Preop

62-63 OBJ: 1 (theory) TOP: Robotic Surgery KEY: Nursing Process Step: Implementation MSC: NCLEX: Safe, Effective Care Environment: Coordinated Care 21. The nurse is aware that the older adult is a greater surgical risk because the older adult has: (Select all that apply.) a. fewer physiologic reserves. b. more probability of a chronic illness. c. more vulnerability to fluid loss. d. less tolerance for pain. e. less psychological stamina.

A, B, C The older adult does have less physiologic reserves, more probability for a chronic illness, and more vulnerability to fluid loss. There is no indication that the older adult has less tolerance for pain or less psychological stamina. DIF: Cognitive Level: Comprehension

70-72 OBJ: 4 (theory) TOP: Preoperative Teaching KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance 24. The nurse instructs the presurgical patient that hypothermia may occur during surgery due to: (Select all that apply.) a. warm atmosphere of the operating room. b. infusion of cool IV fluids. c. inhalation of cool anesthetic gases. d. exposure of body surfaces. e. lowered metabolism.

B, C, D, E The operating room is kept cool to inhibit growth of organisms. All other options listed are potential causes of hypothermia in the operating room. DIF: Cognitive Level: Application

327 TOP: Nursing Process: Implementation MSC: NCLEX: Safe and Effective Care Environment 16. A patient has received atropine before surgery and complains of dry mouth. Which action by the nurse is best? a. Check for skin tenting. b. Notify the health care provider. c. Ask the patient about any dizziness. d. Tell the patient dry mouth is an expected side effect.

D Anticholinergic medications decrease oral secretions, so the patient is taught that a dry mouth is an expected side effect. The dry mouth is not a symptom of dehydration in this case. Therefore there is no immediate need to check for skin tenting. The health care provider does not need to be notified about an expected side effect. Weakness, forgetfulness, and dizziness are side effects associated with other preoperative medications such as opioids and benzodiazepines. DIF: Cognitive Level: Apply (application)

64 OBJ: 1 (theory) TOP: Autologous Transfusion KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity: Reduction of Risk Potential 28. The _____________ functions within the sterile area of the operating room and maintains sterile technique.

scrub nurse scrub person The scrub nurse is a licensed nurse or surgery technician who functions in the sterile area of the operating room and maintains sterility throughout the operative procedure. DIF: Cognitive Level: Knowledge

329 TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity 17. Which statement by a patient scheduled for surgery is most important to report to the health care provider? a. I had a heart valve replacement last year. b. I had bacterial pneumonia 3 months ago. c. I have knee pain whenever I walk or jog. d. I have a strong family history of breast cancer.

A A patient with a history of valve replacement is at risk for endocarditis associated with invasive procedures and may need antibiotic prophylaxis. A current respiratory infection may affect whether the patient should have surgery, but a history of pneumonia is not a reason to postpone surgery. The patients knee pain is the likely reason for the surgery. A family history of breast cancer does not have any implications for the current surgery. DIF: Cognitive Level: Apply (application)

318-319 TOP: Nursing Process: Assessment MSC: NCLEX: Psychosocial Integrity 2. A patient arrives at the ambulatory surgery center for a scheduled laparoscopy procedure in outpatient surgery. Which information is of most concern to the nurse? a. The patient is planning to drive home after surgery. b. The patient had a sip of water 4 hours before arriving. c. The patients insurance does not cover outpatient surgery. d. The patient has not had surgery using general anesthesia before.

A After outpatient surgery, the patient should not drive home and will need assistance with transportation and home care. The patients experience with surgery is assessed, but it does not have as much application to the patients physiologic safety. The patients insurance coverage is important to establish, but this is not usually the nurses role or a priority in nursing care. Having clear liquids a few hours before surgery does not usually increase risk for aspiration. DIF: Cognitive Level: Apply (application)

64 | Elder Care Points OBJ: 2 (theory) TOP: Postoperative Complications KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity: Reduction of Risk Potential 19. The LPN/LVN is in the patients room while the charge nurse is obtaining the patients signature on the surgical consent form. The patient states, I didnt really understand what my surgeon explained, but I trust him completely. Which response by the charge nurse is correct? a. I need to contact your surgeon so your questions can be answered. b. I can answer any questions that you might have regarding your surgery. c. As long as you are comfortable, then you may sign the consent form. d. Maybe we should call your surgeon to be sure it is okay to sign the consent.

A An informed consent means that the surgeon has supplied information regarding the procedure itself, as well as the risks and benefits, and that the patient understands this information. The nurses responsibility is witnessing the signing of the form and ensuring the patient understands what the surgeon has discussed, not providing information if the patient has no understanding of the procedure. DIF: Cognitive Level: Application

N/A TOP: Client Needs Category: Safe and Effective Care Environment (Management of CareInformed Consent) MSC: Integrated Process: Communication and Documentation 2. The nurse is caring for an older adult client with a history of chronic lung disease who will be undergoing surgery the following day. When postoperative care is planned, which potential problem is the highest priority for this client? a. Maintaining oxygenation b. Tolerating activity c. Anxiety and fear d. Hypovolemia

A Breathing problems take priority over the other problems listed. This would be compounded in a client with any chronic lung disorder. DIF: Cognitive Level: Application/Applying or higher

N/A TOP: Client Needs Category: Physiological Integrity (Reduction of Risk PotentialPotential for Complications From Surgical Procedures and Health Alterations) MSC: Integrated Process: Nursing Process (Implementation) 16. Which action is most appropriate during a preoperative chart review? a. Ensure that the consent form is signed, dated, and witnessed. b. Call the surgeon if the client has any food allergies. c. Make sure all marks are washed off the surgical site. d. Make sure the client understands the procedure.

A During the preoperative chart review, the nurse should make sure that the consent form is signed, dated, and witnessed. The nurse does not have to call the surgeon for food allergies, nor should the marks be washed off the surgical site. The client should be taught about the procedure before the preoperative chart review. DIF: Cognitive Level: Comprehension/Understanding

N/A TOP: Client Needs Category: Physiological Integrity (Reduction of Risk PotentialLaboratory Values) MSC: Integrated Process: Nursing Process (Analysis) 8. A client is brought to the emergency department (ED) after a motorcycle accident. The client has suffered a ruptured spleen. What is the immediate priority? a. Emergent surgery to control bleeding b. Aggressive pain control c. Calling the family members d. Assessment of neurologic status

A Emergent surgery is indicated when the client may die without immediate intervention. Other interventions are appropriate but do not have the priority because controlling hemorrhage via surgery is the priority. DIF: Cognitive Level: Application/Applying or higher

65-67 | Table 4-2 OBJ: 2 (theory) TOP: Perioperative Management KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Reduction of Risk Potential 3. The presurgical patient asks why it is that her height and weight are recorded. The nurse replies that the information is essential for: a. calculating anesthesia dose. b. predicting blood loss. c. assessing respiratory volume. d. anticipating fluid needs.

A Height and weight are used to calculate anesthesia dosages. DIF: Cognitive Level: Comprehension

76 | Box 4-4 OBJ: 3 (theory) TOP: Immediate Preoperative Care KEY: Nursing Process Step: Implementation MSC: NCLEX: Safe, Effective Care Environment: Coordinated Care 14. The nurse clarifies that the difference between regional anesthesia and procedural sedation anesthesia is that procedural sedation anesthesia uses: a. IV sedation and regional anesthesia. b. general anesthesia and IV sedation. c. alternative medicine herbs and regional anesthesia. d. IV sedation and local anesthesia.

A Procedural sedation anesthesia uses both IV sedation and regional anesthesia. DIF: Cognitive Level: Comprehension

64 OBJ: 3 (theory) TOP: Presurgical Assessment KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Reduction of Risk Potential 4. The nurse is reviewing the presurgical patients lab reports and notes an elevated aspartate aminotransferase (AST) and bilirubin. The nurse is most concerned that this patient is at risk for: a. excessive bleeding during or after surgery. b. an increased serum albumin level. c. postsurgical respiratory infection. d. delayed wound healing.

