reference: 274 Heading: Introduction Integrated Processes: Nursing Process - Implementation Client Need: Safe and Effective Care Environment - Management of Care Cognitive level: Application [Applying] Concept: Perioperative Difficulty: Moderate Feedback 1 The nurse on day shift preparing to send the patient to surgery would document time of last voiding and administration of preoperative medication. 2 The nurse on night shift could check the medical record to ensure that a history and physical have been completed, and that the consent for surgery is signed. 3 The nurse on day shift preparing to send the patient to surgery would document time of last voiding and administration of preoperative medication. 4 Many patients prefer to wait until just before going to surgery before removing dentures, contact lenses, and other prostheses.

The nurse is conducting a medication assessment for a preoperative patient. Which action by the nurse is appropriate for the patient who is prescribed metoprolol? 1) Obtaining a baseline ECG 2) Monitoring blood pressure 3) Assessing for hyperglycemia 4) Tapering the drug two days prior to surgery

ANS: 2 Chapter number and title: 15, Priorities for the Preoperative Patient Chapter learning objective: Explaining the priority assessments for the surgical patient Chapter page reference: 280-284 Heading: Patient Assessment Integrated Processes: Nursing Process - Assessment Client Need: Physiological Integrity - Physiological Adaptation Cognitive level: Application [Applying] Concept: Perioperative Difficulty: Moderate Feedback 1 This nursing action is appropriate for a patient who is prescribed an antiarrhythmic. 2 The prescribed drug is an antihypertensive; therefore, the most appropriate nursing action is to monitor the patient's blood pressure. 3 This nursing action is appropriate for a patient who is prescribed a corticosteroid drug. 4 The nursing action is appropriate for a patient who is prescribed an anticoagulant drug.

Which laboratory test should the nurse include in the plan of care for a patient who may require a blood transfusion during the surgical procedure? 1) Urinalysis 2) Type and crossmatch 3) Basic metabolic panel 4) Arterial blood gas analysis

ANS: 2 Chapter number and title: 15, Priorities for the Preoperative Patient Chapter learning objective: Identifying the vital preoperative preparation for the patient Chapter page reference: 284-286 Heading: Patient Preparation for Surgical Experience Integrated Processes: Nursing Process - Planning Client Need: Physiological Integrity - Reduction of Risk Potential Cognitive level: Application [Applying] Concept: Perioperative Difficulty: Moderate Feedback 1 A urinalysis is not anticipated for a patient who may require a blood transfusion during a surgical procedure. 2 A type and crossmatch is anticipated for a patient who may require a blood transfusion during a surgical procedure. This will allow for type specific blood to be available for the patient if a transfusion is required. 3 A basic metabolic panel is not anticipated for a patient who may require a blood transfusion during a surgical procedure. 4 An arterial blood gas analysis is not anticipated for a patient who may require a blood transfusion during a surgical procedure.

Which action should the circulating nurse anticipate during the induction of general anesthesia? 1) Securing the patient's airway 2) Administering oxygen to the patient by face mask 3) Maintaining the patient using balanced anesthesia 4) Suctioning the patient to decrease incidence of aspiration

ANS: 2 Chapter number and title: 16, Priorities for the Intraoperative Patient Chapter learning objective: Analyzing the importance of airway management in the OR Chapter page reference: 301-303 Heading: Airway Management Integrated Processes: Nursing Process - Implementation Client Need: Safe and Effective Care Environment - Management of Care Cognitive level: Application [Applying] Concept: Perioperative Difficulty: Moderate Feedback 1 The patient's airway is secured during the intubation phase of general anesthesia. 2 Oxygen is administered to the patient by face mask during the induction of general anesthesia. 3 The patient is maintained with balanced anesthesia during maintenance phase of general anesthesia. 4 The patient is suctioned to decrease the incidence of aspiration during emergence phase of general anesthesia.

The circulating nurse is assisting the anesthesiologist with patient monitoring during a surgical procedure. When documenting the administration of propofol, which terminology should the nurse use? 1) A narcotic analgesic 2) An intravenous anesthetic 3) A depolarizing muscle relaxant 4) A nondepolarizing muscle relaxant

ANS: 2 Chapter number and title: 16, Priorities for the Intraoperative Patient Chapter learning objective: Discussing types of anesthesia utilized in the OR Chapter page reference: 295-301 Heading: Anesthesia Integrated Processes: Communication and Documentation Client Need: Physiological Integrity - Pharmacological and Parenteral Therapies Cognitive level: Application [Applying] Concept: Perioperative; Medication Difficulty: Moderate Feedback 1 Morphine sulfate is a narcotic analgesic. 2 Propofol is an intravenous anesthetic. 3 Succinylcholine is a depolarizing muscle relaxant. 4 Cisatracurium is a nondepolarizing muscle relaxant.

Which term should the nurse document for a patient who is having surgery for the removal of female reproductive organs? 1) Episiotomy 2) Hysterectomy 3) Amniocentesis 4) Cholecystectomy

ANS: 2 Chapter number and title: 16, Priorities for the Intraoperative Patient Chapter learning objective: Explaining priority assessments and procedures in the OR Chapter page reference: 290-291 Heading: Overview of the Surgical Experience Integrated Processes: Communication and Documentation Client Need: Safe and Effective Care Environment - Management of Care Cognitive level: Application [Applying] Concept: Communication; Perioperative Difficulty: Moderate Feedback 1 An episiotomy is an incision made to the vagina during childbirth; -otomy is the suffix that indicates an incision. 2 A hysterectomy is the removal of the female reproductive organs; -ectomy is the suffix that indicates the removal of organs. 3 An amniocentesis is the removal of amniotic fluid during pregnancy for analysis; -centesis is the suffix that indicates puncture. 4 A cholecystectomy is the removal of the gallbladder; -ectomy is the suffix that indicates the removal of organs.

he patient arrives at the surgeon's office one week after surgery to have the sutures removed. Which classification would the nurse use when documenting care for this patient? 1) Preoperative 2) Postoperative 3) Perioperative 4) Intraoperative

ANS: 2 Chapter number and title: 17, Priorities for the Postoperative Patient Chapter learning objective: Discussing the significance of the postoperative period Chapter page reference: 310-312 Heading: Introduction Integrated Processes: Communication and Documentation Client Need: Safe and Effective Care Environment - Management of Care Cognitive level: Application [Applying] Concept: Perioperative; Communication Difficulty: Moderate Feedback 1 The preoperative phase begins when surgery is planned, and ends when the patient is transferred to the operating table. 2 The patient is in the postoperative phase. The postoperative phase begins with the admission of the patient to the postanesthesia care unit, and ends when healing is complete. 3 The perioperative period covers all three time periods, from planning surgery until healing is complete. 4 The intraoperative phase begins when the patient is transferred to the operating table, and ends when the patient is admitted to the recovery room.

The postanesthesia care nurse is providing care to a patient with fluid volume overload who is experiencing cardiac dysrhythmias. Which laboratory test should the nurse monitor for this patient? 1) Serum glucose 2) Serum potassium 3) Prothrombin (PT) time 4) Blood urea nitrogen (BUN)

ANS: 2 Chapter number and title: 17, Priorities for the Postoperative Patient Chapter learning objective: Explaining the priority assessments for the postsurgical patient Chapter page reference: 312-314 Heading: Patient Care in the Post-Anesthesia Care Unit (PACU) Integrated Processes: Nursing Process - Assessment Client Need: Physiological Integrity - Reduction of Risk Potential Cognitive level: Application [Applying] Concept: Perioperative Difficulty: Difficult Feedback 1 Serum glucose is monitored for a patient who is having difficult regaining consciousness in the postoperative period. 2 Serum potassium is monitored for patients who experienced abnormal fluid or blood losses and for patients who may have been overhydrated. Patients who experience either hyperkalemia, or hypokalemia, may exhibit cardiac dysrhythmias. 3 A PT time is monitored closely for any patient who is prescribed warfarin. Warfarin is often stopped for several days prior to a surgical procedure. However, this patient will continue to be at an increased risk for bleeding. 4 A BUN is monitored for any patient who may have experienced abnormal fluid or blood losses during surgery. A BUN should also be monitored for older adult patients and for those with renal disease.

