Test 3 Questions

The nurse is preparing the preoperative client for surgery. The following statements that indicate the client is knowledgeable about his impending surgery, except: A. "After surgery, I will need tow ear the pneumatic compression device while sitting in the chair" B. "The skin prep area is going to be longer and wider than the anticipated incision" C. "I cannot have anything to drink or eat after midnight on the night before the surgery" D. "To ensure my safety, a 'time out' will be conducted in the operating room"

C. "I cannot have anything to drink or eat after midnight on the night before the surgery" *No food or drink 6-8 hours before surgery

The patient had undergone thyroidectomy. Which of the following are the earliest signs of poor tissue perfusion and poor respiratory function? A. Cyanosis, lethargy B. Fast, thready pulse, bradypnea C. Apprehension and restlessness D. Faintness, pallor

C. Apprehension and restlessness

A postoperative client receives a dinner tray with gelatin, pudding, and vanilla ice cream. Based on the foods on the client's tray, what would the nurse anticipate the client's current diet order to be: A. Bland diet B. Soft diet C. Full liquid diet D. Regular diet

C. Full liquid diet

Which of the following is the primary purpose of maintaining NPO for 6-8 hours before surgery? A. To prevent malnutrition B. To prevent electrolyte imbalance C. To prevent aspiration pneumonia D. To prevent intestinal obstruction

C. To prevent aspiration pneumonia

A nurse just reassessed the condition of postoperative client who was admitted 1 hr ago to the surgical unit. The nurse plans to most carefully monitor which of the following parameters during the next hour? A. Serous drainage on the surgical dressing B. Blood pressure of 100/70 mm Hg C. Urinary output of 20 mL/hr D. Temperature of 99.6 F (37.6 C)

C. Urinary output of 20 mL/hr

The nursing is preparing a client for surgery. What is the most effective method for obtaining an accurate blood pressure reading from the client? A. Obtain a cuff that covers the upper one third of the clients arm B. Position the cuff approximately 4 inches above the antecubital arm C. Use a cuff that is wide enough to cover the upper 2/3 of the clients arm D. Identify the Korotkoff sounds, and take a systolic reading at 10 mmHg after the first sound

C. Use a cuff that is wide enough to cover the upper 2/3 of the clients arm

A preoperative client expresses anxiety to the nurse about the upcoming surgery. Which of the following responses by the nurse is most likely to stimulate further discussion between the client and nurse? A. "I will be happy to explain the entire surgical procedure to you." B. "Let me tell you about the care you about the care you'll receive after surgery and the amount of pain you can anticipate." C. "If it's any help, everyone is nervous before surgery." D. "Can you share with me what you've been told about your surgery?"

D. "Can you share with me what you've been told about your surgery?"

When performing a surgical dressing change of client's abdominal dressing, a nurse notes an increase in the amount of drainage and separation of the incision line. The underlying tissue is visible to the nurse. The nurse should plan to do which of the following in the initial care of this wound? A. Leave the incision open to the air to dry the area B. Apply a povidone- iodine -soaked sterile dressing C. Irrigate the wound and apply a dry sterile dressing D. Apply a sterile dressing soaked with NS

D. Apply a sterile dressing soaked with NS

A client is scheduled for surgery in the morning. Preoperative orders have been written. What is most important to do before surgery? A. Remove all jewelries or tape wedding ring B. Verify that all lab work is complete C. Inform family or next of kin D. Have all consent forms signed

D. Have all consent forms signed

Which of the following items on a client's pre-surgery lab results would indicate a need to contact the surgeon? A. Platelet count of 250,000/cu.mm B. Total cholesterol of 325 mg/dl C. Blood urea nitrogen (BUN) 17 mg/dl D. Hemoglobin of 9.5 mg/dl

