Pre-peri-Post Surgical care practice questions

The nurse received a report the elderly postoperative client became confused during the previous shift. Which client problem would the nurse include in the plan of care? a. risk of injury b. altered comfort level c. impaired circulation d. impaired skin integrity

A. Risk of injury

The nurse is interviewing a surgical client in the holding area. Which information should the nurse report to the anesthesiologistt? Select all that apply: a. The client has loose, decayed teeth. b. The client is experiencing anxiety. c. The client smokes two packs of cigarettes a day. d. The client has had a chest X-ray which does not show infiltrates. e. The client reports using herbs.

C. The client smokes two packs of cigarettes a day. E. The client reports using herbs.

The nurse is planning care of the surgical client having procedural sedation. Which intervention has highest priority? a. assess the client's respiratory status b. monitor the client's urinary output c. take a 12 lead ECG prior to injection d. attempt to keep the client focused

a. Assess the client's respiratory status.

Which client assessment data are priority for the PACU nurse? a. Bowel sounds b. vital signs c. IV fluid rate d. surgical site

b. Vital signs

The nurse and an unlicensed assistive personnel are caring for clients on a surgery unit. Which task would be most appropriate to delegate the UAP? a. Explain to the client how to cough and deep breathe b. Discuss the preoperative plans with the client and family. c. Determine the ability of the caregivers to provide postoperative care. d. Assist the client to a povidone-iodine (betadine) shower.

d. Assist the client a povidone-iodine (butadiene) shower.

The nurse is preparing a client for surgery who will be receiving general anesthesia. Which medication should the nurse question administering? a. metoprolol PO b. Cefazolin sodium IVPB c. EMLA cream topical d. Dabigatran etexilate

d. Dabigatran etexilate (it's an anticoagulant)

The client diagnosed with appendicitis has undergone appendectomy. At two hours postoperative the nurse take the vital signs and notes T102.6F, P132, R26, and BP92/46. Which interventions should the nurse implement? List in order of priority Increase the IV rate Notify the health care provider Elevate the food of the bed check the abdominal dressing determine if the IV antibiotics have been administered

1.increase IV rate 2.elevate the head of the bed 3.check the abdominal dressing 4.determine if the IV antibiotics have been administered 5. notify the health care provider

The nurse in the holding area of the surgery department is interviewing a client who requests to keep his religious medal on during surgery. Which intervention should the nurse implement? a. Notify the surgeon about the client's request to wear the medal b. Tape the medal to the client and allow the client to wear the medal c. Request the family member to take the medal prior to surgery d. Explain taking the medal to surgery is against the policy

B. Tape the medal to the client and allow the client to wear the medal.

The circulating nurse is positioning clients for surgery. Which client has the greatest potential for nerve damage? a. The 16 year old client in the dorsal recumbent position having an appendectomy. b. The 68 year old client in the trendelenburg position having a cholecystectomy. c. The 45 year old client in the reverse trendenlenburg position having a biopsy. d. The 22 year old client in the lateral position having a nephrectomy.

B. The 68 year old client in the trendelenburg position having a cholecystectomy.

Which statement would be an expected outcome for the postoperative client who had general anesthesia? a. The client will be able to sit in the chair for 30 mins. b. The client will have a pulse oximetry reading of 97% on room air. c. The client will have a urine output of 30 mL per hour. d. The client will be able to distinguish sharp from dull sensations.

B. The client will have a pulse oximetry reading of 97% on room air.

The nurse is completing a preoperative assessment on a male client who states, "I am allergic to codeine". Which intervention should the nurse implement first? a. apply an allergy bracelet on the client's wrist b. label the client's allergies on the front of the chart c. Ask the client client what happens when he takes the codeine. d. Document the allergy on the medication administration record.

C. Ask the client what happens when he takes the codeine.

The postoperative client is transferred from the PACU to the surgical floor. Which action should the nurse implement first? a. Apply anti embolism hose to the client b. Attach the drain to 20cm suction c. Assess the client's vital signs d. Listen to the report from the anesthesiologist.