The nurse is providing care to a patient in the postanesthesia care unit (PACU) who lost a large amount of blood during a surgical procedure. Which assessment finding should the nurse monitor this patient for based on the current data? 1) Bradypnea 2) Tachycardia 3) Hypothermia 4) Hypertension

Which tasks can the nurse assign to the unlicensed assistive personnel (UAP) who is assisting with providing care to postoperative patients on a medical-surgical unit? Select all that apply. 1) Documenting the assessment completed by the nurse 2) Giving the patient pain medication as ordered by the health-care provider 3) Assisting with patient exercises 4) Reporting when a patient cannot complete exercises 5) Conducting discharge teaching

ANS: 2, 3, 4 Chapter number and title: 17, Priorities for the Postoperative Patient Chapter learning objective: Applying the vital postoperative interventions for the patient in the immediate postoperative period Chapter page reference: 315-317 Heading: Nursing Interventions Integrated Processes: Nursing Process - Implementation Client Need: Safe and Effective Care Environment - Management of Care Cognitive level: Application [Applying] Concept: Perioperative Difficulty: Moderate Feedback 1. This is incorrect. The nurse performs and documents the patient assessment, not the UAP. 2. This is incorrect. The UAP cannot pass medications. 3. This is correct. The UAP can assist the patient with exercises and report any problems the patient has when performing exercises. 4. This is correct. The UAP can assist the patient with exercises and report any problems the patient has when performing exercises. 5. This is incorrect. The UAP cannot conduct discharge teaching.

Which classification should the nurse document, according to the American Society of Anesthesiologists, for a patient who is diagnosed with a severe systemic disease that is a threat to life? 1) 2 2) 3 3) 4 4) 5

ANS: 3 Chapter number and title: 16, Priorities for the Intraoperative Patient Chapter learning objective: Discussing types of anesthesia utilized in the OR Chapter page reference: 295-301 Heading: Anesthesia Integrated Processes: Communication and Documentation Client Need: Safe and Effective Care Environment - Management of Care Cognitive level: Application [Applying] Concept: Communication; Perioperative Difficulty: Moderate Feedback 1 This is the appropriate classification for a patient with mild systemic disease. 2 This is the appropriate classification for a patient with severe systemic disease. 3 This is the appropriate classification for a patient with severe systemic disease that is a constant threat to life. 4 This is the appropriate classification for a moribund patient who is not expected to survive without the operation.

The nurse is preparing a patient for emergency surgery to repair liver and colon lacerations caused by a motor vehicle crash. Which information about this type of surgery will the nurse use to guide the patient's care? Select all that apply. 1) An organ is going to be removed. 2) This is an emergency surgery. 3) The patient will be hospitalized longer. 4) The patient is at risk for blood loss. 5) The patient is at risk for hypothermia.

ANS: 2, 3, 4, 5 Chapter number and title: 15, Priorities for the Preoperative Patient Chapter learning objective: Developing teaching and support strategies for the surgical patient and his or her family Chapter page reference: 284-286 Heading: Patient Preparation for the Surgical Experience Integrated Processes: Nursing Process - Planning Client Need: Physiological Integrity - Physiological Adaptation Cognitive level: Application [Applying] Concept: Perioperative Difficulty: Moderate Feedback 1. This is incorrect. The suffix -ectomy indicates removal of an organ. The patient is having surgery to repair lacerations. No organ is identified for removal. 2. This is correct. Emergency surgery is performed when a condition is life-threatening. 3. This is correct. Surgery to control internal hemorrhage from lacerations is an example of emergency surgery. An open procedure usually requires a longer hospital stay. 4. This is correct. Open procedures place the patient at a higher risk for blood loss. 5. This is correct. If there is a large surgical opening, the patient cannot be adequately covered and will be exposed to cold surgical suite air, and can develop hypothermia. PTS: 1 CON: Perioperative

A patient is informed that a surgical procedure is to be scheduled in two weeks. Which teaching points should the nurse focus to prepare the patient for the surgery? Select all that apply. 1) Maintaining a patent airway 2) Deep breathing and coughing 3) Caring for the surgical incision 4) Managing constipation 5) Managing pain

ANS: 2, 3, 4, 5 Chapter number and title: 15, Priorities for the Preoperative Patient Chapter learning objective: Developing teaching and support strategies for the surgical patient and his or her family Chapter page reference: 284-286 Heading: Patient Preparation for the Surgical Experience Integrated Processes: Teaching and Learning Client Need: Safe and Effective Care Environment - Management of Care Cognitive level: Application [Applying] Concept: Perioperative Difficulty: Moderate Feedback 1. This is incorrect. Maintaining a patent airway is a nursing action that is performed during the postoperative phase of surgical care. 2. This is correct. In the preoperative phase, when the patient is alert and oriented, the nurse should focus teaching on deep breathing and coughing exercises, care of the surgical incision, managing constipation, and managing pain. 3. This is correct. In the preoperative phase, when the patient is alert and oriented, the nurse should focus teaching on deep breathing and coughing exercises, care of the surgical incision, managing constipation, and managing pain. 4. This is correct. In the preoperative phase, when the patient is alert and oriented, the nurse should focus teaching on deep breathing and coughing exercises, care of the surgical incision, managing constipation, and managing pain. 5. This is correct. In the preoperative phase, when the patient is alert and oriented, the nurse should focus teaching on deep breathing and coughing exercises, care of the surgical incision, managing constipation, and managing pain.

Which is included in the scope of practice for the circulating registered nurse (RN)? Select all that apply. 1) Obtaining informed consent 2) Conducting the initial assessment 3) Assisting the CRNA with patient monitoring 4) Labeling patient samples and sending for analysis 5) Documenting information pertinent the surgical procedure

ANS: 2, 3, 4, 5 Chapter number and title: 16, Priorities for the Intraoperative Patient Chapter learning objective: Identifying the roles and responsibilities of operating room (OR) team members Chapter page reference: 291-293 Heading: Overview of Surgical Team Members Integrated Processes: Nursing Process - Implementation Client Need: Safe and Effective Care Environment - Management of Care Cognitive level: Comprehension [Understanding] Concept: Perioperative Difficulty: Easy Feedback 1. This is incorrect. The surgical provider obtained the informed consent during the preoperative period. 2. This is correct. The circulating RN conducts the initial assessment when the patient is received to the surgical suite. 3. This is correct. The circulating RN assists the anesthesia provider with patient monitoring. 4. This is correct. The circulating RN labels patient samples and sends them for analysis. 5. This is correct. The circulating RN documents information pertinent to the surgical procedure.

The nurse is creating a pain management plan using the three-step approach for a patient with intractable pain. Which interventions should the nurse include in this plan? Select all that apply. 1) Administer an opioid analgesic first. 2) Administer a nonopioid analgesic first. 3) Administer a mild opioid analgesic last. 4) Administer analgesics upon patient request. 5) Administer a combination nonopioid-opioid second.

ANS: 2, 3, 5 Chapter number and title: 11, Pain Management Chapter learning objective: Incorporating both pharmacologic and nonpharmacologic evidence-based interventions into a plan of care for patients with pain Chapter page reference: 179-196 Heading: Pain Management Options Integrated Processes: Nursing Process - Implementation Client Need: Physiological Integrity - Pharmacological and Parental Therapies Cognitive level: Application [Applying] Concept: Comfort Difficulty: Moderate Feedback 1. This is incorrect. An opioid analgesic is not the first choice when using the three-step approach in pain management. 2. This is correct. The first step in the three-step approach to pain management involves administering a nonopioid drug first. 3. This is correct. If the patient is still experiencing pain, the mild opioid should be replaced with a stronger opioid in step 3. 4. This is incorrect. Pain-relieving drugs should be given "by the clock" (every 3-6 hours) rather than on demand to maintain freedom from pain. 5. This is correct. If pain is not adequately controlled with this mild intervention, patients should advance to step 2 and receive a mild opioid in combination with the same or a new nonopioid drugs.

Which drug should the nurse prepare for the anesthesiologist to reverse the effects of cisatracurium during a surgical procedure? 1) Fentanyl 2) Atropine 3) Neostigmine 4) Glycopyrrolate

ANS: 3 Chapter number and title: 16, Priorities for the Intraoperative Patient Chapter learning objective: Discussing types of anesthesia utilized in the OR Chapter page reference: 295-301 Heading: Anesthesia Integrated Processes: Nursing Process - Planning Client Need: Physiological Integrity - Pharmacological and Parenteral Therapies Cognitive level: Application [Applying] Concept: Perioperative; Medication Difficulty: Moderate Feedback 1 Fentanyl is a narcotic analgesic administered for pain. 2 Atropine is an anticholinergic agent that reverses muscle relaxants, not depolarizing neuromuscular agents. 3 Neostigmine is a cholinergic agent that reverses the effects of cisatracurium, a depolarizing neuromuscular agent. 4 Glycopyrrolate is an anticholinergic agent that reverses muscle relaxants, not depolarizing neuromuscular agents.

