Unit 5 perioperative

Which statement made by the nursing student indicates a need for further learning regarding postoperative instructions given to a patient undergoing abdominal surgery? Select all that apply. A. " I should instruct the patient to resume the regular diet" B. "I should instruct the patient to perform all activities normally" C. " I should provide guidelines for the patient about wound care" D. "I should allow the patient and family members to ask questions" E. " I should give an instruction sheet to the patient along with emergency contact information"

A B "I should instruct the patient to resume the regular diet" "I should instruct the patient to perform all activities normally"

Which of the following independent and dependent nursing interventions help prevent thrombophlebitis during the postoperative period? Select all that apply. A. Applying lower extremity sequential compression devices when in bed B. Wearing anti embolism stockings when out of bed C. Walking in the hall several times a day D. Using an incentive spirometer E. Coughing and deep breathing

A B C Applying lower extremity SCD when in bed Wearing anti embolism stockings when out of bed Walking in the hall several times a day

The speed of recovery depends on? Select all that apply. A. The type or extent of surgery B. Risk factors C. Pain management D. Postoperative E. The age of the patient

A B C D The type or event of the surgery B> Risk factors C. Pain management D. Postoperative

Which information would the nurse provide to the postoperative patient before discharge to home? Select all that apply. A. Wound care B. Medications C. Follow up tests D. Diet instructions E. Allowed activities

A B D E Wound care medications diet instructions allowed activities

A nurse is caring for a client recovering from abdominal surgery. Which nursing action is effective in facilitating ventilation? Select all that apply. A. Encouraging fluid intake B. Preventing abdominal distention C. Positioning side lying position D. Implementing passive range of motion E. Ensuring that an incentive spirometer is used every hour when awake

A B E Encouraging fluid intake Preventing abdominal distention Ensuring that an incentive spirometer is used every hour when awake

When providing postoperative care for a patient, which nursing action represents the use of clinical decision making? Select all that apply. A. Concluding that the patient's wound is infected after noting incisional drainage and an elevated patient temperature B. Reflecting on past experiences with patients who have had similar postoperative experiences C. Deciding to medicate the patient for pain before changing the incisional dressing D. Gathering assessment information to identify patient problems E. Discussing physical therapy progress with the patient

A C Concluding that the patient's wound is infected after noting incisional drainage and an elevated patient temperature Deciding to medicate the patient for pain before changing the incisional dressing

Which problem is considered a high priority for a patient? Select all that apply. A. Reduced oxygenation B. Compromised physical mobility C. Insufficient circulation D. Lack of knowledge about postoperative recovery E. Skin lesions

A C Reduced oxygenation Insufficient circulation

The nurse is teaching incisional care to a patient who had been discharged after abdominal surgery. Which instruction must the nurse include? Select all that apply. A. Use antibacterial soap B. take a shower 3 times a day C. Practice proper hand washing technique D. Use sterile technique

A C Use antibacterial soap practice proper hand washing technique

For which potential postoperative complication does the nurse assess when caring for a patient who is obese and underwent a surgical procedure yesterday? Select all that apply. A. Wound dehiscence B. Fluid and electrolyte imbalances C. Reduced cardiac function D. Reduced ventilatory function E. Increased enzyme activity

A C D Wound dehiscence reduced cardiac function reduced ventilatory function

A nurse is teaching a postoperative client the nutrients that are the best for supporting collagen production that promotes wound healing. Which food selected by the client indicates that the teaching was effective? Select all that apply. A. Yellow bell peppers B. Whole grain bread C. Cantaloupe D. Oranges E. Kiwi

A C D E Yellow bell peppers Canteloupe Oranges kiwi

When changing the patient's dressing, the nurse would assess the surgical site for which characteristics? Select all that apply. A. Signs of infection B. Type of tape closure C. Placement of drains D. Condition of dressing E. Approximation of edges

A C E Signs of infection Placement of drains Approximation of edges

Which procedure is considered a palliative surgical procedure? Select all that apply. A. Colostomy B. Appendectomy C. Repair of cleft palate D. Resection of nerve roots E. Debridement of necrotic tissue

A D E Colostomy Resection of nerve roots Debridement of necrotic tissue Palliative surgery reduces the intensity of the disease or its symptoms, but is not intended to be curative