A The AST and bilirubin are liver studies. Elevated levels may indicate a dysfunctional liver. The liver is directly involved with clotting factors; therefore, this patient would be at risk for excessive bleeding. The serum albumin level would most likely be decreased if the liver is not functioning properly. Postsurgical wound infection and delayed wound healing risks are not directly related to liver function. DIF: Cognitive Level: Analysis

320 TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity 7. The surgical unit nurse has just received a patient with a history of smoking from the postanesthesia care unit. Which action is most important at this time? a. Auscultate for adventitious breath sounds. b. Obtain the patients blood pressure and temperature. c. Remind the patient about harmful effects of smoking. d. Ask the health care provider about prescribing a nicotine patch.

A The nurse should first ensure a patent airway and check for breathing and circulation (airway, breathing, and circulation [ABCs]). Circulation and temperature can be assessed after a patent airway and breathing have been established. The immediate postoperative period is not the optimal time for patient teaching about the harmful effects of surgery. Requesting a nicotine patch may be appropriate, but is not a priority at this time. DIF: Cognitive Level: Apply (application)

N/A TOP: Client Needs Category: Safe and Effective Care Environment (Management of CareInformed Consent) MSC: Integrated Process: Communication and Documentation 20. Four clients are scheduled for surgery. Which client does the nurse determine is at highest risk for postsurgical complications? a. 89-year-old scheduled for a knee replacement b. 40-year-old requiring gallbladder surgery c. 19-year-old requiring a laparoscopy d. 10-year-old admitted for a tonsillectomy

A The older client is at highest risk for postoperative complications. Older adults often have multiple medical conditions, take several medications, are slightly dehydrated, and may have cognitive or physical impairments that potentially could hinder their recovery from an operation. DIF: Cognitive Level: Application/Applying or higher

216 KEY: Preoperative nursing| safety MSC: Integrated Process: Nursing Process: Implementation NOT: Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control 1. A patient scheduled for an elective hysterectomy tells the nurse, I am afraid that I will die in surgery like my mother did! Which response by the nurse is most appropriate? a. Tell me more about what happened to your mother. b. You will receive medications to reduce your anxiety. c. You should talk to the doctor again about the surgery. d. Surgical techniques have improved a lot in recent years.

A The patients statement may indicate an unusually high anxiety level or a family history of problems such as malignant hyperthermia, which will require precautions during surgery. The other statements may also address the patients concerns, but further assessment is needed first. DIF: Cognitive Level: Apply (application)

N/A TOP: Client Needs Category: Physiological Integrity (Pharmacological and Parenteral TherapiesAdverse Effects/Contraindications/Side Effects/Interactions) MSC: Integrated Process: Nursing Process (Intervention) 7. The nurse reviews a clients laboratory results before surgery and notes a fasting blood glucose of 120 mg/dL, a prothrombin time (PT) of 25 seconds, and potassium (K+) of 3.8 mEq/L. Which action by the nurse is best? a. Ask the surgeon for additional laboratory studies. b. Administer a potassium supplement of 20 mEq. c. Increase the IV infusion of D5W to 100 mL/hr. d. Record laboratory results on the preoperative assessment.

A The prothrombin time is elevated, which could lead to bleeding during or after surgery. The surgeon and the anesthesiologist should be notified of this laboratory test result right away, and additional coagulation studies will be needed. The potassium is within normal limits. The blood glucose level is elevated but not critically so. The surgeon should be notified of all laboratory work, and the client may need an IV solution without glucose. The results should be recorded, but the surgery will likely be cancelled owing to the coagulation problem, which is the priority concern with this client. DIF: Cognitive Level: Application/Applying or higher

N/A TOP: Client Needs Category: Physiological Integrity (Reduction of Risk PotentialPotential for Complications From Surgical Procedures and Health Alterations) MSC: Integrated Process: Nursing Process (Implementation) 13. A client will be undergoing palliative surgery. The clients daughter asks what this means. What is the nurses best response? a. The surgery will relieve the symptoms but will not cure your father. b. There are fewer risks with this type of surgery. c. There is no guarantee of the outcome of the surgery. d. The surgery must be performed immediately to save your fathers life.

A The purpose of palliative surgery is to improve the clients quality of life by reducing or eliminating distressing symptoms. It does not cure a health problem and often does not prolong life. DIF: Cognitive Level: Comprehension/Understanding

321 OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment MSC: NCLEX: Safe and Effective Care Environment 5. A patient who is scheduled for a therapeutic abortion tells the nurse, Having an abortion is not right. Which functional health pattern should the nurse further assess? a. Value-belief b. Cognitive-perceptual c. Sexuality-reproductive d. Coping-stress tolerance

A The value-belief pattern includes information about conflicts between a patients values and proposed medical care. In the cognitive-perceptual pattern, the nurse will ask questions about pain and sensory intactness. The sexuality-reproductive pattern includes data about the impact of the surgery on the patients sexuality. The coping-stress tolerance pattern assessment will elicit information about how the patient feels about the surgery. DIF: Cognitive Level: Understand (comprehension)

221 KEY: Preoperative nursing| discharge planning| older adult MSC: Integrated Process: Communication and Documentation NOT: Client Needs Category: Safe and Effective Care Environment: Management of Care 4. A clinic nurse is teaching a client prior to surgery. The client does not seem to comprehend the teaching, forgets a lot of what is said, and asks the same questions again and again. What action by the nurse is best? a. Assess the client for anxiety. b. Break the information into smaller bits. c. Give the client written information. d. Review the information again.

A Anxiety can interfere with learning and cooperation. The nurse should assess the client for anxiety. The other actions are appropriate too, and can be included in the teaching plan, but effective teaching cannot occur if the client is highly anxious. DIF: Applying/Application

234 KEY: Preoperative nursing| sedation| safety MSC: Integrated Process: Nursing Process: Implementation NOT: Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control 13. A student is caring for clients in the preoperative area. The nurse contacts the surgeon about a client whose heart rate is 120 beats/min. After consulting with the surgeon, the nurse administers a beta blocker to the client. The student asks why this was needed. What response by the nurse is best? a. A rapid heart rate requires more effort by the heart. b. Anesthesia has bad effects if the client is tachycardic. c. The client may have an undiagnosed heart condition. d. When the heart rate goes up, the blood pressure does too.

A Tachycardia increases the workload of the heart and requires more oxygen delivery to the myocardial tissues. This added strain is not needed on top of the physical and emotional stress of surgery. The other statements are not accurate. DIF: Applying/Application

219 KEY: Preoperative nursing| tachycardia| beta blocker MSC: Integrated Process: Teaching/Learning NOT: Client Needs Category: Physiological Integrity: Physiological Adaptation 14. The perioperative nurse manager and the postoperative unit manager are concerned about the increasing number of surgical infections in their hospital. What action by the managers is best? a. Audit charts to see if the Surgical Care Improvement Project (SCIP) outcomes were met. b. Encourage staff on both units to provide peer pressure to adhere to hand hygiene policy. c. Hold educational meetings with the nursing and surgical staff on infection prevention. d. Monitor staff on both units for consistent adherence to established hand hygiene practices.

A The SCIP project contains core measures that are mandatory for all surgical clients and focuses on preventing infection, serious cardiac events, and venous thromboembolism. The managers should start by reviewing charts to see if the guidelines of this project were implemented. The other actions may be necessary too, but first the managers need to assess the situation. DIF: Applying/Application

222 KEY: Preoperative nursing| malnutrition| nutrition MSC: Integrated Process: Communication and Documentation NOT: Client Needs Category: Safe and Effective Care Environment: Management of Care 16. A nurse is concerned that a preoperative client has a great deal of anxiety about the upcoming procedure. What action by the nurse is best? a. Ask the client to describe current feelings. b. Determine if the client wants a chaplain. c. Reassure the client this surgery is common. d. Tell the client there is no need to be anxious.