C. Assess the client's vital signs.

The circulating nurse observes the surgical scrub technician remove a sponge from the edge of the sterile field with a clamp and place the sponge and clamp in a designated area. Which action should the nurse implement? a. Place the sponge back where it was. b. Tell the technician not to waste supplies c. Do nothing because this is the correct procedure d. Take the sponge out of the room immediately.

C. Do nothing because this is the correct procedure.

The surgical client's vital signs are T: 98F P:106 R:24 and BP: 88/40. The client is awake and oriented times three, and the skin is pale and damp. Which intervention should the nurse implement first? a. Call the surgeon and report the vital signs b. Start an IV of D5 RL with 20 mEq KCl at 125 mL/hr c. Elevate the feet and lower the head d. Monitor the vital signs every 15 minutes

C. Elevate the feet and lower the head.

The unlicensed assistive personnel (UAP) reports the vital signs for a first day postoperative client as T 100.8 P80 R24 and BP 148/80. Which intervention would be most appropriate for the nurse to implement? a. administer the antibiotic earlier than scheduled b. Change the dressing over the wound c. Have the client turn, cough, and deep breathe every 2 hours. d. Encourage the client to ambulate in the hall.

C. Have the client turn, cough, and deep breathe every 2 hours.

Which situation demonstrates the circulating nurse acting as the client's advocate? a. Plays the client's favorite audio books during surgery b. Keeps the family informed of the findings of the surgery c. Keeps the operating room door closed at all times d. Calls the client by the first name when the client is recovering

C. Keeps the operating room door closed at all times.

The nurse must obtain surgical consent forms for the scheduled surgery. Which client would not be able to consent legally to surgery? a. The 65 year old client who cannot read or write. b. The 30 year old Client who does not understand English. c. The 16 year old client who has a fractured ankle. d. The 80 year old client who is not oriented to the day.

C. The 16 year old client who has a fractured ankle.

Which situation is an example of the nurse fulfilling the role of client advocate? a. the nurse brings the client pain medication when it is due. b. The nurse collaborates with other disciplines during the care conference. c. The nurse contacts the healthcare provider when pain relief is not obtained. d. The nurse teaches the client to ask for medication before the pain gets to a 5.

C. The nurse contacts the healthcare provider when pain relief is not obtained.

The nurse is preparing a client for surgery. Which intervention should the nurse implement first? a. check the permit for the spouses's signature b. Take and document intake and output c. Administer the on call sedative d. Complete the preoperative checklist

Complete the preoperative checklist.

The circulating nurse and the scrub technician find a discrepancy in the sponge count. Which action should the circulating nurse take first? a. Notify the client's surgeon b. Complete an occurrence report c. Contact the surgical manager d. Recount all sponges

D. Recount all sponges

Which violation of surgical asepsis would require immediate intervention by the circulating nurse? a. Surgical supplies were cleaned and sterilized prior to the case. b. The circulating nurse is wearing a long sleeved sterile gown. c. Masks covering the mouth and nose are being worn by the surgical team. d. The scrub nurse setting up the sterile field is wearing artificial nails.

D. The scrub nurse setting up the sterile field is wearing artificial nails.

The nurse is assessing a client in the day surgery unit who states, "I am really afraid of having this surgery. I'm afraid of what they will find". Which statement would be the most therapeutic response by the nurse? a. Don't worry about your surgery. It is safe. b. Tell me why you're worried about your surgery. c. Tell me about your fears of having this surgery. d. I understand how you feel. Surgery is frightening

Tell me about your fears of having this surgery.

The circulating nurse is planning the care for an intraoperative client. Which statement is the expected outcome? a. The client has no injuries from the OR equipment. b. The client has no postoperative infection. c. The client has stable vital signs during the surgery. d. The client recovers from anesthesia.

The client has no injuries from the OR equipment.

The nurse is reviewing the pathology report of a client post-cervical neck node dissection. The health care provider has explained the results of the biopsy to the client. Which should the nurse implement? a. allow the client the opportunity to discuss feelings about the results b. assess the clients neck dissection dressing for bleeding c. monitor the clients white blood cell count for elevation d. call the pathology department to verify the report is correct.

a. Allow the client the opportunity to discuss feelings about the results.