Which actions by the nurse are appropriate when preparing a patient for a surgical procedure that requires Fowler's positioning? Select all that apply. 1) Placing the patient in a lateral position 2) Supporting the patient's head in a headrest 3) Placing the patient's feet on a padded footboard 4) Placing the patient's arms at the sides with palms down 5) Lowering the foot of the bed flexing the patient's knees

ANS: 2, 3, 5 Chapter number and title: 16, Priorities for the Intraoperative Patient Chapter learning objective: Developing support strategies for the surgical patient and his or her family Chapter page reference: 303-307 Heading: Positioning the Patient in the OR Integrated Processes: Nursing Process - Implementation Client Need: Safe and Effective Care Environment - Management of Care Cognitive level: Application [Applying] Concept: Perioperative Difficulty: Moderate Feedback 1. This is incorrect. The lateral position is side-lying and would not be used if the surgical procedure required the patient to be positioned in Fowler's position. 2. This is correct. This nursing action is appropriate for Fowler's position during a surgical procedure. 3. This is correct. This nursing action is appropriate for Fowler's position during a surgical procedure. 4. This is incorrect. This is an appropriate nursing action when using the supine position during a surgical procedure. 5. This is correct. This nursing action is appropriate for Fowler's position during a surgical procedure.

The nurse administers a nonsteroidal anti-inflammatory drug (NSAID) to a patient who is experiencing chronic pain. When teaching the patient about this medication, which effects will the nurse include in the session? Select all that apply. 1) Sedating effects 2) Analgesic effects 3) Anesthetic effects 4) Antipyretic effects 5) Anti-inflammatory effects

ANS: 2, 4, 5 Chapter number and title: 11, Pain Management Chapter learning objective: Developing patient educational strategies to promote self-care and improved patient outcomes Chapter page reference: 179-196 Heading: Pain Management Options Integrated Processes: Teaching and Learning Client Need: Physiological Integrity - Pharmacological and Parenteral Therapies Cognitive level: Application [Applying] Concept: Comfort Difficulty: Moderate Feedback 1. This is incorrect. These medications do not have sedating or anesthetic effects in most patients, although some patients might report being able to fall asleep more easily once pain is reduced. 2. This is correct. Nonsteroidal anti-inflammatory drugs (NSAIDs) have anti-inflammatory, analgesic, and antipyretic effects. 3. This is incorrect. These medications do not have sedating or anesthetic effects in most patients, although some patients might report being able to fall asleep more easily once pain is reduced. 4. This is correct. Nonsteroidal anti-inflammatory drugs (NSAIDs) have anti-inflammatory, analgesic, and antipyretic effects. 5. This is correct. Nonsteroidal anti-inflammatory drugs (NSAIDs) have anti-inflammatory, analgesic, and antipyretic effects.

Which of these items would the perioperative nurse identify as part of the intraoperative documentation? Select all that apply. 1) Pain assessment 2) Start and stop times of anesthesia 3) Medication review 4) Antibiotic infusion times 5) Start and stop times of the procedure

ANS: 2, 4, 5 Chapter number and title: 16, Priorities for the Intraoperative Patient Chapter learning objective: Explaining priority assessments and procedures in the OR Chapter page reference: 293-295 Heading: Priority Assessments and Procedures Integrated Processes: Communication and Documentation Client Need: Safe and Effective Care Environment - Management of Care Cognitive level: Comprehension [Understanding] Concept: Communication; Perioperative Difficulty: Easy Feedback 1. This is incorrect. The pain assessment and medication review are documented during both the preoperative and postoperative assessments. 2. This is correct. Intraoperative documentation is to include documentation about specific times, such as the start and stop times of anesthesia, antibiotic infusion times, and start and stop times of the procedure. 3. This is incorrect. The pain assessment and medication review are documented during both the preoperative and postoperative assessments. 4. This is correct. Intraoperative documentation is to include documentation about specific times, such as the start and stop times of anesthesia, antibiotic infusion times, and start and stop times of the procedure. 5. This is correct. Intraoperative documentation is to include documentation about specific times, such as the start and stop times of anesthesia, antibiotic infusion times, and start and stop times of the procedure.

The patient has pain in the lower back that radiates down the leg as the result of a herniated disk compressing the sciatic nerve that began 4 months ago. When documenting this patient's pain, which term will the nurse use? 1) Acute somatic pain 2) Acute visceral pain 3) Acute neuropathic pain 4) Chronic neuropathic pain

ANS: 3 Chapter number and title: 11, Pain Management Chapter learning objective: Defining types of pain Chapter page reference: 166-169 Heading: Definitions of Pain Integrated Processes: Communication and Documentation Client Need: Physiological Integrity - Basic Care and Comfort Cognitive level: Application [Applying] Concept: Comfort Difficulty: Moderate Feedback 1 The terminology is not used to document this patient's pain. 2 The terminology is not used to document this patient's pain. 3 The pain is considered acute because it has lasted less than 6 months. It is neuropathic pain because it is caused by damage to the sciatic nerve. 4 The terminology is not used to document this patient's pain.

Which term should the nurse use to document the maximum amount of pain is able to tolerate? 1) Allodynia 2) Hyperalgesia 3) Pain tolerance 4) Pain threshold

ANS: 3 Chapter number and title: 11, Pain Management Chapter learning objective: Defining types of pain Chapter page reference: 172-174 Heading: Factors Shaping the Pain Experience Integrated Processes: Communication and Documentation Client Need: Physiological Integrity - Basic Care and Comfort Cognitive level: Application [Applying] Concept: Comfort Difficulty: Moderate Feedback 1 Allodynia is pain produced by nonpainful stimuli, such as the touch of wind to the area. 2 Hyperalgesia, or hyperpathia, denotes a heightened response to painful stimuli. 3 Pain tolerance is the maximum amount of pain a client can tolerate. 4 Pain threshold is the lowest amount of stimuli needed for a person to label a sensation as pain.

The nurse finds a postoperative patient perspiring with fist clenched upon entering the room. The nurse administers routine medication and provides care. The patient is pleasant and cooperative. Which action by the nurse is appropriate? 1) Asking the patient if pain is being experienced 2) Instructing the patient to use the call bell if he experiences pain 3) Informing the patient that he looks uncomfortable and asking him to describe his pain 4) Documenting "no complaints of pain offered" and assessing that the patient is comfortable

ANS: 3 Chapter number and title: 11, Pain Management Chapter learning objective: Developing a comprehensive plan of nursing care for patients with pain Chapter page reference: 177-179 Heading: Nursing Management of Pain Integrated Processes: Nursing Process - Implementation Client Need: Physiological Integrity - Basic Care and Comfort Cognitive level: Application [Applying] Concept: Comfort Difficulty: Moderate Feedback 1 Some patients might feel that admitting to pain is a sign of weakness, and might not bring it up unless the nurse specifically refers to the patient's apparent discomfort and asks him to describe his pain and indicates the patient's apparent discomfort. 2 Instructing the patient to use the call bell puts the responsibility for pain assessment on the patient instead of on the nurse. 3 It is the nurse's responsibility to assess for pain and not wait for the patient to mention it. 4 The patient's body language indicates the likelihood of pain.

The nurse is providing care to a postoperative patient who is getting out of bed for the first time since surgery. When conducting the pain assessment, the patient states, "It hurts, but I do not want to take any more drugs. I do not want to end up addicted." Which response by the nurse is most appropriate? 1) "Don't worry about getting addicted. I will make sure you don't get addicted." 2) "If you don't take the pain medication on a regular schedule, you won't get addicted." 3) "People who have real pain are unlikely to become addicted to analgesics provided to treat the pain." 4) "You are wise to be concerned; it is probably time to stop taking narcotics if you can manage the pain in other ways."