A The nurse needs to conduct further assessment of the clients anxiety. Asking open-ended questions about current feelings is an appropriate way to begin. The client may want a chaplain, but the nurse needs to do more for the client. Reassurance can be good, but false hope is not, and simply reassuring the client may not be helpful. Telling the client not to be anxious belittles the clients feelings. DIF: Applying/Application

234 KEY: Preoperative nursing| safety| hydroxyzine MSC: Integrated Process: Nursing Process: Implementation NOT: Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies 18. A client is on the phone when the nurse brings a preoperative antibiotic before scheduled surgery. The circulating nurse has requested the antibiotic be started. The client wants the nurse to wait before starting it. What response by the nurse is most appropriate? a. Explain the rationale for giving the medicine now. b. Leave the room and come back in 15 minutes. c. Provide holistic client care and come back later. d. Tell the client you must start the medication now.

A The preoperative antibiotic must be given within 60 minutes of the surgical start time to ensure the proper amount is in the tissues when the incision is made. The nurse should explain the rationale to the client for this timing. The other options do not take this timing into consideration and do not give the client the information needed to be cooperative. DIF: Applying/Application

216 KEY: Preoperative nursing| Surgical Care Improvement Project (SCIP)| infection MSC: Integrated Process: Nursing Process: Implementation NOT: Client Needs Category: Safe and Effective Care Environment: Management of Care 15. A nurse assesses a client in the preoperative holding area and finds brittle nails and hair, dry skin turgor, and muscle wasting. What action by the nurse is best? a. Consult the surgeon about a postoperative dietitian referral. b. Document the findings thoroughly in the clients chart. c. Encourage the client to eat more after recovering from surgery. d. Refer the client to Meals on Wheels after discharge.

A This client has signs of malnutrition, which can impact recovery from surgery. The nurse should consult the surgeon about prescribing a consultation with a dietitian in the postoperative period. The nurse should document the findings but needs to do more. Encouraging the client to eat more may be helpful, but the client needs a professional nutritional assessment so that the appropriate diet and supplements can be ordered. The client may or may not need Meals on Wheels after discharge. DIF: Applying/Application

72 OBJ: 3 (theory) TOP: Preoperative Medication KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Pharmacological Therapies 23. The nurse determines that the patient demonstrates an understanding of preoperative teaching with which responses? (Select all that apply.) a. I will need to sign a consent form before I am given my medications prior to my surgery. b. The surgeon will want me to ambulate as soon as possible after my surgery. c. My nurse will want me to take the deepest breaths I can tolerate following my surgery. d. I may experience some constipation if I am taking much pain medication after my surgery. e. The general anesthesia will prevent me from having pain for the first 24 hours after surgery.

A, B, C, D Consent forms must be signed before preoperative pain medications are administered; early ambulation is common with most surgeries; deep breaths prevent postoperative respiratory complications; and constipation is common with the use of narcotic analgesics. General anesthesia does not prevent pain 24 hours after surgery, so this statement demonstrates the need for further preoperative teaching. DIF: Cognitive Level: Application

64 | Elder Care Points OBJ: 2 (theory) TOP: Older Adult Surgical Patient KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity: Physiological Adaptation 22. The nurse reinforces that the purpose of preoperative medication is to: (Select all that apply.) a. reduce anxiety. b. decrease mucus secretion. c. counteract nausea. d. synergize anesthesia. e. enhance ventilation.

A, B, C, D Preoperative medications are given to reduce anxiety, decrease mucus production, counteract nausea, and enhance anesthesia. Many preoperative medications depress ventilation. DIF: Cognitive Level: Comprehension

222 KEY: Preoperative nursing| nutrition| malnutrition MSC: Integrated Process: Teaching/Learning NOT: Client Needs Category: Physiological Integrity: Physiological Adaptation 6. A student nurse asks why older adults are at higher risk for complications after surgery. What reasons does the registered nurse give? (Select all that apply.) a. Decreased cardiac output b. Decreased oxygenation c. Frequent nocturia d. Mobility alterations e. Inability to adapt to changes

A, B, C, D Older adults have many age-related physiologic changes that put them at higher risk of falling and other complications after surgery. Some of these include decreased cardiac output, decreased oxygenation of tissues, nocturia, and mobility alterations. They also have a decreased ability to adapt to new surroundings, but that is not the same as being unable to adapt. DIF: Understanding/Comprehension

N/A TOP: Client Needs Category: Health Promotion and Maintenance (Principles of Teaching/Learning) MSC: Integrated Process: Teaching/Learning 4. What data are essential for the nurse to assess on a client who is scheduled for surgery? (Select all that apply.) a. Use of tobacco b. Current medications c. Use of herbal or over-the-counter therapy d. Mental status examination e. Power of attorney f. Allergies g. Date of last tetanus shot

A, B, C, D, F The client should be screened for things that may increase the risk of complications during surgery. Smoking, certain medications and herbs, and allergies may increase a clients risk. Mental status examination is essential to determine competency and ability to teach. The date of the clients last tetanus shot is not required information from a preoperative chart review. DIF: Cognitive Level: Comprehension/Understanding

68 OBJ: 3 (theory) TOP: Informed Consent KEY: Nursing Process Step: Implementation MSC: NCLEX: Safe, Effective Care Environment: Management of Care MULTIPLE RESPONSE 20. The patient questions the nurse about robotics surgery. The nurse correctly responds, Robotics: (Select all that apply.) a. gives the surgeon greater magnification than the human eye. b. allows the surgeon to be more precise than normal. c. allows for a smaller incision. d. increases healing time. e. procedures generally cause less postoperative pain.

A, B, C, E Robotics have 12 times magnification of the operative site, steady hands, and use a smaller incision, which results in less postoperative pain. Healing time is decreased with robotics. DIF: Cognitive Level: Comprehension

N/A TOP: Client Needs Category: Physiological Integrity (Reduction of Risk PotentialLaboratory Values) MSC: Integrated Process: Nursing Process (Assessment) 2. Which medications does the nurse correctly administer preoperatively? (Select all that apply.) a. Hydroxyzine (Atarax, Vistaril) for sedation b. Lorazepam (Ativan) for anxiety c. Hydromorphone (Dilaudid) to decrease postoperative secretions d. Metoclopramide (Reglan) to increase stomach emptying e. Aspirin to decrease blood clotting postoperatively f. Cimetidine (Tagamet) to prevent infection

A, B, D The nurse will administer hydroxyzine (Atarax) for sedation, lorazepam (Ativan) for anxiety, and metoclopramide (Reglan) to increase stomach emptying. Hydromorphone is given for pain, and cimetidine (Tagamet) decreases histamine. Aspirin would not be administered preoperatively because it can increase bleeding. DIF: Cognitive Level: Application/Applying or higher

220 KEY: Preoperative nursing| older adult MSC: Integrated Process: Teaching/Learning NOT: Client Needs Category: Health Promotion and Maintenance 7. A client is clearly uncomfortable and anxious in the preoperative holding room waiting for emergent abdominal surgery. What actions can the nurse perform to increase comfort? (Select all that apply.) a. Allow the client to assume a position of comfort. b. Allow the clients family to remain at the bedside. c. Give the client a warm, non-caffeinated drink. d. Provide warm blankets or cool washcloths as desired. e. Pull the curtains around the bed to provide privacy.