The client has undergone an abdominal perineal resection of the colon for colon cancer with a left lower quadrant colostomy. Which interventions should the nurse implement? select all that apply a. Assess the stoma for color every 4 hours and PRN. b. Encourage the client to turn, cough, and deep breathe every 2 hours. c. Maintain the head of the bed 30 to 40 degrees elevated at all times. d. Auscultate for bowel sounds every 4 hours. e. Administer pain medications sparingly to prevent addiction.

a. Asses the stoma for color every 4 hours and PRN. b. Encourage the client to turn, cough, and deep breathe every 2 hours. d. Auscultate for bowel sounds every 4 hours.

The PACU nurse is receiving the client form the OR. Which intervention should the nurse implement first? a. assess the client's breath sounds b. apply oxygen via nasal cannula c. take the client's blood pressure d. monitor the pulse oximeter reading

a. Assess the client's breath sounds

Which nursing intervention is priority for the client experiencing acute pain? a. assess the client's verbal and nonverbal behavior. b. Wait for the client to request pain medication. c. administer the pain medication on a scheduled basis d. teach the client to use only imagery every hour for the pain.

a. Assess the client's verbal and nonverbal behavior.

The client is complaining of left shoulder pain. Which intervention should the nurse implement first? a. Assess the neurovascular status of the left hand. b. Check the medication administration record (MAR) c. Ask if the client wants pain medication. d. Administer the clients pain medication.

a. Assess the neuromuscular status of the left hand.

The nurse clears the PCA pump and discovers the client has used only a small amount of medication during the shift. Which intervention should the nurse implement? a. Determine why the client is not using the PCA pump. b. Document the amount and take no action. c. Chart the client is not having pain. d. Contact the HCP and request oral medication.

a. Determine why the client is not using the PCA pump.

The client one day postoperative develops elevated temperature. Which intervention would have priority for the client? a. Encourage the client to deep breathe and cough every hour. b. Encourage the client to drink 200mL of water ever shift. c. Monitor the client's wound for drainage every 8 hours. d. Assess the urine output for color and clarity every 4 hours.

a. Encourage the client to deep breathe and cough every hour.

The nurse is conducting an interview with a 75 year old client admitted with acute pain. Which question would have priority when assisting with pain management? a. Have you ever had difficulty getting your pain controlled? b. What types of surgery have you had in the last 10 years? c. Have you ever been addicted to narcotics? d. Do you have a list of your prescription medications?

a. Have you ever had difficulty getting your pain controlled?

The nurse requests the client to sign a surgical informed consent form for an emergency appendectomy. Which statement by the client indicates a further teaching is needed? a. I will be glad when this is over so I can go home today b. I will not be able to eat or drink anything prior to my surgery c. I can practice relaxing by listening to my favorite music d. I will need to get up and walk as soon as possible

a. I will be glad when this is over so I can go home today.

Which activities are the circulating nurse's responsibilities in the operating room? a. monitor the position of the client, prepare the surgical site, and ensure the client's safety. b. Give preoperative medication in the holding area and monitor the client's response to anesthesia. c. Prepare sutures, set up sterile field, and count all needles, sponges, and instruments. d. Prepare the medications to be administered by the anesthesiologist and change the tubing for the anesthesia machine.

a. Monitor the position of the client, prepare the surgical site, and ensure the clients safety.

The 68 year old client scheduled for intestinal surgery does not have clear fecal contents after 3 tap water enemas. Which intervention should the nurse implement first? a. Notify the surgeon of the client's status b. Continue giving enemas until clear c. Increase the client's IV fluid rate d. Obtain STAT serum electrolytes.

a. Notify the surgeon of the client's status

Which problem should the nurse identify as priority for client who is day postoperative? a. Potential for hemorrhaging b. Potential for injury c. Potential for fluid volume excess d. Potential for infection

a. Potentila for hemorrhaging

The circulating nurse assesses tachycardia and hypotension in the client. Which interventions should the nurse implement? a.Prepare ice packs and mix dantrolene sodium. b. Request the defibrillator be brought into the OR c. Draw a PTT and prepare a heparin drip d. Obtain a finger stick blood glucose immediately.

a. Prepare ice packs and mix dantrolene sodium.