Which information about general anesthesia would the nurse include in the preoperative teaching? Select all that apply. A. The entire body is anesthetized B. Only the affected body part is anesthetized C. The anesthesia is administered subcutaneously D. The anesthesia is administered intravenously or by inhalation E. Drug calculation is based on the patient's condition, weight, and duration of surgery

A D E The entire body is anesthetized The anesthesia is administered intravenously or by inhalation Drug calculation is based on the patient's condition, weight, and duration of surgery

For which type of surgery would a patient most likely be discharged by the nurse in the PACU? A. Cataract surgery B. Hip replacement C. Hysterectomy D. Breast reduction

A. Cataract surgery

Which is the most common dietary prescription the nurse can anticipate after a client who had abdominal surgery exhibits a return of intestinal peristalsis? A. Clear liquid B. Full liquids C. Low fiber D. Regular

A. Clear liquid

Which description illustrates the beginning of the postoperative period? A. Completion of the surgical procedure B. Completion of a wet to dry dressing changes C. Middle of surgical procedure D. Beginning of physical exam

A. Completion of the surgical procedure

A nurse is assessing a client who had spinal anesthesia. For which common response should the nurse assess the client? A. Headache B. Neuropathy C. Lower bak discomfort D. Increased blood pressure

A. Headache

A patient is scheduled for surgery on a fractured foot. The nurse demonstrates postoperative exercises and asks the patient to return demonstrate the exercises. Which purpose does this nursing action serve? A. Increases the patient's self efficacy B. Determines the patient's learning needs C. Assess the patient's motivation D. Improves the patient's attentiveness

A. Increases the patient's self efficacy When people believe they can achieve a particular behavior, they are more likely to perform the behavior consistently and correctly.

Which client having emergency surgery should the nurse anticipate to be at the greatest risk for postoperative mortality? A. Individual who has alcoholism B. Person who has epilepsy C. Middle aged adult D. Infant

A. Individual who has alcoholism

What is the priority during phase 3 recovery? A. Maintain patent airway B. Check vital signs hourly C. Have the patient pass flatus D. Have patient ambulating

A. Maintain patent airway

Which factor places a client at the greatest risk for postoperative nausea and vomiting after receiving general anesthesia? A. Obesity B. Inactivity C. Hypervolemia D. Unconsciousness

A. Obesity

A postoperative patient refuses to eat and complains of a loss of appetite. Which intervention would the nurse perform to improve the patient's appetite? A. Offer smaller and more frequent meals B. Ensure that the patient eats alone C. Provide a low fiber diet D. Instruct the patient to skip breakfast

A. Offer smaller and more frequent meals

A nurse is assessing a postoperative client. Which client response identified by the nurse indicates altered renal perfusion? A. Oliguria B. Cachexia C. Yellow sclera D. Suprapubic distention

A. Oliguria

Which serious complication can result form retained pulmonary secretions in a postoperative patient? A. Pneumonia B. Hypoxemia C. Fluid imbalance D. Pulmonary embolism

A. Pneumonia

A patient arrives at an outpatient surgery center before a tonsillectomy. Which action is the priority during this phase of surgery? A. Preoperative assessment B. Intraoperative medication C. Intraoperative assessment D. Postoperative instructions

A. Preoperative assessment

A patient diagnosed with appendicitis is advised to have surgery. After collection the patient's medical history, the nurse anticipates that the surgery will be postponed. Which option may necessitate surgical postponement? A. The patient takes aspirin for cardiovascular disease B. The patient takes gentamicin for infection C. The patient takes neomycin for infection D. The patient is on prednisone therapy

A. The patient takes aspirin for cardiovascular disease. Aspirin is an anticoagulant that increases the risk of bleeding during surgery.