A, B, D, E There are many nonpharmacologic comfort measures the nurse can employ, such as allowing the client to remain in the position that is most comfortable, letting the family stay with the client, providing warmth or cooling measures as requested by the client, and providing privacy. The client in the preoperative holding area is NPO, so drinks should not be provided. DIF: Applying/Application

N/A TOP: Client Needs Category: Health Promotion and Maintenance (Principles of Teaching/Learning) MSC: Integrated Process: Teaching/Learning MULTIPLE RESPONSE 1. The nurse is assessing a client before surgery. Which assessments contraindicate the client having surgery as scheduled? (Select all that apply.) a. Potassium level of 2.8 mEq/L b. International normalized ratio (INR) of 4 c. Prothrombin time (PTT) of 30 seconds d. Calcium level of 8.8 mEq/dL e. Positive pregnancy test f. Platelet count of 150,000

A, B, E Hypokalemia, elevated bleeding times, and a positive pregnancy test could all contradict the client having surgery as scheduled and could lead to complications. Normal PTT, normal calcium, and normal platelet count would not contradict surgery. DIF: Cognitive Level: Application/Applying or higher

N/A TOP: Client Needs Category: Physiological Integrity (Pharmacological and Parenteral TherapiesExpected Actions/Outcomes) MSC: Integrated Process: Nursing Process (Assessment) 3. The nurse is conducting preoperative teaching with a client who will be undergoing pelvic surgery. What teaching is essential for this client? (Select all that apply.) a. Wearing elastic stockings and using pneumatic compression devices are essential after surgery. b. Extended bedrest will help you heal after this type of surgery. c. Coughing and deep breathing will help to decrease postoperative complications. d. Turning and moving your legs after surgery will help prevent clots from forming. e. You will need to have your abdomen shaved before surgery. f. You cannot wear your hearing aid into the surgical suite.

A, C, D A pneumatic compression device and elastic stockings will help prevent clots after pelvic surgery. Coughing and deep breathing will help to decrease postoperative respiratory complications. Turning and moving legs after surgery will also help prevent clots. Hearing aids can be worn into the surgical suite because this will help communication before surgery. Extended bedrest is not helpful, and shaving would not be necessary. DIF: Cognitive Level: Application/Applying or higher

218 KEY: Preoperative nursing| surgical procedures MSC: Integrated Process: Teaching/Learning NOT: Client Needs Category: Physiological Integrity: Physiological Adaptation 3. A nurse is caring for several clients prior to surgery. Which medications taken by the clients require the nurse to consult with the physician about their administration? (Select all that apply.) a. Metformin (Glucophage) b. Omega-3 fatty acids (Sea Omega 30) c. Phenytoin (Dilantin) d. Pilocarpine hydrochloride (Isopto Carpine) e. Warfarin (Coumadin)

A, C, D, E Although the client will be on NPO status before surgery, the nurse should check with the provider about allowing the client to take medications prescribed for diabetes, hypertension, cardiac disease, seizure disorders, depression, glaucoma, anticoagulation, or depression. Metformin is used to treat diabetes; phenytoin is for seizures; pilocarpine is for glaucoma, and warfarin is an anticoagulant. The omega-3 fatty acids can be held the day of surgery. DIF: Analyzing/Analysis

231 KEY: Preoperative nursing| venous thromboembolism prevention MSC: Integrated Process: Teaching/Learning NOT: Client Needs Category: Physiological Integrity: Reduction of Risk Potential 5. A student nurse is caring for clients on the postoperative unit. The student asks the registered nurse why malnutrition can lead to poor surgical outcomes. What responses by the nurse are best? (Select all that apply.) a. A malnourished client will have fragile skin. b. Malnourished clients always have other problems. c. Many drugs are bound to protein in the body. d. Protein stores are needed for wound healing. e. Weakness and fatigue are common in malnutrition.

A, C, D, E Malnutrition can lead to poorer surgical outcomes for several reasons, including fragile skin that might break down, altered pharmacokinetics, poorer wound healing, and weakness or fatigue that can interfere with recovery. Malnutrition can exist without other comorbidities. DIF: Understanding/Comprehension

Table 16-1, p. 242 TOP: Client Needs Category: Physiological Integrity (Basic Care and ComfortNon-Pharmacological Comfort Measures) MSC: Integrated Process: Communication and Documentation 14. Twenty minutes after a client has received a preoperative injection of atropine and midazolam (Versed), the client tells the nurse that he must be allergic to the medication because his mouth is dry and his heart seems to be beating faster than normal. What is the nurses priority action? a. Document the findings. b. Assess the clients pulse and blood pressure. c. Administer diphenhydramine (Benadryl). d. Explain to the client that these symptoms are expected.

B Although these are expected physiologic responses to the preoperative medication, whenever the client states that he or she can feel a change in normal cardiac function, he should be assessed. DIF: Cognitive Level: Application/Applying or higher

322 TOP: Nursing Process: Assessment MSC: NCLEX: Safe and Effective Care Environment 4. A patient who has never had any prior surgeries tells the nurse doing the preoperative assessment about an allergy to bananas and avocados. Which action is most important for the nurse to take? a. Notify the dietitian about the food allergies. b. Alert the surgery center about a possible latex allergy. c. Reassure the patient that all allergies are noted on the medical record. d. Ask whether the patient uses antihistamines to reduce allergic reactions.

B Certain food allergies (e.g., eggs, avocados, bananas, chestnuts, potatoes, peaches) are related to latex allergies. When a patient is allergic to latex, special nonlatex materials are used during surgical procedures, and the staff will need to know about the allergy in advance to obtain appropriate nonlatex materials and have them available during surgery. The other actions also may be appropriate, but prevention of allergic reaction during surgery is the most important action. DIF: Cognitive Level: Apply (application)

320 TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity 19. Which information in the preoperative patients medication history is most important to communicate to the health care provider? a. The patient uses acetaminophen (Tylenol) occasionally for aches and pains. b. The patient takes garlic capsules daily but did not take any on the surgical day. c. The patient has a history of cocaine use but quit using the drug over 10 years ago. d. The patient took a sedative medication the previous night to assist in falling asleep.

B Chronic use of garlic may predispose to intraoperative and postoperative bleeding. The use of a sedative the previous night, occasional acetaminophen use, and a distant history of cocaine use will not usually affect the surgical outcome. DIF: Cognitive Level: Apply (application)

p. 252 TOP: Client Needs Category: Safe and Effective Care Environment (Management of CareAdvance Directives MSC: Integrated Process: Communication and Documentation 19. A client is brought to the hospital unconscious and needs emergency surgery. The clients only family member cannot come to the hospital before the surgery. Which is the best option for obtaining informed consent for the clients emergent surgery? a. Proceed with surgery and have the family member sign the consent as soon as possible. b. Contact the family member by phone and obtain verbal consent with two witnesses. c. Obtain written consultation with two surgeons that the surgery is needed. d. Have the hospital administrator appoint a temporary legal guardian.

B In the event that a family member cannot come to the hospital before the surgery needs to begin, verbal consent should be obtained over the phone with two witnesses. DIF: Cognitive Level: Application/Applying or higher

N/A TOP: Client Needs Category: Physiological Integrity (Pharmacological and Parenteral TherapiesExpected Actions/Outcomes) MSC: Integrated Process: Nursing Process (Implementation) 15. A client undergoing preoperative assessment informs the nurse that he takes medication for high blood pressure and for asthma. What is the nurses best action? a. Tell the client not to take the medication on the day of surgery. b. Notify the surgeon and the anesthesiologist. c. Document the information in the clients record. d. Tell the client to take medications preoperatively with a sip of water.

B Medications for cardiac and respiratory problems usually are given with sips of water before surgery. However, the nurse should notify the surgeon and the anesthesiologist before giving the client any advice. While some medications can be given with a sip of water, other medications must be held for a specified time before surgery. Documentation should occur, but only after the nurse has consulted with the physician and anesthesiologist and has spoken to the client. DIF: Cognitive Level: Application/Applying or higher

329 TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity 13. A patient who has diabetes and uses insulin to control blood glucose has been NPO since midnight before having a knee replacement surgery. Which action should the nurse take? a. Withhold the usual scheduled insulin dose because the patient is NPO. b. Obtain a blood glucose measurement before any insulin administration. c. Give the patient the usual insulin dose because stress will increase the blood glucose. d. Administer a lower dose of insulin because there will be no oral intake before surgery.

