N1 EXAM 5 - peri-op ATI

A nurse is admitting a client to the surgical unit from the PACU following a cholecystectomy. Which of the following assessments is the nurse's priority? a.) Bowel sounds b.) Surgical dressing c.) Temperature d.) Oxygen saturation

d.) Oxygen saturation Rationale: The priority action the nurse should take when using the airway, breathing, circulation approach to client care is to assess the client's oxygen saturation. The nurse should check the client's airway, listen to the client's breath sounds, and check the client's pulse oximetry to assess for respiratory depression.

A nurse is assessing a client who is 3 days postoperative following abdominal surgery and notes the absence of bowel sounds, abdominal distention, and the client passing no flatus. Which of the following conditions should the nurse suspect? a.) Ulcerative colitis b.) Cholecystitis c.) Paralytic ileus d.) Wound dehiscence

c.) Paralytic ileus Rationale: A paralytic ileus in a postoperative client is indicated by the absence of bowel sounds, abdominal distention, and the client passing no stool or flatus. It is often caused by bowel handling during surgery and opioid analgesic use.

A nurse is caring for a client who is postoperative following abdominal surgery. Which of the following findings should indicate to the nurse the client's peristalsis is returning? a.) Hypoactive bowel sounds in two quadrants b.) Request for a cup of tea and some toast c.) Passage of flatus d.) Abdominal distention

c.) Passage of flatus Rationale: Passing flatus and belching indicate the return of peristaltic activity.

A nurse is caring for a client who is 2 days postoperative following abdominal surgery and observes that the client's wound has eviscerated. After calling for help, Which of the following actions should the nurse take first? a.) Raise the head of the client's bed 15° to 20°. b.) Place the client supine with knees bent. c.) Assess the client for manifestations of shock. d.) Cover the area with a sterile dressing, moistened with 0.9% sodium chloride irrigation.

d.) Cover the area with a sterile dressing, moistened with 0.9% sodium chloride irrigation. Rationale: According to evidence-based practice, the nurse should first cover the area with a sterile dressing moistened with normal saline to protect the client's internal organs. The nurse should not attempt to reinsert the client's organs or viscera.

A nurse is assessing a client who will undergo abdominal surgery in 2 hr. The client reports being nervous about the surgery, last had food and fluids at 2330 the previous evening, and signed the surgical consent 2 days ago. Which of the following is an appropriate nursing action regarding these findings? a.) Call the anesthesiologist to sedate the client. b.) Notify the surgeon of the client's food and fluid consumption. c.) Witness the surgical consent. d.) Document the findings in the client's medical record.

d.) Document the findings in the client's medical record. Rationale: Whenever a nurse collects data from a client, documentation is essential. However, in this case, all these findings are expectations for a client who is preoperative, so there is no need for the nurse to take any action other than documenting.

A nurse is assessing a client who is postoperative following a vaginal hysterectomy. Which of the following findings is a manifestation of deep-vein thrombosis (DVT)? a.) Coolness of the leg or legs b.) Decreased pedal pulses c.) Pain in the ankle and foot d.) Unilateral leg edema

d.) Unilateral leg edema Rationale: Unilateral edema is a manifestation of DVT.

A nurse is teaching a client who is preoperative how to do deep-breathing exercises and cough effectively after surgery. Which of the following statements by the client indicates an understanding of the teaching? a.) "I'll splint my incision with a pillow to cough." b.) "I'll ask for pain medication after I do the exercises." c.) "I'll use the incentive spirometer when I can get out of bed." d.) "I'll breathe deeply and cough every 4 hours."

a.) "I'll splint my incision with a pillow to cough." Rationale: The client should use a pillow to splint the incision to reduce the pain and discomfort of coughing.

A nurse is planning care for a client who is 4 hr postoperative. Which of the following actions should the nurse include in the plan of care? (Select all that apply.) a.) Assist the client to cough and deep breathe every hour. b.) Administer PRN analgesics as needed. c.) Encourage the client to turn every 4 hr. d.) Give the client a back massage. e.) Teach the client relaxation techniques.

a.) Assist the client to cough and deep breathe every hour. b.) Administer PRN analgesics as needed. d.) Give the client a back massage. e.) Teach the client relaxation techniques.

A nurse is assessing a client who is postoperative and has anemia due to excess blood loss following surgery. Which of the following findings should the nurse expect? a.) Fatigue b.) Hypertension c.) Bradycardia d.) Diarrhea

a.) Fatigue Rationale: The nurse should identify that the client who has anemia due to blood loss following surgery will experience fatigue. This is due to the body's decreased ability carry oxygen to vital tissues and organs.