D. Hemoglobin of 9.5 mg/dl *Normal is 12-16 *Lower than 7 = blood transfusion

Which of the following factors ensure validity of informed written consent, except: A. The patient is of legal age with proper mental disposition B. If the patient is a child, secure consent from the parents or legal guardian C. The consent is secured before administration of preoperative meds D. If the patient is unable to write, the nurse signs the consent for the patient

D. If the patient is unable to write, the nurse signs the consent for the patient

A nurse is teaching a client about the use of an incentive spirometer in the postoperative period. The nurse should include which of the following pieces of information in discussions with the client? A. Keep a loose seal between the lips and the moutpiece B. Inhale as rapidly as possible C. After maximum inspiration, hold the breath for 10 seconds and exhale D. The best results are achieved when sitting at least halfway or fully upright

D. The best results are achieved when sitting at least halfway or fully upright

The patient had undergone a total hip replacement. He complains of pain in the operative site. Which of following is the appropriate initial nursing action? A. Administer the ordered analgesic B. Instruct the pt to do deep breathing and coughing exercises C. Assess the patients pain level and vital signs D. Change the patients position

C. Assess the patients pain level and vital signs

Which of the following drugs is administrated to minimize respiratory secretions preoperatively? A. Valium B. Phenergan C. Atropine sulfate D. Demerol

C. Atropine sulfate *dries secretions by blocking the para sympathetic nervous system

The diabetic patient who had undergone abdominal surgery experiences wound evisceration. Which of the following is the most appropriate immediate nursing action? A. Cover the wound with sterile gauze moistened with sterile NS B. Cover the wound with sterile dry gauze C. Cover the wound with water-soaked gauze D. Leave the wound uncovered and pull the skin edge together

A. Cover the wound with sterile gauze moistened with sterile NS

A client with a perforated gastric ulcer is scheduled for emergency surgery. The client cannot sign the operative consent form because he has been sedated with opioid analgesics. The nurse should take which of the following actions in the care of this client? A. Obtain a telephone consent from the family member witnessed by two persons B. Obtain a court order for the surgery C. Send the client without surgery without the consent form being signed D. Have the hospital chaplain sign the informed consent immediately

A. Obtain a telephone consent from the family member witnessed by two persons

A nurse is assigned to assist in caring for a client who recently returned from the operating room. On data collection, the nurse notes that the client's vital signs are as follows: blood pressure (BP) 102/62 mm Hg, pulse 91 beats per minute, RR 16 breaths per minute. Preoperative vitals signs were BP 124/78 mm Hg, pulse 74 BPM, RR 20 BPM. Which of the following actions should the nurse plan to take first? A. Recheck the vital signs in 15 minutes B. Call the surgeon immediately C. Cover the client with a warm blanket D. Shake gently to arouse

A. Recheck the vital signs in 15 minutes

In the recovery room, the postoperative client suddenly becomes cyanotic. What is the most appropriate nursing action? A. Start administration of oxygen through a nasal cannula B. Call for assistance C. Reposition the head and determine patency of airway D. Insert an oral airway and suction the nasopharynx

A. Start administration of oxygen through a nasal cannula

Which of the following postoperative patients is at risk for respiratory complications? A. The obese patient with long history of smoking who had undergone upper abdominal surgery B. The patent with normal pulmonary function who had undergone upper abdominal surgery C. An adolescent patient with diabetes mellitus who had undergone cholecystectomy D. A football player who had undergone knee replacement surgery

A. The obese patient with long history of smoking who had undergone upper abdominal surgery

Which of the following is experienced by the patient who is under general anesthesia? A. The patient is unconscious B. The patient is awake C. The patient experiences slight pain D. The patient experiences loss of sensation in the lower half of the body

A. The patient is unconscious

The nurse is caring for a first day postoperative surgical patient. Prioritize the patient's desired dietary progression. Arrange in sequence the dietary progression from 1 to 4: 1. Full liquid; 2. NPO; 3. Clear liquid; 4 Soft A. 1,2,3,4 B. 2,3,1,4 C. 2,1,4,3 D. 4,3,2,1