B Preoperative insulin administration is individualized to the patient, and the current blood glucose will provide the most reliable information about insulin needs. It is not possible to predict whether the patient will require no insulin, a lower dose, or a higher dose without blood glucose monitoring. DIF: Cognitive Level: Apply (application)

66 | Box 4-2, 67 | Table 4-2 OBJ: 2 (theory) TOP: Preoperative Lab Studies KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity: Reduction of Risk Potential 5. The patient received a preoperative dose of lorazepam (Ativan) 20 minutes ago. The safety precaution the nurse should take in regard to this drug is to: a. monitor respiratory status. b. raise bed rails. c. elevate the head of the bed 30 degrees. d. take seizure precautions.

B Raising the bed rails is a safety precaution against the dizziness and hypotension caused by this drug. DIF: Cognitive Level: Application

66 OBJ: 2 (theory) TOP: Assessment of Surgical Risk Factors KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity: Basic Care and Comfort 7. The patient refuses to take off her diamond wedding band prior to going to the operating room. The nurse should first: a. record in the chart that the patient refused to remove jewelry. b. tape the ring to finger, covering the ring. c. request that the patient sign a waiver to release the hospital from responsibility. d. alert the surgery team to the presence of the jewelry.

B Taping the ring will protect the ring and secure it to the finger. Care must be taken not to wrap the tape too tightly. The nurse will also need to document the presence of the ring on the preoperative checklist or in the nurses notes. There is no need for a signature on a waiver. Most facilities have policies in which the patient signs a release of responsibility for valuables. There is no need to notify the surgical team of the presence of the ring. DIF: Cognitive Level: Comprehension

N/A TOP: Client Needs Category: Physiological Integrity (Physiological AdaptationMedical Emergencies) MSC: Integrated Process: Nursing Process (Implementation) 9. The nurse has just completed preoperative teaching with a client who will be having surgery the following day. Which statement by the client indicates that additional teaching is needed? a. When I brush my teeth before surgery, I will be sure to spit out the water. b. I will go to the bathroom as soon as I receive all my preoperative medications. c. I will remember to wear my glasses tomorrow instead of my contact lenses. d. I wont have to worry about putting my makeup on tomorrow morning.

B The client should void before receiving any preoperative medication. The medication could make the client sleepy and at risk for falling. The other statements are correct. DIF: Cognitive Level: Application/Applying or higher

76 | Box 4-4 OBJ: 6 (theory) TOP: Circulating Nurse Duties KEY: Nursing Process Step: Implementation MSC: NCLEX: Safe, Effective Care Environment: Coordinated Care 12. The nurse warns the patient that, in order to retard the growth of microorganisms, the operating room is kept at a temperature of _____ to _____ degrees. a. 60; 65 b. 66; 70 c. 71; 74 d. 75; 77

B The operating suite is kept at a temperature of 66 to 70 degrees to discourage microbial growth. DIF: Cognitive Level: Knowledge

324-325 TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity 11. Five minutes after receiving the ordered preoperative midazolam (Versed) by IV injection, the patient asks to get up to go to the bathroom to urinate. Which action by the nurse is most appropriate? a. Assist the patient to the bathroom and stay with the patient to prevent falls. b. Offer a urinal or bedpan and position the patient in bed to promote voiding. c. Allow the patient up to the bathroom because medication onset is 10 minutes. d. Ask the patient to wait because catheterization is performed just before the surgery.

B The patient will be at risk for a fall after receiving the sedative, so the best nursing action is to have the patient use a bedpan or urinal. Having the patient get up either with assistance or independently increases the risk for a fall. The patient will be uncomfortable and risk involuntary incontinence if the bladder is full during transport to the operating room. DIF: Cognitive Level: Apply (application)

320 | 324 TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity 9. The nurse is preparing to witness the patient signing the operative consent form when the patient says, I do not really understand what the doctor said. Which action is best for the nurse to take? a. Provide an explanation of the planned surgical procedure. b. Notify the surgeon that the informed consent process is not complete. c. Administer the prescribed preoperative antibiotics and withhold any ordered sedative medications. d. Notify the operating room staff that the surgeon needs to give a more complete explanation of the procedure.

B The surgeon is responsible for explaining the surgery to the patient, and the nurse should wait until the surgeon has clarified the surgery before having the patient sign the consent form. The nurse should communicate directly with the surgeon about the consent form rather than asking other staff to pass on the message. It is not within the nurses legal scope of practice to explain the surgical procedure. No preoperative medications should be administered until the patient understands the surgical procedure and signs the consent form. DIF: Cognitive Level: Apply (application)

N/A TOP: Client Needs Category: Physiological Integrity (Reduction of Risk PotentialLaboratory Values) MSC: Integrated Process: Nursing Process (Implementation) 12. What recently learned information about a client who is scheduled to have surgery within the next 2 hours is the nurse certain to communicate to the surgical team? a. An allergy to cats b. Hearing problem c. Consumption of a glass of wine 12 hours ago d. Taking 2000 mg of vitamin C each day

B The team will need to communicate with the client in the surgical holding area, in the operating room, and in the postanesthesia recovery unit. Any problem with communication, such as a hearing impairment, should be stressed, so that team members can use alternative means to ensure accurate communication with the client. DIF: Cognitive Level: Application/Applying or higher

72 | Cultural Considerations OBJ: 2 (theory) TOP: Immediate Preoperative Care KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity: Pharmacological Therapies 9. The nurse recognizes a need for further instruction about the emotional preparation for surgery when a patient says: a. Im going to hug my surgeon tomorrow. b. My fate is in the hands of my surgeon. Im frightened about the outcome. c. Ill be ready for a cheeseburger when I get back. d. I know I may have some pain, but this gallbladder will be gone when I wake up.

B This response demonstrates the patients fear and insecurity, which warrant further discussion. Providing additional information or answering patient questions may help alleviate the patients emotional unpreparedness for surgery. The plan for a cheeseburger indicates a potential need to further review nutrition in the postoperative period. The other responses demonstrate positive statements regarding the upcoming postsurgical period. DIF: Cognitive Level: Analysis

325 TOP: Nursing Process: Assessment MSC: NCLEX: Safe and Effective Care Environment 3. A 38-year-old female is admitted for an elective surgical procedure. Which information obtained by the nurse during the preoperative assessment is most important to report to the anesthesiologist before surgery? a. The patients lack of knowledge about postoperative pain control measures b. The patients statement that her last menstrual period was 8 weeks previously c. The patients history of a postoperative infection following a prior cholecystectomy d. The patients concern that she will be unable to care for her children postoperatively

B This statement suggests that the patient may be pregnant, and pregnancy testing is needed before administration of anesthetic agents. Although the other data may also be communicated with the surgeon and anesthesiologist, they will affect postoperative care and do not indicate a need for further assessment before surgery. DIF: Cognitive Level: Apply (application)

230 KEY: Preoperative nursing| drains MSC: Integrated Process: Nursing Process: Evaluation NOT: Client Needs Category: Physiological Integrity: Reduction of Risk Potential 10. A client waiting for surgery is very anxious. What intervention can the nurse delegate to the unlicensed assistive personnel (UAP)? a. Assess the clients anxiety. b. Give the client a back rub. c. Remind the client to turn. d. Teach about postoperative care.

B A back rub reduces anxiety and can be delegated to the UAP. Once teaching has been done, the UAP can remind the client to turn, but this is not related to relieving anxiety. Assessing anxiety and teaching are not within the scope of practice for the UAP. DIF: Applying/Application

222 KEY: Preoperative nursing| anxiety| support MSC: Integrated Process: Nursing Process: Assessment NOT: Client Needs Category: Psychosocial Integrity 17. A client has been given hydroxyzine (Atarax) in the preoperative holding area. What action by the nurse is most important for this client? a. Document giving the drug. b. Raise the siderails on the bed. c. Record the clients vital signs. d. Teach relaxation techniques.