The nurse and the unlicensed assistive personnel (UAP) are working on the surgical unit. Which task can the nurse delegate to the UAP? a. Take routine vital signs on the clients b. Check the Jackson Pratt insertion site. c. Hang the clients next IV bag. d. Ensure the client obtains pain relief.

a. Take routine vital signs on the clients.

Which client would the nurse identify as having the highest risk for developing postoperative complications? a. The 67 year old client who is obese, has diabetes, and takes insulin b. The 50 year old client with arthritis taking non steroidal anti inflammatory drugs. c. the 45 year old client having abdominal surgery to remove the gall bladder. d. The 60 year old client with anemia who smokes one pack of cigarettes per day.

a. The 67 year old client who is obese, has diabetes, and takes insulin.

Which action by the client indicates to the nurse preoperative teaching has been effective a. The client demonstrates how to use the incentive spirometer device. b. The client demonstrates the use of the patient controlled analgesia pump. c. The client can name two anesthesia agents used during surgery. d. The client ambulates down the hall to the nurse's station each hour.

a. The client demonstrates how to use the incentive spirometer device.

The nurse received a male client from the PACU. Which assessment data would warrant immediate intervention? a. The clients vital signs are T97F P108 R24 and BP 80/40 b. The client is sleepy but opens the eyes to his name. c. The client is complaining of pain at a 5 on a 1 to 10 scale. d. The client has 20 mL of urine in the urinary drainage bag.

a. The clients vital signs are T97F, P108, R24, and BP 80/40

Which intervention has priority for the nurse in the surgical holding area? a. Verify the surgical checklist b. Prepare the client's surgical site c. Assist the client to the bathroom d. Restrain the client on the surgery table.

a. Verify the surgical checklist

The nurse is caring for a client in acute pain as a result of surgery. Which intervention should the nurse implement? a. administer pain medication as soon as the time frame allows. b. Use non pharmacological methods to replace medications. c. Use cryotherapy after heat therapy because it works faster. d. Instruct family members to administer medications with the PCA.

a. administer pain medication as soon as the time frame allows.

The nurse is administering an opioid narcotic to the client. Which interventions should the nurse implement for client safety? select all that apply a. compare the hospital number on the MAR to the clients bracelet b. Hava a witness verify the wasted portion of the narcotic c. Assess the client's vital signs prior to administration d. Determine if the client has any allergies to medications. e. Clarify all pain medication orders with the health care provider.

a. compare the hospital number on the MAR to the clients bracelet c. Assess the client's vital signs prior to administration. d. Determine if the client has any allergies to medications.

The circulating nurse notes a discrepancy in the needle count. What intervention should the nurse implement first? a. Inform the other members of the surgical team about the problem b. assume the original count was wrong and change the record c. call the radiology department to perform a portable X-ray d. complete an occurrence reported notify the risk manager.

a. inform the other members of the surgical team about the problem.

The client in the surgery holding area identifies the left arm as the correct surgical site, but the operative permit designates surgery to be performed on the right arm. Which interventions should the nurse implement? select all that apply a. review the client's chart b. notify the surgeon c. immediately call a time out .d. correct the surgical permit e. request the client mark the left arm

a. review the client's chart b. notify the surgeon c. immediately call a time out e. request the client mark the left arm

Which intervention is appropriate for the nurse to delegate to the unlicensed assistive personnel (UAP) when caring for the female client experiencing acute pain? a. Take the pain medication to the room b. apply an ice pack to the site of pain c. check on the client 30 minutes after she takes the pain medication. d. observe the clients ability to use the PCA.

b. Apply an ice pack to the site of pain

The 26 year old male client in the PACU has a heart rate of 110 and a rising temperature and complains of muscle stiffness. Which interventions should the nurse implement? Select all that apply a. give a back rub to the client to relieve stiffness b. Apply ice packs to the axillary and groin areas. c. prepare an ice slush for the client to drink. d. Prepare to administer dantrolene, a smooth muscle relaxant. e. Reposition the client on a warming blanket.

b. Apply ice packs to the axillary and groin areas. d. Prepare to administer dantrolene, a smooth muscle relaxant.