The hospice nurse is making a home visit to a patient with terminal cancer. The patient reports poor pain control when the spouse says, "I am giving such big doses of medication, I am afraid she is going to overdose if I give her more." Which response by the nurse is the most appropriate? 1) "You are not giving adequate pain relief, and she is in severe pain as a result." 2) "You are wise to be concerned. These are very strong medications you're administering." 3) "Let's talk about the medication you're giving and warning signs to be concerned about." 4) "You are not giving enough pain medication, so she is in severe pain. You need to give more."

ANS: 3 Chapter number and title: 11, Pain Management Chapter learning objective: Developing patient educational strategies to promote self-care and improved patient outcomes Chapter page reference: 177-179 Heading: Nursing Management of Pain Integrated Processes: Communication and Documentation Client Need: Physiological Integrity - Basic Care and Comfort Cognitive level: Application [Applying] Concept: Comfort; Communication Difficulty: Moderate Feedback 1 This response is likely to make the spouse feel guilty and does not provide information to provide the best care possible. 2 Telling the patient's spouse that his or her concern is warranted is untrue. 3 It is not unusual for a family caregiver to withhold medication out of fear of overdosing the cancer patient. It is important for the nurse to inform the caregiver that his feelings are not unusual, and then provide him with the information he needs to make an informed and appropriate decision that will make the client more comfortable. 4 This response is likely to make the spouse feel guilty and does not provide information to provide the best care possible.

Which is the reason for the nurse to administer ibuprofen, over acetaminophen, when providing patient pain management? 1) Analgesic effects 2) Antipyretic effects 3) Anti-inflammatory effects 4) Antipyretic and anti-inflammatory effects

ANS: 3 Chapter number and title: 11, Pain Management Chapter learning objective: Examining pain management strategies Chapter page reference: 179-196 Heading: Pain Management Options Integrated Processes: Nursing Process - Planning Client Need: Physiological Integrity - Pharmacological and Parenteral Therapies Cognitive level: Comprehension [Understanding] Concept: Comfort Difficulty: Easy Feedback 1 Both ibuprofen and acetaminophen provide analgesic effects. 2 Both ibuprofen and acetaminophen provide antipyretic effects. 3 Ibuprofen is administered over acetaminophen when anti-inflammatory properties are desired for pain management. 4 While ibuprofen is administered for its anti-inflammatory properties both acetaminophen and ibuprofen have antipyretic properties.

The nurse is reviewing the medical records for patients who are scheduled for surgery the next day. Which patient may not provide consent to receive blood products? 1) A Hispanic Catholic patient. 2) An African-American Baptist patient. 3) A Caucasian Jehovah's Witness patient. 4) A Native American patient with no religious affiliation.

ANS: 3 Chapter number and title: 15, Priorities for the Preoperative Patient Chapter learning objective: Analyzing the nursing role in the preoperative process Chapter page reference: 274-279 Heading: Informed Consent Integrated Processes: Nursing Process - Assessment Client Need: Psychosocial Integrity Cognitive level: Comprehension [Understanding] Concept: Perioperative; Diversity Difficulty: Easy Feedback 1 This patient is likely to provide consent to receive blood products. 2 This patient is likely to provide consent to receive blood products. 3 A patient who is a Jehovah's Witness is not likely to provide consent to receive blood products during the perioperative period. 4 This patient is likely to provide consent to receive blood products.

The nurse is conducting a medication assessment for a preoperative patient. Which action by the nurse is appropriate for the patient who is prescribed dexamethoasone? 1) Obtaining a baseline ECG 2) Monitoring blood pressure 3) Assessing for hyperglycemia 4) Tapering the drug two days prior to surgery

ANS: 3 Chapter number and title: 15, Priorities for the Preoperative Patient Chapter learning objective: Explaining the priority assessments for the surgical patient Chapter page reference: 280-284 Heading: Patient Assessment Integrated Processes: Nursing Process - Assessment Client Need: Physiological Integrity - Physiological Adaptation Cognitive level: Application [Applying] Concept: Perioperative Difficulty: Moderate Feedback 1 This nursing action is appropriate for a patient who is prescribed an antiarrhythmic. 2 This nursing action is appropriate for a patient who is prescribed an antihypertensive drug. 3 The prescribed drug is a corticosteroid; therefore, the most appropriate nursing action is to assess the patient for hyperglycemia. 4 The nursing action is appropriate for a patient who is prescribed an anticoagulant drug.

The nurse is conducting a medication assessment for a preoperative patient. Which action by the nurse is appropriate for the patient who is prescribed phenobarbital? 1) Obtaining a baseline ECG 2) Monitoring blood pressure 3) Maintaining the drug during the perioperative period 4) Assessing blood glucose levels closely during the perioperative period

ANS: 3 Chapter number and title: 15, Priorities for the Preoperative Patient Chapter learning objective: Explaining the priority assessments for the surgical patient Chapter page reference: 280-284 Heading: Patient Assessment Integrated Processes: Nursing Process - Assessment Client Need: Physiological Integrity - Physiological Adaptation Cognitive level: Application [Applying] Concept: Perioperative Difficulty: Moderate Feedback 1 This nursing action is appropriate for a patient who is prescribed an antiarrhythmic. 2 This nursing action is appropriate for a patient who is prescribed an antihypertensive drug. 3 The prescribed drug is a medication used to control seizures; therefore, this drug should be maintained during the perioperative period. 4 The nursing action is appropriate for a patient who is prescribed insulin for diabetes management.

Which is the priority action by the nurse when a patient discloses a medication allergy during the health history prior to a surgical procedure? 1) Asking the patient to describe the reaction that occurs 2) Documenting the information on the patient's medical record 3) Placing an alert bracelet on the patient prior to leaving the unit 4) Verifying the information with the patient's family members at the bedside

ANS: 3 Chapter number and title: 15, Priorities for the Preoperative Patient Chapter learning objective: Identifying the vital preoperative preparation for the patient Chapter page reference: 280-284 Heading: Patient Assessment Integrated Processes: Nursing Process - Implementation Client Need: Safe and Effective Care Environment - Management of Care Cognitive level: Analysis [Analyzing] Concept: Perioperative Difficulty: Difficult Feedback 1 While it is important to determine the type of reaction the patient experiences, this is not the priority nursing action. 2 While it is important to document the information in the patient's medical record, this is not the priority nursing action. 3 The nurse should immediately place an alert bracelet on the patient and communicate this information with the surgical team. 4 It is not necessary to verify the information with the patient's family members at the bedside.

The nurse is preparing a patient, diagnosed with asthma, for surgery. Which should the nurse include in the plan of care for this patient? 1) Monitoring blood pressure every hour 2) Assessing bowel sounds twice per shift 3) Monitoring pulse oximetry continuously 4) Assessing deep tendon reflexes every hour

ANS: 3 Chapter number and title: 15, Priorities for the Preoperative Patient Chapter learning objective: Identifying the vital preoperative preparation for the patient Chapter page reference: 280-284 Heading: Patient Assessment Integrated Processes: Nursing Process - Planning Client Need: Physiological Integrity - Physiological Adaptation Cognitive level: Application [Applying] Concept: Perioperative; Oxygenation Difficulty: Moderate Feedback 1 This parameter is not required when planning this patient's care. 2 This parameter is not required when planning this patient's care. 3 A patient diagnosed with asthma, who is scheduled for surgery, may have difficulty being weaned from the mechanical ventilator. This patient would require continuous pulse oximetry and arterial blood gas analysis in the plan of care. 4 This parameter is not required when planning this patient's care.

Which parameter for NPO status is appropriate when providing care to a pediatric patient in the preoperative period? 1) Ensuring nothing by mouth for six hours prior to the surgical procedure 2) Ensuring no solid foods by mouth for six hours prior to the surgical procedure 3) Allowing formula to be included in the child's intake for up to six hours prior to the surgical procedure 4) Allowing breast milk to be included in the child's intake for up to six hours prior to the surgical procedure

ANS: 3 Chapter number and title: 15, Priorities for the Preoperative Patient Chapter learning objective: Identifying the vital preoperative preparation for the patient Chapter page reference: 280-284 Heading: Patient Assessment Integrated Processes: Nursing Process - Planning Client Need: Safe and Effective Care Environment - Management of Care Cognitive level: Comprehension [Understanding] Concept: Perioperative; Nutrition Difficulty: Easy Feedback 1 This parameter is not appropriate for the pediatric patient. 2 This parameter is not appropriate for the pediatric patient. Solid foods are allowed up to up eight hours prior to surgery. 3 The pediatric patient can have formula for up to six hours prior to surgery. 4 This parameter is not appropriate for the pediatric patient. Breast milk is allowed for up to four hours prior to surgery.