B All actions are appropriate for a preoperative client. However, for client safety, the nurse should raise the siderails on the bed because hydroxyzine can make the client sleepy. DIF: Applying/Application

223 KEY: Preoperative nursing| laboratory values MSC: Integrated Process: Communication and Documentation NOT: Client Needs Category: Physiological Integrity: Reduction of Risk Potential 6. An inpatient nurse brings an informed consent form to a client for an operation scheduled for tomorrow. The client asks about possible complications from the operation. What response by the nurse is best? a. Answer the questions and document that teaching was done. b. Do not have the client sign the consent and call the surgeon. c. Have the client sign the consent, then call the surgeon. d. Remind the client of what teaching the surgeon has done.

B In order to give informed consent, the client needs sufficient information. Questions about potential complications should be answered by the surgeon. The nurse should notify the surgeon to come back and answer the clients questions before the client signs the consent form. The other actions are not appropriate. DIF: Applying/Application

226 KEY: Preoperative nursing| informed consent MSC: Integrated Process: Communication and Documentation NOT: Client Needs Category: Safe and Effective Care Environment: Management of Care 7. A client has a great deal of pain when coughing and deep breathing after abdominal surgery despite having pain medication. What action by the nurse is best? a. Call the provider to request more analgesia. b. Demonstrate how to splint the incision. c. Have the client take shallower breaths. d. Tell the client a little pain is expected.

B Splinting an incision provides extra support during coughing and activity and helps decrease pain. If the client is otherwise comfortable, no more analgesia is required. Shallow breathing can lead to atelectasis and pneumonia. The client should know some pain is normal and expected after surgery, but that answer alone does not provide any interventions to help the client. DIF: Applying/Application

230 KEY: Preoperative nursing| nonpharmacologic pain management| splinting MSC: Integrated Process: Teaching/Learning NOT: Client Needs Category: Physiological Integrity: Basic Care and Comfort 8. A nurse is giving a client instructions for showering with special antimicrobial soap the night before surgery. What instruction is most appropriate? a. After you wash the surgical site, shave that area with your own razor. b. Be sure to wash the area where you will have surgery very thoroughly. c. Use a washcloth to wash the surgical site; do not take a full shower or bath. d. Wash the surgical site first, then shampoo and wash the rest of your body.

B The entire proposed surgical site needs to be washed thoroughly and completely with the antimicrobial soap. Shaving, if absolutely necessary, should be done in the operative suite immediately before the operation begins, using sterile equipment. The client needs a full shower or bath (shower preferred). The client should wash the surgical site last; dirty water from shampooing will run over the cleansed site if the site is washed first. DIF: Applying/Application

228 KEY: Preoperative nursing| client education| skin preparation MSC: Integrated Process: Teaching/Learning NOT: Client Needs Category: Physiological Integrity: Reduction of Risk Potential 9. A postoperative client has an abdominal drain. What assessment by the nurse indicates that goals for the priority client problems related to the drain are being met? a. Drainage from the surgical site is 30 mL less than yesterday. b. There is no redness, warmth, or drainage at the insertion site. c. The client reports adequate pain control with medications. d. Urine is clear yellow and urine output is greater than 40 mL/hr.

B The priority client problem related to a surgical drain is the potential for infection. An insertion site that is free of redness, warmth, and drainage indicates that goals for this client problem are being met. The other assessments are normal, but not related to the drain. DIF: Evaluating/Synthesis

234 KEY: Preoperative nursing| antibiotic| Surgical Care Improvement Project (SCIP) MSC: Integrated Process: Nursing Process: Implementation NOT: Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies 19. A nurse is giving a preoperative client a dose of ranitidine (Zantac). The client asks why the nurse is giving this drug when the client has no history of ulcers. What response by the nurse is best? a. All preoperative clients get this medication. b. It helps prevent ulcers from the stress of the surgery. c. Since you dont have ulcers, I will have to ask. d. The physician prescribed this medication for you.

B Ulcer prophylaxis is common for clients undergoing long procedures or for whom high stress is likely. The nurse is not being truthful by saying all clients get this medication. If the nurse does not know the information, it is appropriate to find out, but this is a common medication for which the nurse should know the rationale prior to administering it. Simply stating that the physician prescribed the medication does not give the client any useful information. DIF: Understanding/Comprehension

77 OBJ: 2 (theory) TOP: Potential Intraoperative Complications KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Physiological Adaptation 25. The nurse working in a surgeons office is providing preoperative teaching to a patient who is scheduled for a needle breast biopsy. Which statement by the patient demonstrates a need for further preoperative teaching? (Select all that apply.) a. This procedure will help the doctor determine if I have breast cancer. b. I will most likely have general anesthesia since this is a painful procedure. c. The surgeon will need to perform this procedure within the next 24 to 48 hours. d. I will have less breast pain after having this procedure performed. e. I will not require any further treatment after this procedure is performed.

B, C, D, E A needle breast biopsy is a diagnostic procedure that is used to determine if cancer cells are present. This procedure typically requires only a local or regional anesthetic; procedures that must be performed within 24 to 48 hours are considered urgent procedures for immediate life-threatening conditions; indicating that less pain will be experienced describes a palliative procedure; and indicating that less breast pain will occur describes a curative procedure. DIF: Cognitive Level: Application

228 KEY: Preoperative nursing| medications| NPO MSC: Integrated Process: Nursing Process: Analysis NOT: Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies 4. A nurse recently hired to the preoperative area learns that certain clients are at higher risk for venous thromboembolism (VTE). Which clients are considered at high risk? (Select all that apply.) a. Client with a humerus fracture b. Morbidly obese client c. Client who underwent a prolonged surgical procedure d. Client with severe heart failure e. Wheelchair-bound client

B, C, D, E All surgical clients should be assessed for VTE risk. Those considered at higher risk include those who are obese; are over 40; have cancer; have decreased mobility, immobility, or a spinal cord injury; have a history of any thrombotic event, varicose veins, or edema; take oral contraceptives or smoke; have decreased cardiac output; have a hip fracture; or are having total hip or knee surgery. Prolonged surgical time increases risk due to mobility and positioning needs. DIF: Remembering/Knowledge

233 KEY: Preoperative nursing| comfort MSC: Integrated Process: Nursing Process: Implementation NOT: Client Needs Category: Physiological Integrity: Basic Care and Comfort 8. A nurse working in the preoperative holding area performs which functions to ensure client safety? (Select all that apply.) a. Allow small sips of plain water. b. Check that consent is on the chart. c. Ensure the client has an armband on. d. Have the client help mark the surgical site. e. Allow the client to use the toilet before giving sedation.