Which action is appropriate for a circulating nurse to perform during a surgical procedure? Select all that apply. A. Supplying surgical instruments B. managing patient positioning C. Counting the surgical instruments D. Preparing the skin with antimicrobials E. Cutting and handling patient surgical tissue

B C D Managing patient positioning Counting the surgical instruments Preparing the skin with antimicrobials

Which patient assessment finding is documented as objective data when the nurse is caring for a 50 year old patient 2 days postoperatively after a gallbladder removal who appears to be in pain? Select all that apply. A. Stiffness across the lower back B. Minimal oozing at the incision site C. Stinging pain at the incision site D. Fever of 104.0 F E. Sharp pain on movement

B D Minimal oozing at the incision site Fever 104.0 F

Which nursing action would the nurse implement to prevent pneumonia in a postoperative patient with atelectasis? Select all that apply. A. Suctioning the airway frequently B. Encouraging frequent coughing C. Administering expectorant medications D. Promoting the use of an incentive spirometer E. Placing the patient in the fowler or semi fowler position

B D E Encouraging frequent coughing Promoting the use of an incentive spirometer placing the patient in the fowler or semi fowler position

Which postoperative patient would the nurse see first? A. A 75 year old patient after hip replacement surgery who is complaining of moderate pain in the surgical site, with a heart rate of 92 beats per minute B. A 57 year old patient with a history of OSA who underwent hip replacement 6 hours earlier and who is receiving IV patient-controlled analgesia; the pulse-ox has been going off and reads 85% C. A 36 year old patient after bladder neck suspension who is 30 minutes late to receive her postoperative dose of antibiotics D. A 48 year old patient after total knee replacement who needs help repositioning in bed

B. A 57 year old patient with a history of OSA who underwent hip replacement 6 hours earlier and who is receiving IV patient-controlled analgesia; the pulse-ox has been going off and reads 85%

A nurse is evaluating the effectiveness of nursing interventions for meeting the nutrient needs of clients during the first 2 days after abdominal surgery. Which outcome is most important? A. Nausea and vomiting have not occurred B. Fluid and electrolytes are balanced C. Wound healing is progressing D. Oral intake is reestablished

B. Fluid and electrolytes are balanced

The nurse notices a patient who underwent a surgical procedure develops a decrease in blood pressure; rapid, thready pulse; cool, clammy, pale skin; tachypnea; and restlessness. Which complication does the nurse suspect? A. Depression B. hemorrhage C. Electrolyte imbalance D. Obstructive sleep apnea

B. Hemorrhage

When a patient leaves the OR, what phase of recovery are they in? A. Recovery in ambulatory surgery B. Immediate recovery C. Anesthesia recovery D. Convalescence

B. Immediate recovery

Unless contraindicated by the surgical procedure, which position is preferred for the unconscious patient immediately post op? A. Supine B. Lateral C. Semi fowlers D. High fowlers

B. Lateral

When planning care for a patient who experiences impaired oxygenation due to postoperative atelectasis, the nurse prioritizes which intervention to resolve the condition? A. Reduce oxygen to 2 L/min via nasal cannula B. Perform incentive spirometry every hour C. Apply continuous positive airway pressure overnight D. Identify ways in which the patient cn perform nebulizer treatments independently

B. Perform incentive spirometry every hour

Which action would the nurse in the PACU perform of a patient is suspected of having an airway obstruction? A. Assessing for the gag reflex B. Performing the head tilt/ Chin lift maneuver C. Checking oxygen saturation D. Determining LOC

B. Performing the head tilt/chin lift maneuver. Performing this moves the tongue to prevent airway obstruction

A client has a tonsillectomy and is on a soft diet. Which of the following should the nurse encourage the client to have during the first 24 hours after surgery? Select all that apply. A. Warm pudding B. Milkshakes C. Apple juice D. Ice pops E. Gelatin

C D E Apple juice Ice pops Gelatin

Which assessment findings must be present before a patient is discharged from the PACU? Select all that apply. A. Freedom of pain B. Absence of nausea C. Controlled wound drainage D. Normal temperature E. Vital signs at baseline

C D E Controlled wound drainage Normal temperature Vital signs at baseline

A patient tells the nurse, "I am really nervous about my upcoming surgery." Which response by the nurse is most appropriate to encourage further discussion between the patient and the nurse? A. "Everyone is nervous before surgery" B. "I can explain the entire surgical procedure to you" C. "Can you tell me what has been explained to you about your surgery?" D. "Let me tell you about the care that you will receive after surgery and the amount of pain that you can anticipate"

C. "Can you tell me what has been explained to you about your surgery?"

When would the nurse teach breathing exercises and coughing techniques to a patient who is scheduled for coronary artery bypass graft surgery? A. During discharge B. After the surgery C. Before the surgery D. At the next follow up visit