A nurse is planning care for a client who is postoperative and at risk for paralytic ileus. Which of the following interventions should the nurse plan to take to promote peristalsis? a.) Increase ambulation. b.) Decrease fluid intake. c.) Increase protein intake. d.) Offer the client the bedpan every 2 hr.

a.) Increase ambulation. Rationale: Decreased bowel motility is an adverse effect of anesthesia. The nurse should encourage the client to ambulate and increase fiber intake as prescribed to promote a return of bowel function and reduce the risk for paralytic ileus.

A nurse is teaching a newly licensed nurse about the risk factors for dehiscence for clients who have surgical incisions. Which of the following factors should the nurse include in the teaching? (Select all that apply.) a.) Poor nutritional state b.) Altered mental status c.) Obesity d.) Pain medication administration e.) Wound infection

a.) Poor nutritional state c.) Obesity e.) Wound infection

A nurse is reviewing the diagnostic test results of an older adult female client who is preoperative for a knee arthroplasty. The nurse should notify the surgeon of which of the following results? a.) WBC count 20,000/mm3 b.) Hematocrit 40% c.) Creatinine 0.9 mg/dL d.) Potassium 3.8 mEq/L

a.) WBC count 20,000/mm3 Rationale: This result exceeds the expected reference range for WBC of 5,000 to 10,000/mm3. The client's elevated WBC count indicates infection. The nurse should notify the surgeon.

A nurse is caring for a client who is 1-day postoperative following total hip arthroplasty. It is 0830 and the client is schedule for physical therapy (PT) at 0900. Which of the following interventions should the nurse take? a.) Encourage the client to use full weight bearing. b.) Identify the client's pain level and medicate if needed. c.) Teach the client which positions to avoid during PT. d.) Perform the client's morning care.

b.) Identify the client's pain level and medicate if needed. Rationale: The client should have adequate pain medication and pain relief 20 to 30 min before the PT session so he can work effectively with the therapist.

A nurse is providing preoperative teaching for a client who is scheduled for a gastrectomy. Which of the following information regarding prevention of postoperative complications should the nurse include in in the teaching? a.) Teach the client how to use the PCA pump. b.) Instruct the client about the use of a sequential compression device. c.) Discuss the visitation policy. d.) Review the pain scale.

b.) Instruct the client about the use of a sequential compression device. Rationale: The nurse should instruct the client about the use of a sequential compression device to prevent deep-vein thrombosis, a postoperative complication.

A nurse is caring for a client who is postoperative and is at risk for developing venous thromboembolism (VTE). The nurse should instruct the client to avoid which of the following unsafe actions? a.) Elevating her feet b.) Massaging her legs c.) Flexing her ankles d.) Ambulating soon after surgery

b.) Massaging her legs Rationale: Massaging an extremity that has a blood clot can cause it to detach and become an embolus. The use of sequential compression devices and anti-embolic stockings and therapeutic anticoagulation can help prevent this postoperative complication.

A nurse is assessing a client who has had staples removed from an abdominal wound postoperatively. The nurse notes separation of the wound edges with copious light-brown serous drainage. Which of the following actions should the nurse perform first? a.) Check the client's vital signs. b.) Assess the client's pain level. c.) Cover the wound with a moist, sterile gauze dressing. d.) Obtain a culture and sensitivity of the wound drainage.

c.) Cover the wound with a moist, sterile gauze dressing. Rationale: The nurse should obtain a culture of the wound drainage because the drainage indicates there may be infection present. It will be important to identify the specific organism causing the infection so that proper antibiotics may be prescribed. However, another action is the priority.

A nurse is caring for a client who is postoperative following vascular surgery. Which of the following signs should indicate to the nurse that the client has developed a thrombus? a.) Positive Kernig's sign b.) Positive Homan's sign c.) Dull, aching calf pain d.) Soft, pliable calf muscle

c.) Dull, aching calf pain Rationale: Dull, aching calf pain is a sign of deep-vein thrombosis. Other manifestations are edema, warmth, and redness in the calf.

A nurse is developing a plan of care for a client who is postoperative. Which of the following interventions should the nurse include in the plan to prevent pulmonary complications? a.) Perform range-of-motion exercises b.) Place suction equipment at the bedside c.) Encourage the use of an incentive spirometer d.) Administer an expectorant

c.) Encourage the use of an incentive spirometer Rationale: Incentive spirometry expands the lungs and promotes gas exchange after surgery which can help prevent pulmonary complications.

A nurse is assessing a client who is 48 hr postoperative following abdominal surgery. Which of the following findings should the nurse report to the provider? a.) Blood pressure 102/66 mm Hg b.) Straw-colored urine from an indwelling urinary catheter c.) Yellow-green drainage on the surgical incision d.) Respiratory rate 18/min

c.) Yellow-green drainage on the surgical incision Rationale: Thick yellow-green drainage is indicative of an infection and should be reported immediately.