B, C, D, E Providing for client safety is a priority function of the preoperative nurse. Checking for appropriately completed consent, verifying the clients identity, having the client assist in marking the surgical site if applicable, and allowing the client to use the toilet prior to sedating him or her are just some examples of important safety measures. The preoperative client should be NPO, so water should not be provided. DIF: Applying/Application

234 KEY: Preoperative nursing| histamine blocker| ulcers MSC: Integrated Process: Communication and Documentation NOT: Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies MULTIPLE RESPONSE 1. A new perioperative nurse is receiving orientation to the surgical area and learns about the Surgical Care Improvement Project (SCIP) goals. What major areas do these measures focus on preventing? (Select all that apply.) a. Hemorrhage b. Infection c. Serious cardiac events d. Stroke e. Thromboembolism

B, C, E The SCIP project includes core measures to prevent infection, serious cardiac events, and thromboembolic events such as deep vein thrombosis. DIF: Remembering/Knowledge

216 KEY: Preoperative nursing| Surgical Care Improvement Project (SCIP)| core measures MSC: Integrated Process: Teaching/Learning NOT: Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control 2. A nursing instructor is teaching students about different surgical procedures and their classifications. Which examples does the instructor include? (Select all that apply.) a. Hemicolectomy: diagnostic b. Liver biopsy: diagnostic c. Mastectomy: restorative d. Spinal cord decompression: palliative e. Total shoulder replacement: restorative

B, E A diagnostic procedure is used to determine cell type of cancer and to determine the cause of a problem. An example is a liver biopsy. A restorative procedure aims to improve functional ability. An example would be a total shoulder replacement or a spinal cord decompression (not palliative). A curative procedure either removes or repairs the causative problem. An example would be a mastectomy (not restorative) or a hemicolectomy (not diagnostic). A palliative procedure relieves symptoms but will not cure the disease. An example is an ileostomy. A cosmetic procedure is done to improve appearance. An example is rhinoplasty (a nose job). DIF: Remembering/Knowledge

67-72 OBJ: 3 (theory) TOP: Planning KEY: Nursing Process Step: Evaluation MSC: NCLEX: Psychosocial Integrity: Psychosocial Adaptation 10. Prior to administering the preoperative medication of Demerol and atropine, the nurse should confirm that: a. a family member is present. b. underwear is removed. c. a consent form is signed. d. bed rails are up.

C Consent forms must be signed prior to giving any sedative or preoperative drug. Removal of underwear and the raising of the side rails can be done after the administration of the drug. The family member does not have to present. DIF: Cognitive Level: Comprehension

71 | 77 OBJ: 2 (theory) TOP: Intraoperative Complications KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity: Reduction of Risk Potential 17. The patient has just been given medication to reverse neuromuscular blocking agents. The nurse is aware that the patient is in the general anesthetic stage of: a. induction. b. introduction. c. emergence. d. maintenance.

C Emergence is the stage of surgery in which surgery is completed and the patient is prepared to return to consciousness, and neuromuscular blocking agents are reversed. DIF: Cognitive Level: Comprehension

323 OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity MULTIPLE RESPONSE 1. The nurse is caring for a patient who has received epoetin alfa (Epogen) 2 to 3 weeks prior to a scheduled surgery. The nurse understands that this patient will likely: a. require an antibiotic immediately prior to surgery. b. have difficulty with blood clotting following surgery. c. not require a blood transfusion during surgery. d. develop an electrolyte imbalance during surgery.

C Epoetin alfa (Epogen) is given to increase red blood cell production prior to surgery with the goal of having a bloodless surgery. Epoetin alfa (Epogen) will not affect the need for an antibiotic preoperatively, nor will it cause difficulty with clotting or cause an electrolyte imbalance. DIF: Cognitive Level: Application

N/A TOP: Client Needs Category: Physiological Integrity (Pharmacological and Parenteral TherapiesExpected Actions/Outcomes) MSC: Integrated Process: Communication and Documentation 6. A client receiving preoperative medication tells the nurse that she took all the following vitamins and herbs last night before going to bed. Which one does the nurse report to the surgical team as a priority? a. Valerian root b. St. Johns wort c. Garlic d. Chamomile

C Garlic interferes with coagulation, increasing the clients risk for bleeding during and after the surgical procedure. This would be a critical piece of information for the surgical team to know. DIF: Cognitive Level: Application/Applying or higher

77 OBJ: 6 (clinical) TOP: Malignant Hyperthermia KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity: Reduction of Risk Potential 16. The nurse is caring for a postsurgical patient whose surgical procedure lasted 3 hours. The nurse anticipates that the patient will experience: a. thrombophlebitis. b. muscle spasms. c. joint pain. d. hyperthermia.

C Long-term immobility places the patient at risk for pressure damage to skin and underlying tissues. Joint complaints are common after a long surgery. Thrombophlebitis, muscle spasms, and hyperthermia are complications that are not expected to occur. DIF: Cognitive Level: Application

326 TOP: Nursing Process: Implementation MSC: NCLEX: Safe and Effective Care Environment 10. Which topic is most important for the nurse to discuss preoperatively with a patient who is scheduled for abdominal surgery for an open cholecystectomy? a. Care for the surgical incision b. Medications used during surgery c. Deep breathing and coughing techniques d. Oral antibiotic therapy after discharge home

C Preoperative teaching, demonstration, and redemonstration of deep breathing and coughing are needed on patients having abdominal surgery to prevent postoperative atelectasis. Incisional care and the importance of completing antibiotics are better discussed after surgery, when the patient will be more likely to retain this information. The patient does not usually need information about medications that are used intraoperatively. DIF: Cognitive Level: Apply (application)

N/A TOP: Client Needs Category: Safe and Effective Care Environment (Management of CareInformed Consent) MSC: Integrated Process: Teaching/Learning 4. During the preoperative assessment, the client tells the nurse that he smokes three packs of cigarettes daily. Which action by the nurse is best? a. Call the surgeon to cancel the surgery. b. Have baseline laboratory studies drawn. c. Perform a respiratory assessment. d. Give a nebulizer treatment.

C Smoking increases the clients risk for atelectasis and hypoxia. The nurse should assess the client for signs of respiratory disease. The physician will need to know this information but will not necessarily cancel the operation. Baseline laboratory studies need to be ordered by the physician. There is no indication for giving a nebulizer to this client. DIF: Cognitive Level: Application/Applying or higher

319 TOP: Nursing Process: Assessment MSC: NCLEX: Psychosocial Integrity 6. A patient undergoing an emergency appendectomy has been using St. Johns wort to prevent depression. Which complication would the nurse expect in the postanesthesia care unit? a. Increased pain b. Hypertensive episodes c. Longer time to recover from anesthesia d. Increased risk for postoperative bleeding

C St. Johns wort may prolong the effects of anesthetic agents and increase the time to waken completely after surgery. It is not associated with increased bleeding risk, hypertension, or increased pain. DIF: Cognitive Level: Apply (application)

75 OBJ: 3 (theory) TOP: The Surgical Suite KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Basic Care and Comfort 13. The nurse explains that the National Patient Safety Goals protocol requires that: a. a licensed caregiver accompany the patient to the operating room. b. side rails should be raised and head of bed elevated 30 degrees. c. surgical site be verified and marked. d. all prosthetic devices be identified.

C The National Patient Safety Goals require that the patient be identified, the surgical consent be signed and correct, and the surgical site be marked. DIF: Cognitive Level: Application

327 TOP: Nursing Process: Implementation MSC: NCLEX: Safe and Effective Care Environment 12. The nurse plans to provide preoperative teaching to an alert older man who has hearing and vision deficits. His wife usually answers most questions that are directed to the patient. Which action should the nurse take when doing the teaching? a. Use printed materials for instruction so that the patient will have more time to review the material. b. Direct the teaching toward the wife because she is the obvious support and caregiver for the patient. c. Provide additional time for the patient to understand preoperative instructions and carry out procedures. d. Ask the patients wife to wait in the hall in order to focus preoperative teaching with the patient himself.

C The nurse should allow more time when doing preoperative teaching and preparation for older patients with sensory deficits. Because the patient has visual deficits, he will not be able to use written material for learning. The teaching should be directed toward both the patient and the wife because both will need to understand preoperative procedures and teaching. DIF: Cognitive Level: Apply (application)

1. A client voluntarily signed the operative consent form. What is the nurses next action? a. Teach the client about the surgery. b. Have family members witness the signature. c. Sign under the clients name as a witness. d. Call for the physician to sign the form.