C. Before the surgery. The patient needs to start doing these exercises immediately after surgery.

What is the primary way in which the nurse can lower a patient's risk for post surgical complications? A. Adequately prepare the patient for discharge from the agency B. Provide continuity of nursing care throughout the patient's stay at the agency C. Identify deviations from normal that may interfere with the recovery process D. Evaluate the patient's emotional reaction to the surgical process

C. Identify deviations from normal that may interfere with the recovery process

Which action by a student nurse needs correction regarding preoperative care? A. Asking about the patient's family history B. Explaining the surgical procedure to the patient C. Instructing the patient to avoid foods rich in carbs and immune-enhancing vitamins 1 week before surgery. D. Instructing the patient to avoid eating or drinking anything 8 to 10 hours before surgery

C. Instructing the patient to avoid foods rich in carbs and immune-enhancing vitamins 1 week before surgery

A nurse is caring for a client who had an abdominal hysterectomy. Which intervention best prevents postoperative thrombophlebitis? A. Utilization of compression stockings at night B. Deep breathing and coughing exercises daily C. Leg exercises 10 per hour when awake D. Elevation of the legs on 2 pillows

C. Leg exercises 10 times per hour when awake

A client's perineal area must be examined by the primary HCP prior to surgery. In which position should the nurse place the client for this physical assessment? A. Sims B. Supine C. Lithotomy D. Trendelenburg

C. Lithotomy

Four days after abdominal surgery, while being transferred from a bed to a chair, a client says to a nurse, "My incision feels funny all of a sudden." Which should the nurse do first? A. Take the vital signs B. Apply an abdominal binder immediately C. Place the client in the low fowlers position D. Encourage slow deep breathing by the client

C. Place the client in low fowler position

A nurse is considering the commonalities and differences of equipment used for gastric decompression. Which is the major advantage to using a double lumen tube? A. Minimizes the risk of bowel obstruction B. Ensures drainage of the intestines C. Prevents gastric mucous damage D. Promotes gastric rest

C. Prevents gastric mucous damage

A nurse is to position a client for surgery in the PACU. Which factor is most important for the nurse to consider? A. Allow for skeletal deformities B. Prevent pressure on bony prominences C. Provide for adequate thoracic expansion D. Avoid stretching of neuromuscular tissue

C. Provide for adequate thoracic expansion

You are caring for a postoperative patient on the medical surgical unit. During each patient assessment, you evaluate your patient for infection. Which sign or symptom would be most indicative of infection? A. Presence of an indwelling catheter B. Oral temperature C. Red, warm, tender incision D. White blood cell count of 8,000

C. Red, warm, tender incision

A patient scheduled for surgery is unable to sign the operative consent form because of sedation from opioid analgesics. Which action does the nurse take? A. Contact the legal department to consult on how to proceed B. Obtain a telephone consent from a family member, following agency policy. C. Refer to the medical record to determine if the patient has a medical power of attorney on file. D. Send the patient to surgery without the consent form being signed with a notation as to why consent was not obtained.

C. Refer to the medical record to determine if the patient has a medical power of attorney on file

Which action would the nurse implement before allowing the patient out of bed for the first time? A. Assessing the patient's blood pressure B. Providing a walker or cane for stability C. Requesting the patient to call assistance D. Advising the patient to move to the chair for a few minutes before standing

C. Requesting the patient to call for assistance.

An obese client has abdominal surgery for removal of the gallbladder. Which should the nurse be most concerned about if exhibited by the client? A. Constipation B. Urinary retention C. Shallow breathing D. Inability to provide self care

C. Shallow breathing

Which is the next most important assessment made by the nurse after insuring a postoperative client has a patent airway? A. Condition of drains B. Level of consciousness C. Stability of the vital signs D. Location of the surgical dressing

C. Stability of the vital signs

Which assessment is a priority in the PACU during the first few minutes after a patient is admitted for an emergency appendectomy? A. Pain assessment B. History and physical C. Systems assessment D. Medication assessment

C. Systems assessment

A client spikes a fever during the first postoperative day after major abdominal surgery. The nurse suspects that the fever indicates an infection. Which site does the nurse conclude most likely is the source of the infection? A. Intestines B. Bladder C. Wound D. Lungs