The circulating nurse is assisting the anesthesiologist with patient monitoring during a surgical procedure. When documenting the administration of succinylcholine, which terminology should the nurse use? 1) A narcotic analgesic 2) An intravenous anesthetic 3) A depolarizing muscle relaxant 4) A nondepolarizing muscle relaxant

ANS: 3 Chapter number and title: 16, Priorities for the Intraoperative Patient Chapter learning objective: Discussing types of anesthesia utilized in the OR Chapter page reference: 295-301 Heading: Anesthesia Integrated Processes: Communication and Documentation Client Need: Physiological Integrity - Pharmacological and Parenteral Therapies Cognitive level: Application [Applying] Concept: Perioperative; Medication Difficulty: Moderate Feedback 1 Morphine sulfate is a narcotic analgesic. 2 Propofol is an intravenous anesthetic. 3 Succinylcholine is a depolarizing muscle relaxant. 4 Cisatracurium is a nondepolarizing muscle relaxant.

The nurse is performing a surgical hand scrub, and holds the hands in which position when rinsing? 1) Straight out from the elbows 2) Lower than the elbows 3) Higher than the elbows 4) Irrelevant as long as the hands are well scrubbed

ANS: 3 Chapter number and title: 16, Priorities for the Intraoperative Patient Chapter learning objective: Explaining priority assessments and procedures in the OR Chapter page reference: 293-295 Heading: Priority Assessments and Procedures Integrated Processes: Nursing Process - Implementation Client Need: Safe and Effective Care Environment - Safety and Infection Control Cognitive level: Application [Applying] Concept: Perioperative Difficulty: Moderate Feedback 1 This is not an appropriate nursing action during the surgical scrub. 2 This is not an appropriate nursing action during the surgical scrub. 3 The hands should be held higher than the elbows so the water drains down to the elbows and prevents contamination of the clean hands by water running from above the scrubbed area. 4 This is not an appropriate nursing action during the surgical scrub.

The nurse is providing care to a postoperative patient who is experiencing pain. The patient rates the pain at a 4 on a 1 to 10 numeric pain assessment scale. Which prescribed medication should the nurse administer to this patient? 1) Fentanyl 2) Morphine 3) Ibuprofen 4) Hydromorphone

ANS: 3 Chapter number and title: 17, Priorities for the Postoperative Patient Chapter learning objective: Applying the vital postoperative interventions for the patient in the immediate postoperative period Chapter page reference: 314-315 Heading: Pain Management Integrated Processes: Nursing Process - Implementation Client Need: Physiological Integrity - Pharmacological and Parenteral Therapies Cognitive level: Application [Applying] Concept: Perioperative; Comfort Difficulty: Moderate Feedback 1 Fentanyl is an opioid analgesic that is reserved for severe pain in the postoperative period. 2 Morphine is an opioid analgesic that is reserved for severe pain in the postoperative period. 3 Ibuprofen is a nonsteroidal anti-inflammatory drug (NSAID) that is appropriate for mild pain in the postoperative period. 4 Hydromorphone is an opioid analgesic that is reserved for severe pain in the postoperative period.

Which nursing action is appropriate when providing care to a patient who is difficult to arouse in the postanesthesia care unit (PACU)? 1) Monitor breath sounds 2) Administer prescribed heparin 3) Hold prescribed opioid analgesics 4) Assess for malignant hyperthermia

ANS: 3 Chapter number and title: 17, Priorities for the Postoperative Patient Chapter learning objective: Applying the vital postoperative interventions for the patient in the immediate postoperative period Chapter page reference: 315 Heading: Potential Complications Integrated Processes: Nursing Process - Implementation Client Need: Physiological Integrity - Physiological Adaptation Cognitive level: Application [Applying] Concept: Perioperative Difficulty: Moderate Feedback 1 The nurse would monitor breath sounds for a patient experiencing inadequate oxygenation. 2 The nurse would administer a prescribed anticoagulant, such as heparin, for a patient who is experiencing venous thromboembolism (VTE). 3 A patient who is difficult to arouse should have prescribed analgesics held until the patient stabilizes.

How many providers from the operating room (OR) should participate in the hand-off communication that occurs with the postanesthesia care (PACU) nurse prior to patient transfer? 1) One 2) Two 3) Three 4) Four

ANS: 3 Chapter number and title: 17, Priorities for the Postoperative Patient Chapter learning objective: Discussing the significance of the postoperative period Chapter page reference: 312-314 Heading: Patient Care in the Post-Anesthesia Care Unit (PACU) Integrated Processes: Communication and Documentation Client Need: Safe and Effective Care Environment - Management of Care Cognitive level: Knowledge [Remembering] Concept: Communication; Perioperative Difficulty: Easy Feedback 1 This is not the appropriate number of OR providers who should participate in the hand-off communication with the PACU nurse. 2 This is not the appropriate number of OR providers who should participate in the hand-off communication with the PACU nurse. 3 Three members of the OR team (anesthesia, surgical provider, and OR nurse) should participate in the hand-off communication with the PACU nurse. 4 This is not the appropriate number of OR providers who should participate in the hand-off communication with the PACU nurse.

The nurse is caring for a patient with a drain connected to a portable drainage suction device shaped like a grenade made of plastic. Which term will the nurse use when describing this system during end-of-shift report? 1) Closed wound drainage system 2) Hemovac 3) Jackson-Pratt 4) Reinfusion drain

ANS: 3 Chapter number and title: 17, Priorities for the Postoperative Patient Chapter learning objective: Explaining the priority assessments for the postsurgical patient Chapter page reference: 312-314 Heading: Patient Care in the Post-Anesthesia Care Unit (PACU) Integrated Processes: Communication and Documentation Client Need: Safe and Effective Care Environment - Management of Care Cognitive level: Application [Applying] Concept: Perioperative; Communication Difficulty: Moderate Feedback 1 All of these drains are nonspecifically known as closed wound drainage systems. 2 A Hemovac is a flat disk. 3 The drain described, shaped like a grenade, is a Jackson-Pratt. 4 A reinfusion drain allows collection of blood from the wound for readministration.

Which laboratory test should the postanesthesia care nurse monitor closely for a patient who is prescribed warfarin in the treatment of atrial fibrillation? 1) Serum glucose 2) Serum potassium 3) Prothrombin (PT) time 4) Blood urea nitrogen (BUN)

ANS: 3 Chapter number and title: 17, Priorities for the Postoperative Patient Chapter learning objective: Explaining the priority assessments for the postsurgical patient Chapter page reference: 312-314 Heading: Patient Care in the Post-Anesthesia Care Unit (PACU) Integrated Processes: Nursing Process - Assessment Client Need: Physiological Integrity - Reduction of Risk Potential Cognitive level: Application [Applying] Concept: Perioperative Difficulty: Moderate Feedback 1 Serum glucose is monitored for a patient who is having difficulty regaining consciousness in the postoperative period. 2 Serum potassium is monitored for patients who experienced abnormal fluid or blood losses and for patients who may have been overhydrated. 3 A PT time is monitored closely for any patient who is prescribed warfarin. Warfarin is often stopped for several days prior to a surgical procedure. However, this patient will continue to be at an increased risk for bleeding. 4 A BUN is monitored for any patient who may have experienced abnormal fluid or blood losses during surgery. A BUN should also be monitored for older adult patients and for those with renal disease.

Upon receiving the patient from the postanesthesia care unit, which nursing action is the priority? 1) Apply clean linens to the bed 2) Assemble required equipment, such as suction, IV pole, or oxygen equipment 3) Assess the patient 4) Notify the family of the patient's return to the room

ANS: 3 Chapter number and title: 17, Priorities for the Postoperative Patient Chapter learning objective: Explaining the priority assessments for the postsurgical patient Chapter page reference: 312-314 Heading: Patient Care in the Post-Anesthesia Care Unit (PACU) Integrated Processes: Nursing Process - Assessment Client Need: Safe and Effective Care Environment - Management of Care Cognitive level: Analysis [Analyzing] Concept: Perioperative Difficulty: Difficult Feedback 1 Clean linens should be applied to the bed as soon as the patient leaves for surgery or upon notification that the patient will be coming to the unit. 2 Equipment should be gathered in advance and set up to be ready when the patient returns. 3 The priority action for the nurse is to perform a thorough assessment of the patient's condition. 4 Only after assessing the patient would the nurse notify family members.