Which nursing intervention has the highest priority when preparing the client for a surgical procedure? a. pad the client's elbows and knees b. apply soft restraint straps to the extremities c. Prepare the client's incision site d. Document the temperature of the room

b. Apply soft restraint straps to the extremities.

The nurse identifies the nursing diagnosis "Risk for injury related to positioning" for the client in the operating room. Which nursing intervention should the nurse implement? a. avoid using the cautery unit which does not have a biomedical tag on it b. carefully pad the clients elbows before covering the client with a blanket c. Apply a warming pad on the OR table before placing the client on the table d. Check the chart for any prescription or over the counter medication use.

b. Carefully pad the clients elbows before covering the client with a blanket

The nurse is caring for a male client scheduled for abdominal surgery. Which interventions should the nurse include in the plan of care? select all that apply a. Perform passive range of motion exercises b. Discuss how to cough and deep breathe effectively c. Tell the client he can have a meal in the PACU d. Teach ways to manage preoperative pain e. Discuss events which occur in the postanesthesia care unit.

b. Discuss how to cough and deep breathe effectively. d. Teach ways to manage preoperative pain d. Discuss events which occur in the post anesthesia care unit.

Which technique would be most appropriate for the nurse to implement when assessing a four year old client in acute pain? a. use words a four year old child can remember b. explain the 0-10 pain scale to the child's parent c. have the child point to the face which describes the pain. d. Administer the medication every 4 hours.

b. Have the child point to the face which describes the pain.

The unlicensed assistive personnel can be overheard talking loudly to the scrub technologist discussing a problem which occurred during one of the surgeries. Which intervention should the nurse in the surgical holding area with a female client implement? a. close the curtains around the client's stretcher b. Instruct the UAP and scrub tech to stop the discussion c. Tell the surgeon on the case what the nurse overheard. d. Inform the client the discussion was not about her surgeon.

b. Instruct the UAP and scrub tech to stop the discussion.

Which problem would be appropriate for the nurse to identify for the preoperative client having an open reduction and internal fixation of the right ankle? a. Alterations in skin integrity b. Knowledge deficit of postoperative care. c. Alteration in gas exchange and pattern. .d. Alteration in urinary elimination.

b. Knowledge deficit of postoperative care.

The client is in lithotomy position during surgery. Which nursing intervention should be implemented to decrease a complication from the positioning? a. Increase the intravenous fluids. b. Lower one leg at a time c. Raise the foot of the stretcher d. Administer epinephrine, a vasopressor

b. Lower one leg at a time.

The nurse is implementing the preoperative checklist for the client who is scheduled for a laparoscopic cholecystectomy. The preoperative complete blood count results are on the chart. Which action should the nurse implement first? WBC: 12.3, RBC: 6.8, Hgb: 14.4 , Hct: 41.8, Platelets: 168 a. Check off that the CBC report is on the chart. b. notify the surgeon of the WBC c. Assess the client for dyspnea d. Teach the client to turn, cough, and deep breathe

b. Notify the surgeon of the WBC

The PACU nurse administers Narcan, an opioid antagonist, to a postoperative client. Which client problem should the nurse include to the plan of care baed on this medication? a. Alteration in comfort b. Risk for depressed respiratory pattern c. Potential for infection d. Fluid and electrolyte imbalance

b. Risk for depressed respiratory pattern.