D. Lungs

A patient is having an elective cosmetic surgery performed on her face. The surgeon will keep her at the surgery center for 24 hours after surgery. What is the nurse's postoperative priority for this patient? A. Manage patient pain B. Control the bleeding C. Maintain fluid balance D. Manage oxygenation status

D. Manage oxygenation status

A patient returns to the postoperative unit after surgery for right shoulder rotator cuff repair. The LPN reports difficulty palpating the heart rate from the patient's right radial pulse. Which action would the nurse take? A. Assess the patient's apical pulse to obtain the heart rate. B. Obtain the heart rate from the left radial site C. Obtain the heart rate using the oximeter probe D. Perform a complete assessment of all pulses

D. Perform a complete assessment of all pulses

A client is admitted to the PACU. Which nursing action is most important during the client's stay in this unit? A. Monitoring urinary output B. Assessing LOC C. Ensuring latency of drainage tubes D. Suctioning mucous from respiratory passages

D. Suctioning mucus from respiratory passages

When would the nurse administer a medication scheduled "on call" for a surgery? A. When the surgeon orders it B. While the surgery is going on C. Whenever the patient requires D. When the surgical staff is coming to get the patient

D. When the surgical staff is coming to get the patient. The nurse should be aware of the right time of. medication administration. A Medication schedules on call for a surgery indicates that the medication should be administered when the surgical staff is coming to get the patient for surgery.

Which instruction is appropriate for a preoperative patient? A. "Take over the counter non steroidal antiimflammatory drugs the night before surgery." B. "Avoid fried food beginning 3 hours before surgery." C. "Begin fasting 2 hours before surgery." D. "Avoid any fluid intake for at least 2 hours before surgery."

D. "Avoid any fluid intake for at least two hours before surgery." The stress of surgery causes fluid and electrolyte imbalance, and sedation can cause complications; therefore, the patient must refrain from drinking any liquids for 2 or more hours before the surgery.

Which statement made by a student nurse indicates a need for further discussion regarding the care of a post surgical older adult? A. "Older adults are at risk of postoperative delirium B. " Medical complications are more common in older adults" C. "Unexpected drug responses are often observed in older adults" D. "Older adults can tolerate long surgeries because of their increased physiologic reserves"

D. "Older adults can tolerate long surgeries because of their increased physiologic reserves" Older adults cannot as easily tolerate long complicated surgeries because their physiologic reserves are decreased.

Which action by a patient on the day of surgery indicates a need for further learning? A. Removing all prostheses B. Wearing a hospital gown for surgery C. Removing makeup and other accessories D. Avoiding emptying the bladder before the surgery

D. Avoiding emptying the bladder before the surgery

Which action helps prevent postoperative atelectasis? A. Pursed lip exhalation B. Using the chest and shoulders while inhaling C. Repeating breathing exercises three to five times D. Deep breathing exercises every 1 to 2 hours

D. Deep breathing exercises every 1 to 2 hours

Which case of recovery should postoperative teaching with patients and family members begin? A. Phase 1 B. Phase 2 C. Phase 3 D. Anytime before discharge

B. Phase 2

Which intervention prevents many postoperative complications including constipation and deep vein thrombophlebitis? A. Soft diet B. Oral laxatives C. IV fluid therapy D. Early ambulation

D. Early ambulation

Which need would the nurse identify in all postoperative patients? A. Management of nausea B. Self care education C. Medication for constipation D. Anxiety management techniques

B. Self care education. All postoperative patients need self care education before discharge

Which assessment finding would alert the nurse to the potential for wound dehiscence? A Purulent drainage B. Granulation tissue C. Reddened incisional site D. Edge nonapproximation

D. Edge non-approximation

What is the first phase of postoperative care? A. Recovery in ambulatory B. Immediate recovery C. Patient teaching D. Patient comfort

B. Immediate recovery

Which team member would the nurse collaborate with about a postoperative patients with atelectasis? A. Surgeon B. Anesthesia provider C. Speech therapist D. Respiratory therapist