The nurse is assessing a patient's postoperative wound and finds it has separated from the suture line with extrusion of the bowel through the opening. When documenting this finding, which term will the nurse use? 1) Wound infection 2) Wound dehiscence 3) Wound evisceration 4) Wound tunneling

Which is the priority initial assessment for a patient who is admitted to the postanesthesia care unit (PACU)? 1) Heart rate 2) Temperature 3) Respirations 4) Blood pressure

ANS: 3 Chapter number and title: 17, Priorities for the Postoperative Patient Chapter learning objective: Explaining the priority assessments for the postsurgical patient Chapter page reference: 315-317 Heading: Nursing Interventions Integrated Processes: Nursing Process - Assessment Client Need: Physiological Integrity - Physiological Adaptation Cognitive level: Analysis [Analyzing] Concept: Perioperative; Assessment Difficulty: Difficult Feedback 1 While heart rate is an important parameter in the nursing assessment, this is not the priority. The ABCs should guide priority during the initial nursing assessment for the patient admitted to the PACU. 2 While temperature is an important parameter in the nursing assessment, this is not the priority. The ABCs should guide priority during the initial nursing assessment for the patient admitted to the PACU. 3 Respirations is the priority initial assessment for a patient who is admitted to the PACU. The ABCs should guide priority during the initial nursing assessment for the patient admitted to the PACU. 4 While blood pressure is an important parameter in the nursing assessment, this is not the priority. The ABCs should guide priority during the initial nursing assessment for the patient admitted to the PACU.

The postoperative patient displays sudden chest pain, shortness of breath, cyanosis, tachycardia, and low blood pressure. The nurse suspects which postoperative complication? 1) Pneumonia 2) Atelectasis 3) Hypovolemia 4) Pulmonary embolism

ANS: 3 Chapter number and title: 17, Priorities for the Postoperative Patient Chapter learning objective: Explaining the priority assessments for the postsurgical patient Chapter page reference: 315-317 Heading: Nursing Interventions Integrated Processes: Nursing Process - Planning Client Need: Safe and Effective Care Environment - Management of Care Cognitive level: Application [Applying] Concept: Perioperative; Nursing Difficulty: Moderate Feedback 1 Activity level, intravenous solutions, and type of diet are ordered by the health-care provider. 2 Activity level, intravenous solutions, and type of diet are ordered by the health-care provider. 3 The nurse will determine the frequency of patient assessments required, within the protocols established by the facility. The minimum frequency is determined by the facility, but more frequent assessment may be determined by the patient's condition, and is the decision of the nurse. 4 Activity level, intravenous solutions, and type of diet are ordered by the health-care provider.

The nurse is obtaining a pain history. The patient reports pain in the right ear. Which response by the nurse is the most appropriate? 1) "Is the pain minor?" 2) "Do you have anything else that hurts?" 3) "I will note that in the record. Is there anything else I should know?" 4) "Tell me more about the pain and what you do for it when it hurts."

ANS: 4 Chapter number and title: 11, Pain Management Chapter learning objective: Describing components that comprise a comprehensive pain assessment Chapter page reference: 174-177 Heading: Comprehensive Assessment Strategies for Acute and Chronic Pain Integrated Processes: Nursing Process - Assessment Client Need: Physiological Integrity - Basic Care and Comfort Cognitive level: Application [Applying] Concept: Comfort Difficulty: Moderate Feedback 1 This is a closed question and will not allow the nurse to gather the information needed regarding the patient's pain. 2 This is a closed question and will not allow the nurse to gather the information needed regarding the patient's pain. 3 This is a closed question and will not allow the nurse to gather the information needed regarding the patient's pain. 4 When the patient reports pain, the nurse should seek more information. When assessing pain, the nurse should assess all aspects of the pain, including character, onset, location, duration, exacerbation, relief, and radiation.

The nurse is conducting a medication assessment for a preoperative patient. Which action by the nurse is appropriate for the patient who is prescribed warfarin? 1) Obtaining a baseline ECG 2) Monitoring blood pressure 3) Assessing for hyperglycemia 4) Tapering the drug two days prior to surgery

ANS: 4 Chapter number and title: 15, Priorities for the Preoperative Patient Chapter learning objective: Explaining the priority assessments for the surgical patient Chapter page reference: 280-284 Heading: Patient Assessment Integrated Processes: Nursing Process - Assessment Client Need: Physiological Integrity - Physiological Adaptation Cognitive level: Application [Applying] Concept: Perioperative Difficulty: Moderate Feedback 1 This nursing action is appropriate for a patient who is prescribed an antiarrhythmic. 2 This nursing action is appropriate for a patient who is prescribed an antihypertensive drug. 3 This nursing action is appropriate for a patient who is prescribed a corticosteroid drug. 4 The prescribed drug is an anticoagulant; therefore, the most appropriate nursing action is to teach the patient to taper the drug for 48 hours prior to the surgical procedure.

When caring for an older adult patient who does not speak English, which assessment tool is the most appropriate for the nurse to use to assess this patient's pain? 1) An interpreter. 2) The patient's affect. 3) The patient's vital signs. 4) The FACES rating scale.

ANS: 4 Chapter number and title: 11, Pain Management Chapter learning objective: Describing components that comprise a comprehensive pain assessment Chapter page reference: 196-199 Heading: Managing Pain in Special Populations Integrated Processes: Nursing Process - Assessment Client Need: Physiological Integrity - Basic Care and Comfort Cognitive level: Comprehension [Understanding] Concept: Comfort Difficulty: Easy Feedback 1 If an interpreter is available the nurse can ask the interpreter to discuss the pain in more detail, but the FACES rating scale will help the nurse to respond to the patient's pain appropriately and quickly without waiting for an interpreter. 2 Affect and vital signs might not be accurate indicators of the patient's discomfort. 3 Affect and vital signs might not be accurate indicators of the patient's discomfort 4 An interpreter might not always be readily available, so the FACES rating scale can be used because it is not necessary to use language.

A nurse overhears another nurse say, "That patient is asking for pain medication again. He is constantly on the call bell, always reporting how severe his pain is, and I think he is just drug-seeking. I am going to make him wait the full 4 hours before I give this medication again." Which action by the nurse is the most appropriate in this situation? 1) Informing the charge nurse of what was overheard 2) Reprimanding the nurse and completing an incident or variance report 3) Ignoring the situation because the patient is not this nurse's responsibility 4) Reminding the nurse, in private, that the sensation of pain is whatever the patient says it is

ANS: 4 Chapter number and title: 11, Pain Management Chapter learning objective: Developing patient educational strategies to promote self-care and improved patient outcomes Chapter page reference: 177-179 Heading: Nursing Management of Pain Integrated Processes: Communication and Documentation Client Need: Safe and Effective Care Environment - Management of Care Cognitive level: Application [Applying] Concept: Communication Difficulty: Moderate Feedback 1 Informing the charge nurse would only be necessary if the nurse who was overheard did not respond constructively to the nurse's correction. 2 This is not an appropriate response by the nurse. 3 It is every nurse's responsibility to speak up and advocate for the client when situations arise that place the client at risk of incorrect treatment. 4 The nurse would address the situation privately, and not in front of others at the nurses' station.

Which risk factor should the nurse include in the preoperative plan of care for a patient who smokes? 1) Angina pain 2) Gastrointestinal upset 3) Cognitive impairment 4) Respiratory depression

ANS: 4 Chapter number and title: 15, Priorities for the Preoperative Patient Chapter learning objective: Analyzing the nursing role in the preoperative process Chapter page reference: 280-284 Heading: Patient Assessment Integrated Processes: Nursing Process - Planning Client Need: Physiological Integrity - Physiological Adaptation Cognitive level: Application [Applying] Concept: Perioperative; Oxygenation Difficulty: Moderate Feedback 1 A patient who smokes is not at a greater risk for angina pain during the perioperative period. 2 A patient who smokes is not at a greater risk for gastrointestinal upset during the perioperative period. 3 A patient who smokes is not at a greater risk for cognitive impairment during the perioperative period. 4 A patient who smokes is at a greater risk for respiratory depression during the perioperative period.