The nurse is receiving a client from the PACU. Which interventions should the nurse implement? select all that apply a. Ambulate the client to the bathroom to void. b. Take the client's vital signs to compare with PACU data. c. Monitor all lines into and out of the clients body. d. Assess the client's surgical site. e Push the client's PCA button to treat for pain during movement.

b. Take the client's vital signs to compare with PACU data. c. Monitor all lines into and out of the client's body. d. Assess the client's surgical site.

The nursing manager is making assignments for the OR. Which case should the manager assign to the inexperienced nurse? a. The client having open heart surgery b. The client having a biopsy of the breast c. The client having laser eye surgery d. The client having a laparoscopic knee repair

b. The client having a biopsy of the breast.

Which statement should the nurse identify as the expected outcome for a client experiencing acute pain? a. The client will have decreased us of medication. b. The client will participate in self-care activities. c. The client will use relaxation techniques. d. The client will repeat instructions about medications.

b. The client will participate in self-care activities.

The nurse is completing the preoperative checklist. Which laboratory value should be reported to the health care provider immediately? a. hemoglobin 13.1 b. glucose 60 c. white blood cells 6 d. potassium 3.8

b. glucose 60

Which problem would be most appropriate for the nurse to identify for the client experiencing acute pain? a. Ineffective coping b. Potential for injury c. Alteration in comfort d. Altered sensory input.

c. Alteration in comfort

The three day postoperative client is complaining of unrelieved pain at the incision site one hour after the administration of narcotic pain medication. Which action should the nurse implement first? a. Check the MAR for another medication to administer b. Teach the client to use guided imagery to relieve pain. c. Assess the client for complications d. Elevate the head of the client's bed.

c. Assess the client for complications.

The postoperative client complains of hearing a "popping sound" and feeling "something opening" when ambulating in the room. Which intervention should the nurse implement first? a. notify the surgeon the client has had an evisceration b. contact the surgery department to prepare for emergency surgery. c. Assess the operative site and cover the site with a moistened dressing d. explain this is a common feeling and tell the client to continue with activity.

c. Assess the operative site and cover the site with a moistened dressing.

The male client in the day surgery unit complaints of difficulty urinating postoperatively. Which intervention should the nurse implement? a. Insert an indwelling catheter b. Increase the intravenous fluid rate c. Assist the client to stand to void d. Encourage the client to increase fluids.

c. Assist the client to stand to void.

The client in the surgical holding area tells the nurse "I am so scared. I have never had surgery before". Which statement would the nurse's most appropriate response? a. Why are you afraid of the surgery? b. This is the best hospital in the city c. Does having surgery make you afraid? d. There is no reason to be afraid

c. Does having surgery make you afraid?

Which statement made by the client who is postoperative abdominal surgery indicates the discharge teaching has been effective? a. I will take temperature each week and report my elevation b. I will not need any pain medication when I go home. c. I will take all of my antibiotics until they are gone. d. I will not take a shower until my 3 month check up.

c. I will take all of my antibiotics until they are gone.

The client returned to the medical surgical unit at 1800 following a two hour surgery and one hour in the PACU. The nurse is reviewing the client's intake and output at midnight. Which intervention should the nurse implement based on the recorded data? a. Immediately place and indwelling catheter in the client b. Assess the clients skin turgor in the abdominal area c. Recheck the client's urinary output in two hours d. Encourage the client to drink 500 mL of clear liquids.

c. Recheck the client's urinary output in two hours.

Which problem is appropriate for the nurse to identify for a client in the intraoperative phase of surgery? a. Alteration in comfort b. Disuse syndrome c. Risk for injury d. Altered gas exchange

c. Risk for injury

The circulating nurse observes the surgeon tossing a bloody gauze sponge onto the sterile field. Which action should the circulating nurse implement first? a. Include the sponge in the sponge count b. obtain a new sterile instrument pack c. Tell the surgical technologist about the sponge d. Throw the sponge in the sterile trashcan

c. Tell the surgical technologist about the sponge.