D. Respiratory therapist

A client has a right abdominal incision. Which should the nurse teach the client to do when getting out of bed? Select all that apply. A. Exit from he left side of the bed B. Ask the nurse to apply an abdominal binder C. Hold a pillow against the abdomen with both hands D. Use the left arm to push up to a sitting position on the side of the bed E. Sit on the side of the bed for a few minutes before moving to a standing position

A D E Exit from the left side of the bed Use the left arm to push up to a sitting position on the side of the bed Sit on the side of the bed for a few minutes before moving to a standing position

Which factor may predispose a patient to unintended hypothermia during surgery? A. Age B. Obesity C. Smoking D. Nutrition

A. Age

Why would the nurse include the family members or significant others in postoperative teaching? A. They can coach and encourage the patient after surgery B. They can teach the patient what to do after the surgery C. It relieves anxiety over their family member D. It frees up the recovery nurse for other tasks

A. They can coach and encourage the patient after surgery

On the second postoperative day after an above the knee amputation, the client's elastic dressing accidentally comes off. Which should the nurse do first? A. wrap the residual limb with an elastic compression bandage B. Apply a saline dressing to the residual limb C. Notify the primary HCP D. Place two pillows under the limb

A. Wrap the residual limb with an elastic compression bandage

A nurse is performing preoperative teaching a week before surgery. The client is taking 650 mg of aspirin twice a day for arthritis. Which instruction should the nurse expect the surgeon to have the nurse include in the preoperative teaching? A. Continue to take the aspirin indefinitely B. Stop taking the aspirin 5 days before surgery C. withheld the dose of aspirin on the morning of the surgery D. Reduce the dose of aspirin to 81 mg a day until after the surgery

B. Stop taking the aspirin 5 days before surgery.

When should the nurse initiate planned interventions regarding a client's preoperative management? A. When the consent form is signed B. When the decision for surgery is made C. When the client is admitted for surgery D. When the cleat is transferred to the operating room

B. When the decision for surgery is made

When caring for a patient postoperatively, which nursing intervention prevents atelectasis? A. Postural drainage B. Chest percussion C. Incentive spirometry D. Suctioning

C. Incentive spirometry

Which statement describes the cause of respiratory depression during surgery? A. The patient was taking herbal supplements B. The patient was prescribed prednisone therapy C. The patient received tobramycin 2 weeks before the surgery D. The patient was on warfarin therapy 48 hours before the surgery

C. The patient received tobramycin 2 weeks before the surgery

A patient is admitted to phase one recovery, who is responsible for explaining the patient's condition to family members? A> The nurse B. The patient themselves C. The surgeon D. The rounding physician

C. The surgeon

While caring for a postoperative patient, the nurse observes and palpates the calves for redness, warmth, and tenderness. Which statement describes the rationale behind this nursing action? A. To determine mobility restrictions B. To assess for the risk of respiratory complications C. To assess for phlebitis and thrombosis D. To determine the patient's ability to learn exercises

C. To assess for phlebitis and thrombosis

A patient is scheduled for surgery and has been fasting the whole night. The surgery was postponed for 3 hours, and the patient feels hungry. Which action by the nurse is appropriate? A. Give solid food to the patient B. Give fried food to the patient C. Give fatty food to the patient D. Give clear liquids to the patient

D. Give clear liquid to the patient. Clear liquids can be metabolized within 2 hours and may not interfere with the GI function or the anesthesia process.

A patient fasting for surgery forgot to take the prescribed antibiotic. Which nursing action is appropriate in this situation? A. Replace the medicine B. Avoid giving the antibiotic C. Give the antibiotic after surgery D. Give the antibiotic with a sip of water

D. Give the antibiotic with a sip of water.

The nurse is assessing a postoperative patient's GI system. What is the best indicator that peristaltic activity has resumed? A. Patient is eating B. Patient is urinating C. Profuse sweating D. Passing of flatus or stool

D. Passing of flatus or stool

You are the recovery room nurse who is admitting a patient from the OR. What is the first assessment you would make on a newly admitted patient? A. Heart rate B. Nail perfusion C. Core temperature D. Patency of the airway

D. Patency of the airway

A nurse is caring for a client who had abdominal surgery. Which type of incisional drainage should the nurse expect 4 hours after surgery? A. Serous wound drainage B. Purulent wound drainage C. Sanguineous wound drainage D. Serosanguineous wound drainage

D. Serosanguineous wound drainage