The nurse administers the preoperative medication to the patient one hour before elective surgery, and then discovers the preoperative consent is not signed. Which action by the nurse is the most appropriate? 1) Have the patient sign the consent quickly, before the medication begins taking effect. 2) Have a family member or medical power of attorney sign the consent. 3) Send the patient to the holding area without a signed consent. 4) Notify the health-care provider that surgery will need to be canceled.

ANS: 4 Chapter number and title: 15, Priorities for the Preoperative Patient Chapter learning objective: Discussing the essentials of the surgical experience Chapter page reference: 274-279 Heading: Informed Consent Integrated Processes: Nursing Process - Implementation Client Need: Safe and Effective Care Environment - Management of Care Cognitive level: Application [Applying] Concept: Legal; Perioperative Difficulty: Moderate Feedback 1 The nurse cannot have the patient sign the consent once the preoperative medication has been administered, because it affects the patient's ability to reason. 2 Emergency surgery, in some facilities, may be performed if a family member or medical power of attorney signs the consent when the patient is unable to do so, but elective surgery requires the patient's signature if she is capable of making a reasoned decision. 3 The nurse cannot send the patient to the holding area without a signed consent form. 4 The nurse will notify the health-care provider, who will need to cancel surgery until the preoperative medication is excreted and no longer affecting the patient's ability to make informed decisions, at which time the consent can be signed.

The nurse is conducting a medication assessment for a preoperative patient. Which action by the nurse is appropriate for the patient who is prescribed insulin? 1) Obtaining a baseline ECG 2) Monitoring blood pressure 3) Holding the drug during the perioperative period 4) Assessing blood glucose levels closely during the perioperative period

ANS: 4 Chapter number and title: 15, Priorities for the Preoperative Patient Chapter learning objective: Explaining the priority assessments for the surgical patient Chapter page reference: 280-284 Heading: Patient Assessment Integrated Processes: Nursing Process - Assessment Client Need: Physiological Integrity - Physiological Adaptation Cognitive level: Application [Applying] Concept: Perioperative Difficulty: Moderate Feedback 1 This nursing action is appropriate for a patient who is prescribed an antiarrhythmic. 2 This nursing action is appropriate for a patient who is prescribed an antihypertensive drug. 3 This nursing action is inappropriate as insulin should be administered throughout the perioperative period. 4 The prescribed drug is administered to control the patient's blood glucose level; therefore, the nurse should monitor the patient's blood glucose level closely during the perioperative period.

Which information should the nurse collect during the health history that is conducted during the preoperative period? 1) Caretaker after discharge 2) Oral intake over the last day 3) Date of last sexual encounter 4) Previous response to anesthesia

ANS: 4 Chapter number and title: 15, Priorities for the Preoperative Patient Chapter learning objective: Explaining the priority assessments for the surgical patient Chapter page reference: 280-284 Heading: Patient Assessment Integrated Processes: Nursing Process - Assessment Client Need: Safe and Effective Care Environment - Management of Care Cognitive level: Comprehension [Understanding] Concept: Perioperative; Assessment Difficulty: Easy Feedback 1 While the support system and living conditions should be assessed it is unnecessary to determine a specific caregiver after discharge. 2 Last oral intake, not intake over the previous day, is information collected. 3 The date of the patient's last sexual encounter is not needed. 4 The patient's previous response to anesthesia should be determined at this time.

Which is the priority nursing action when providing patient care during the preoperative phase of care? 1) Ensuring NPO status 2) Monitoring vital signs 3) Obtaining informed consent 4) Completing a preoperative checklist

ANS: 4 Chapter number and title: 15, Priorities for the Preoperative Patient Chapter learning objective: Identifying the vital preoperative preparation for the patient Chapter page reference: 274 Heading: Introduction Integrated Processes: Nursing Process - Implementation Client Need: Safe and Effective Care Environment - Management of Care Cognitive level: Analysis [Analyzing] Concept: Perioperative Difficulty: Difficult Feedback 1 While ensuring NPO status is important, this is not the priority nursing action. 2 While monitoring vital signs is important, this is not the priority nursing action. 3 The health-care provider, not the nurse, is responsible for obtaining informed consent. 4 The priority nursing action during the preoperative period is to complete the preoperative checklist prior to the patient being transferred to the surgical suite.

Which should the nurse teach the patient regarding NPO status prior to a surgical procedure? 1) Nothing by mouth for 12 hours prior to surgery 2) Nothing solid by mouth for six hours prior to surgery 3) No clear liquids by mouth for four hours prior to the surgery 4) No clear liquids by mouth for two hours prior to the surgery

ANS: 4 Chapter number and title: 15, Priorities for the Preoperative Patient Chapter learning objective: Identifying the vital preoperative preparation for the patient Chapter page reference: 280-284 Heading: Patient Assessment Integrated Processes: Teaching and Learning Client Need: Safe and Effective Care Environment - Management of Care Cognitive level: Application [Applying] Concept: Perioperative Difficulty: Moderate Feedback 1 This is not the guideline regarding NPO status prior to a surgical procedure. 2 This is not the guideline regarding NPO status prior to a surgical procedure. 3 This is not the guideline regarding NPO status prior to a surgical procedure. 4 The guidelines for NPO status prior to a surgical procedure is nothing solid by mouth for eight hours prior to the procedure and no clear liquids by mouth for two hours prior to the procedure. NPO status is meant to decrease the patient's risk for aspiration.

Which action should the circulating nurse anticipate during the emergence phase of general anesthesia? 1) Securing the patient's airway 2) Administering oxygen to the patient by face mask 3) Maintaining the patient using balanced anesthesia 4) Suctioning the patient to decrease incidence of aspiration

ANS: 4 Chapter number and title: 16, Priorities for the Intraoperative Patient Chapter learning objective: Analyzing the importance of airway management in the OR Chapter page reference: 301-303 Heading: Airway Management Integrated Processes: Nursing Process - Implementation Client Need: Safe and Effective Care Environment - Management of Care Cognitive level: Application [Applying] Concept: Perioperative Difficulty: Moderate Feedback 1 The patient's airway is secured during the intubation phase of general anesthesia. 2 Oxygen is administered to the patient by face mask during the induction of general anesthesia. 3 The patient is given drugs for balanced anesthesia during maintenance of general anesthesia. 4 The patient is suctioned to decrease the incidence of aspiration during emergence phase of general anesthesia.

Which action by the circulating nurse is appropriate when providing care to a patient during the maintenance phase of general anesthesia? 1) Securing the patient's airway 2) Administering oxygen to the patient by face mask 3) Suctioning the patient to decrease incidence of aspiration 4) Documenting drugs for administered for balanced anesthesia

ANS: 4 Chapter number and title: 16, Priorities for the Intraoperative Patient Chapter learning objective: Analyzing the importance of airway management in the OR Chapter page reference: 301-303 Heading: Airway Management Integrated Processes: Nursing Process - Implementation Client Need: Safe and Effective Care Environment - Management of Care Cognitive level: Application [Applying] Concept: Perioperative Difficulty: Moderate Feedback 1 The patient's airway is secured during the intubation phase of general anesthesia. 2 Oxygen is administered to the patient by face mask during the induction of general anesthesia. 3 The patient is suctioned to decrease the incidence of aspiration during emergence phase of general anesthesia. 4 The circulating nurse will document the drugs that are administered to maintain balanced anesthesia during the maintenance phase of general anesthesia.

The circulating nurse is assisting the anesthesiologist with patient monitoring during a surgical procedure. When documenting the administration of cisatracurium, which terminology should the nurse use? 1) A narcotic analgesic 2) An intravenous anesthetic 3) A depolarizing muscle relaxant 4) A nondepolarizing muscle relaxant

ANS: 4 Chapter number and title: 16, Priorities for the Intraoperative Patient Chapter learning objective: Discussing types of anesthesia utilized in the OR Chapter page reference: 295-301 Heading: Anesthesia Integrated Processes: Communication and Documentation Client Need: Physiological Integrity - Pharmacological and Parenteral Therapies Cognitive level: Application [Applying] Concept: Perioperative; Medication Difficulty: Moderate Feedback 1 Morphine sulfate is a narcotic analgesic. 2 Propofol is an intravenous anesthetic. 3 Succinylcholine is a depolarizing muscle relaxant. 4 Cisatracurium is a nondepolarizing muscle relaxant.