Which assessment data indicate the postoperative client who had spinal anesthesia is suffering a complication of the anesthesia? a. Loss of sensation at the lumbar L5 dermatome b. Absence of the client's posterior tibial pulse c. The client has a respiratory rate of 8 d. The blood pressure is within 20% of the client's baseline.

c. The client has a respiratory rate of 8,

The nurse is completing the preoperative checklist on a client going to surgery. Which information should the nurse report to the surgeon? a. The client understands the purpose of the surgery. b. The client stopped taking aspirin 3 weeks ago. c. The client uses the oral supplements licorice and garlic d. The client has mild levels of preoperative anxiety.

c. The client uses the oral supplements licorice and garlic.

Which client outcome would the nurse identify for the preoperative client? a. The client's abnormal laboratory data will be reported to the anesthesiologist. b. The client will not have any postoperative complications for the first 24 hours. c. The client will demonstrate the use of a pillow to splint while deep breathing. d. The client will complete an advance directive before having the surgery.

c. The client will demonstrate the use of a pillow to splint while deep breathing.

Which nursing task would be most appropriate to delegate to the unlicensed assistive personnel on a postoperative unit? a. Change the dressing over the surgical site b. teach the client how to perform incentive spirometry c. empty and record the amount of drainage in the JP drain. d. auscultate the bowel sounds in all four quadrants.

c. empty and record the amount of drainage in the JP drain.

Which task would be most appropriate for the nurse to delegate to the unlicensed assistive personnel? a. Complete the preoperative checklist b. Assess the client's preoperative vital signs c. Teach the client about coughing and deep breathing d. Assist the client to remove clothing and jewelry.

d. Assist the client remove clothing and jewelry.

Which nursing intervention is the highest priority when administering pain medication to a client experiencing acute pain? a. monitor the clients vital signs b. verify the time of the last dose c. check for the client's allergies d. Discuss the pain with the client

d. Discuss the pain with the client

Which data indicate to the nurse the client who is one day postoperative right total hip replacement is progressing as expected? a. urine output was 160 mL in the past 8 hours. b. paralysis and parasthesia of the right leg. c. T:99F, P98, R20, and BP 100/60 d. Lungs are clear bilaterally in all lobes

d. Lungs are clear bilaterally in all lobes.

Which laboratory result would require immediate intervention by the nurse for the client scheduled for surgery? a. Calcium 9.2 mg/dL b. Bleeding time 2 minutes c. Hemoglobin 15g/dL d. Potassium 2.4 mEq/L

d. Potassium 2.4 mEq/L

The charge nurse is making shift assignments. Which postoperative client should be assigned to the most experienced nurse? a. The 4 year old client who had a tonsillectomy and is able to swallow fluids. b. The 74 year old client with a repair of the left hip who is able to ambulate. c. The 24 year old client who had an uncomplicated appendectomy the previous day. d. The 80 year old client with a small bowel obstruction and congestive heart failure.

d. The 80 year old client with a small bowel obstruction and congestive heart failure.

The nurse is caring for a client scheduled for total hip replacement. Which behavior indicates the need for further preoperative teaching? a. The client uses the diaphragm and abdominal muscles to inhale through the nose and exhale through the mouth. b. The client demonstrates dosiflexion of the feet, flexing of the toes, and move the feet in a circular motion. c. The client uses the incentive spirometer and inhales slowly and deeply so the piston rises to the preset volume. d. The client gets out of bed by lifting straight upright from the waist and then swings both legs along the side of the bed.

d. The client gets out of bed by lifting straight upright from the waist and then swings both legs along the side of the bed.

Which statement explains the nurse's responsibility when obtaining informed consent for the client undergoing a surgical procedure? a. The nurse should provide detailed information about the procedure. b. The nurse should inform the client of any legal consultation needed. c. The nurse should write a list of the risks for postoperative complications. d. The nurse should ensure the client is voluntarily giving consent.

d. The nurse should ensure the client is voluntarily giving consent.

The client received naloxone, an opioid antagonist, in the PACU. Which nursing intervention should the nurse include in the care plan? a. measure the client's intake and output hourly. b. administer sleep medications at night c. encourage the client to verbalize feelings d. monitor respirations every 15 to 30 minutes

d. monitor respirations every 15 to 30 minutes.