B. 2,3,1,4

A nurse is reviewing the physician's order sheet for the preoperative client, which states that the client must be on nothing (NPO) status after midnight. The nurse would clarify whether which of the following medications should be given to the client and not withheld? A. Conjugated estrogen (Premarin) B. Atenolol ( Tenormin) C. Cyclobenzaprine (Flexeril) D. Ferrous sulfate

B. Atenolol ( Tenormin)

A client is admitted to the surgical unit postoperatively with a wound drain (Hemovac) in place. Which of the following nursing actions would the nurse avoid in the care of the drain? A. Check the drain for patency B. Curl the drain tightly and tape it firmly to the body C. Maintain aseptic technique when emptying D. Observe for bright red bloody drainage

B. Curl the drain tightly and tape it firmly to the body

A nurse is preparing the client for transfer to the operating room (OR). The nurse should take which of the following actions in the care of this client at this time? A. Administer all of the daily medications B. Ensure that the client has voided C. Verify that the client has not eaten for the last 24 hours. D. Practice postoperative breathing exercises

B. Ensure that the client has voided

The patient had undergone spinal anesthesia for appendectomy. To prevent spinal headache, the nurse should place the patient in which of the following positions? A. Semi-Fowlers B. Flat on bed for 6-8 hours C. Prone position D. Modified Trendelenburg position

B. Flat on bed for 6-8 hours

To prevent complications of immobility, which activities would the nurse plan for the first postoperative day after a colon resection? A. Turn, cough, and deep breathe every 30 min around the clock B. Get the client out of bed and ambulate to a bedside chair C. Provide passive range of motion three times a day D. It is not necessary to worry about complications of immobility on the first postoperative day

B. Get the client out of bed and ambulate to a bedside chair

Which of the following is most dangerous complication during induction of spinal anesthesia? A. Cardiac Arrest B. Hypotension C. Hyperthermia D. Respiratory paralysis

B. Hypotension

A nurse is monitoring the status of the postoperative client. The nurse would become most concerned with which of the following signs, which could indicate an evolving complication? A. Blood pressure of 110/70 mm Hg with a pulse of 86 beats per minute B. Increasing restlessness C. Hypoactive bowel sounds in all four quadrants D. A negative Homans' sign

B. Increasing restlessness

The nurse will provide preoperative teaching on deep breathing, coughing, and turning exercises. When is the best time to provide the preoperative teachings? A. Before administration of preoperative medications B. The afternoon or evening prior to surgery C. Several days prior to surgery D. Upon admission of the client in the recovery room

B. The afternoon or evening prior to surgery

Which of the following assessment data is most important to determine when caring for a patient who has received spinal anesthesia? A. The time of return of motion and sensation to the patient's legs and toes B. The character of the patient's respirations C. The patient's level of consciousness D. The amount of would drainage

B. The character of the patient's respirations

The nurse is caring for a patient who had undergone exploratory laparotomy. Which of the following postoperative findings should the nurse report to the physician? A. The patient pushes out the oral airway with his tongue B. The patients urine output is 20mL/hr for the past 2 hr C. The patients vital signs are as follows: BP = 100/70 mmHG; PR = 95 bpm; RR = 9 minute; T = 36.8 C D. The patients wound drainage

B. The patients urine output is 20mL/hr for the past 2 hr

The nurse is transferring the patient from the postanesthesia to the surgical unit. Which of the following is the primary reason for gradual change of the position of the patient? A. To prevent muscle injury B. To prevent sudden drop of BP C. To prevent respiratory distress D. To promote comfort

B. To prevent sudden drop of BP

The nurse is admitting a patient to the operating room. Which of the following nursing actions should be given highest priority by the nurse? A. Assessing the patient's level of consciousness B. Checking the patient's vital signs C. Checking the patient's identification and correct operative permit D. Positioning and performing skin preparation to the patient

C. Checking the patient's identification and correct operative permit