Which American Society of Anesthesiologists' classification should the circulating nurse document for a patient who is brain-dead and having organs procured for donation? 1) 3 2) 4 3) 5 4) 6

ANS: 4 Chapter number and title: 16, Priorities for the Intraoperative Patient Chapter learning objective: Discussing types of anesthesia utilized in the OR Chapter page reference: 295-301 Heading: Anesthesia Integrated Processes: Communication and Documentation Client Need: Safe and Effective Care Environment - Management of Care Cognitive level: Application [Applying] Concept: Communication; Perioperative Difficulty: Moderate Feedback 1 This is the appropriate classification for a patient with mild systemic disease. 2 This is the appropriate classification for a patient with severe systemic disease. 3 This is the appropriate classification for a patient with severe systemic disease that is a constant threat to life. 4 This is the appropriate classification for a moribund patient who is not expected to survive without the operation.

Which term should the nurse document for a patient who is having surgery for the removal of the gallbladder? 1) Episiotomy 2) Hysterectomy 3) Amniocentesis 4) Cholecystectomy

ANS: 4 Chapter number and title: 16, Priorities for the Intraoperative Patient Chapter learning objective: Explaining priority assessments and procedures in the OR Chapter page reference: 290-291 Heading: Overview of the Surgical Experience Integrated Processes: Communication and Documentation Client Need: Safe and Effective Care Environment - Management of Care Cognitive level: Application [Applying] Concept: Communication; Perioperative Difficulty: Moderate Feedback 1 An episiotomy is an incision made to the vagina during childbirth; -otomy is the suffix that indicates an incision. 2 A hysterectomy is the removal of the female reproductive organs; -ectomy is the suffix that indicates the removal of organs. 3 An amniocentesis is the removal of amniotic fluid during pregnancy for analysis; -centesis is the suffix that indicates puncture. 4 A cholecystectomy is the removal of the gallbladder; -ectomy is the suffix that indicates the removal of organs.

The patient is transferred to the operating table. Which dimension of the operative period is the patient currently experiencing? 1) Postoperative period 2) Preoperative period 3) Perioperative period 4) Intraoperative period

ANS: 4 Chapter number and title: 16, Priorities for the Intraoperative Patient Chapter learning objective: Explaining priority assessments and procedures in the OR Chapter page reference: 290-291 Heading: Overview of the Surgical Experience Integrated Processes: Nursing Process - Planning Client Need: Safe and Effective Care Environment - Management of Care Cognitive level: Knowledge [Remembering] Concept: Perioperative Difficulty: Easy Feedback 1 The postoperative phase begins with the admission of the patient to the postanesthesia care unit, and ends when healing is complete. 2 The preoperative phase begins when surgery is planned, and ends when the patient is transferred to the operating table. 3 The perioperative period covers all three time periods, from planning surgery until healing is complete. 4 The intraoperative phase begins when the patient is transferred to the operating table, and ends when the patient is admitted to the recovery room.

Which personal protective equipment should the scrub nurse don to decrease the likelihood of a splash injury during a surgical procedure? 1) Gloves 2) Gown 3) Mask 4) Eyewear

ANS: 4 Chapter number and title: 16, Priorities for the Intraoperative Patient Chapter learning objective: Explaining priority assessments and procedures in the OR Chapter page reference: 293-295 Heading: Priority Assessments and Procedures Integrated Processes: Nursing Process - Planning Client Need: Safe and Effective Care Environment - Safety and Infection Control Cognitive level: Application [Applying] Concept: Perioperative; Infection Difficulty: Moderate Feedback 1 Gloves do not decrease the risk for a splash injury during a surgical procedure. 2 Gowns do not decrease the risk for a splash injury during a surgical procedure. 3 Masks do not decrease the risk for a splash injury during a surgical procedure. 4 Eyewear is worn by the scrub nurse to decrease the risk for a splash injury during a surgical procedure.

Which is the priority laboratory test that the postanesthesia care nurse should monitor closely for an older adult patient with renal disease who retained fluid during a surgical procedure? 1) Serum glucose 2) Serum potassium 3) Prothrombin (PT) time 4) Blood urea nitrogen (BUN)

ANS: 4 Chapter number and title: 17, Priorities for the Postoperative Patient Chapter learning objective: Explaining the priority assessments for the postsurgical patient Chapter page reference: 312-314 Heading: Patient Care in the Post-Anesthesia Care Unit (PACU) Integrated Processes: Nursing Process - Assessment Client Need: Physiological Integrity - Reduction of Risk Potential Cognitive level: Analysis [Analyzing] Concept: Perioperative Difficulty: Difficult Feedback 1 Serum glucose is monitored for a patient who is having difficult regaining consciousness in the postoperative period. 2 Serum potassium is monitored for patients who experienced abnormal fluid or blood losses and for patients who may have been overhydrated. 3 A PT time is monitored closely for any patient who is prescribed warfarin. Warfarin is often stopped for several days prior to a surgical procedure. However, this patient will continue to be at an increased risk for bleeding. 4 A BUN is monitored for any patient who may have experienced abnormal fluid or blood losses during surgery. A BUN should also be monitored for older adult patients and for those with renal disease.

The medical-surgical nurse is providing care to a postoperative patient who is experiencing an elevated temperature. Which laboratory value should the nurse monitor to gather more information? 1) Platelet count 2) Serum glucose 3) Red blood cell (RBC) count 4) White blood cell (WBC) count

ANS: 4 Chapter number and title: 17, Priorities for the Postoperative Patient Chapter learning objective: Explaining the priority assessments for the postsurgical patient Chapter page reference: 312-314 Heading: Patient Care in the Post-Anesthesia Care Unit (PACU) Integrated Processes: Nursing Process - Assessment Client Need: Physiological Integrity - Reduction of Risk Potential Cognitive level: Application [Applying] Concept: Perioperative; Infection Difficulty: Moderate Feedback 1 The nurse would monitor a platelet count for a patient who is experiencing bleeding in the postoperative period. 2 A serum glucose level is monitored for a patient with diabetes mellitus. 3 An RBC count is monitored for a patient who experienced significant blood loss during a surgical procedure in order to determine if anemia has occurred. 4 An elevated temperature often indicates the patient is experiencing an infection. An increased WBC count would support this diagnosis.

Which patient finding would indicate the need for further monitoring rather than discharge home after an outpatient surgical procedure? 1) Pain management with opioid analgesics 2) Lethargy that resolves after several hours 3) Inability to void without fluid retention 4) Persistent nausea without vomiting

ANS: 4 Chapter number and title: 17, Priorities for the Postoperative Patient Chapter learning objective: Explaining the priority assessments for the postsurgical patient Chapter page reference: 312-314 Heading: Patient Care in the Post-Anesthesia Care Unit (PACU) Integrated Processes: Nursing Process - Planning Client Need: Safe and Effective Care Environment - Management of Care Cognitive level: Application [Applying] Concept: Perioperative Difficulty: Moderate Feedback 1 Effective pain management with opioid analgesics does not indicate the need for further monitoring. This patient can be discharged home. 2 Lethargy that resolves does not indicate the need for further monitoring. This patient can be discharged home. 3 An inability to void postsurgery, without a history of urinary retention, does not require further monitoring. This patient can be discharged home. 4 Persistent nausea, without vomiting, would indicate the need for further monitoring. This patient is not stable enough for discharge home.

The postanesthesia care unit (PACU) nurse is providing care for a patient who is exhibiting hypothermia. Which nursing action is appropriate? 1) Monitor breath sounds 2) Check serum glucose level 3) Hold prescribed opioid analgesics 4) Provide warm blankets or warming devices

ANS: 4 Chapter number and title: 17, Priorities for the Postoperative Patient Chapter learning objective: Explaining the priority assessments for the postsurgical patient Chapter page reference: 315 Heading: Potential Complications Integrated Processes: Nursing Process - Assessment Client Need: Physiological Integrity - Physiological Adaptation Cognitive level: Application [Applying] Concept: Perioperative Difficulty: Moderate Feedback 1 The nurse would monitor breath sounds for a patient experiencing inadequate oxygenation. 2 The nurse would monitor serum glucose levels for a patient who exhibited confusion. 3 A patient who is difficult to arouse should have prescribed analgesics held until the patient stabilizes. 4 The nurse would provide warm blankets or warming devices for a patient with hypothermia.

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