C The nurses signature as a witness indicates that the consent form was signed by the client voluntarily. None of the other steps are necessary. DIF: Cognitive Level: Application/Applying or higher

p. 259 TOP: Client Needs Category: Physiological Integrity (Reduction of Risk PotentialPotential for Complications From Surgical Procedures and Health Alterations) MSC: Integrated Process: Nursing Process (Assessment) 17. The nurse is caring for a client who will be undergoing emergency surgery as soon as possible. Which information is most important for the nurse to teach the client at this time? a. How the surgery will be performed b. Importance of early ambulation after surgery c. What to expect in the operating and recovery rooms d. Complications that may occur after surgery

C With only a few minutes before surgery, the nurse should tell the client what to expect in the operating room and in the recovery room to minimize his or her anxiety. Although the other information is important, the nurse needs to start with what is vital for the client to know right now. DIF: Cognitive Level: Application/Applying or higher

233 KEY: Preoperative nursing| anxiety| client education MSC: Integrated Process: Nursing Process: Assessment NOT: Client Needs Category: Psychosocial Integrity 5. A preoperative nurse is reviewing morning laboratory values on four clients waiting for surgery. Which result warrants immediate communication with the surgical team? a. Creatinine: 1.2 mg/dL b. Hemoglobin: 14.8 mg/dL c. Potassium: 2.9 mEq/L d. Sodium: 134 mEq/L

C A potassium of 2.9 mEq/L is critically low and can affect cardiac and respiratory status. The nurse should communicate this laboratory value immediately. The creatinine is at the high end of normal, the hemoglobin is normal, and the sodium is only slightly low (normal low being 136 mEq/L), so these values do not need to be reported immediately. DIF: Applying/Application

234 KEY: Preoperative nursing| metoclopramide| gastric emptying MSC: Integrated Process: Nursing Process: Implementation NOT: Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies 12. A client in the preoperative holding room has received sedation and now needs to urinate. What action by the nurse is best? a. Allow the client to walk to the bathroom. b. Delegate assisting the client to the nurses aide. c. Give the client a bedpan or urinal to use. d. Insert a urinary catheter now instead of waiting.

C Although possibly uncomfortable or embarrassing for the client, the client should not be allowed out of bed after receiving sedation. The nurse should get the client a bedpan or urinal. The client may or may not need a urinary catheter. DIF: Applying/Application

233 KEY: Preoperative nursing| anxiety| unlicensed assistive personnel (UAP) MSC: Integrated Process: Nursing Process: Implementation NOT: Client Needs Category: Safe and Effective Care Environment: Management of Care 11. A client who collapsed during dinner in a restaurant arrives in the emergency department. The client is going to surgery to repair an abdominal aortic aneurysm. What medication does the nurse prepare to administer as a priority for this client? a. Hydroxyzine (Atarax) b. Lorazepam (Ativan) c. Metoclopramide (Reglan) d. Morphine sulfate

C Reglan increases gastric emptying, an important issue for this client who was eating just prior to the operation. The other drugs are appropriate for any surgical client. DIF: Applying/Application

228 KEY: Preoperative nursing| herbs and supplements| medication interactions MSC: Integrated Process: Communication and Documentation NOT: Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies 3. A nurse works on the postoperative floor and has four clients who are being discharged tomorrow. Which one has the greatest need for the nurse to consult other members of the health care team for post-discharge care? a. Married young adult who is the primary caregiver for children b. Middle-aged client who is post knee replacement, needs physical therapy c. Older adult who lives at home despite some memory loss d. Young client who lives alone, has family and friends nearby

C The older adult has the most potentially complex discharge needs. With memory loss, the client may not be able to follow the prescribed home regimen. The clients physical abilities may be limited by chronic illness. This client has several safety needs that should be assessed. The other clients all have evidence of a support system and no known potential for serious safety issues. DIF: Applying/Application

72 OBJ: 3 (theory) TOP: Immediate Preoperative Care KEY: Nursing Process Step: Implementation MSC: NCLEX: Safe, Effective Care Environment: Coordinated Care 8. Noting that the Asian patient was given atropine as a preoperative drug, the nurse will closely monitor for: a. oliguria. b. hyperventilation. c. hypotension. d. tachycardia.

D Asians often metabolize atropine differently from other populations. The drug can greatly accelerate the heart rate in the Asian patient. DIF: Cognitive Level: Application

321 TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity 8. The nurse obtains a health history from a patient who is scheduled for elective hip surgery in 1 week. The patient reports use of garlic and ginkgo biloba. Which action by the nurse is most appropriate? a. Ascertain that there will be no interactions with anesthetic agents. b. Teach the patient that these products may be continued preoperatively. c. Advise the patient to stop the use of all herbs and supplements at this time. d. Discuss the herb and supplement use with the patients health care provider.

D Both garlic and ginkgo biloba increase a patients risk for bleeding. The nurse should discuss the herb and supplement use with the patients health care provider. The nurse should not advise the patient to stop the supplements or to continue them without consulting with the health care provider. Determining the interactions between the supplements and anesthetics is not within the nurses scope of practice. DIF: Cognitive Level: Apply (application)

323 TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity 15. As the nurse prepares a patient the morning of surgery, the patient refuses to remove a wedding ring, saying, I have never taken it off since the day I was married. Which response by the nurse is best? a. Have the patient sign a release and leave the ring on. b. Tape the wedding ring securely to the patients finger. c. Tell the patient that the hospital is not liable for loss of the ring. d. Suggest that the patient give the ring to a family member to keep.

D Jewelry is not allowed to be worn by the patient, especially if electrocautery will be used. There is no need for a release form or to discuss liability with the patient. DIF: Cognitive Level: Apply (application)

76 OBJ: 5 (theory) TOP: Stages of General Anesthesia KEY: Nursing Process Step: NA MSC: NCLEX: NA 18. The nurse is planning care for four postoperative patients. The nurse determines that the patient who is most likely to develop postoperative complications is the patient who is: a. 36 years old with a history of controlled diabetes. b. 52 years old with a history of hypothyroidism. c. 45 years old with a history of a myocardial infarction (MI). d. 79 years old with mild osteoarthritis.

D Patients over the age of 75 are 3 times more likely to experience surgical complications. The elderly patient is less able to adjust and compensate for the stress of surgery, as physiologic reserves (cardiac, respiratory, renal) have already declined with age. DIF: Cognitive Level: Application

N/A TOP: Client Needs Category: Physiological Integrity (Reduction of Risk PotentialPotential for Complications From Surgical Procedures and Health Alterations) MSC: Integrated Process: Nursing Process (Intervention) 5. When the nurse brings a clients preoperative medications, the client responds, I dont need that. I had a good nights sleep last night. What is the nurses best response? a. The doctor ordered this medication so you should take it. b. I will make a note that you refused to take the medication. c. I will ask your surgeon if you have to take the medication. d. Let me teach you about your medications for surgery.

D Preoperative medications can include sedatives but are often given to prevent laryngospasm and to help reduce pharyngeal and gastric secretions. The client must be fully aware of the rationale for all medications and the risks of not taking them. DIF: Cognitive Level: Application/Applying or higher

N/A TOP: Client Needs Category: Safe and Effective Care Environment (Safety and Infection ControlAccident/Injury Prevention) MSC: Integrated Process: Teaching/Learning 10. The nurse is performing preoperative teaching with an older adult client who will be having colon resection surgery the following day. The surgeon has ordered bowel preparation the night before. Which action is a priority? a. Administer antibiotics with a sip of water. b. Encourage the client to drink plenty of juice. c. Teach the client to eat only low-fat foods the night before surgery. d. Tell the client not to get up and go to the bathroom alone.

D Safety is the priority, and the older adult client can become exhausted and may fall. Antibiotics, if ordered, would be administered with a sip of water, but this is not the priority. The client would not be encouraged to drink juice, because this is not a clear liquid. DIF: Cognitive Level: Application/Applying or higher

323 TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity 14. The outpatient surgery nurse reviews the complete blood cell (CBC) count results for a patient who is scheduled for surgery in a few days. The results are white blood cell (WBC) count 10.2 103/L; hemoglobin 15 g/dL; hematocrit 45%; platelets 150 103/L. Which action should the nurse take? a. Call the surgeon and anesthesiologist immediately. b. Ask the patient about any symptoms of a recent infection. c. Discuss the possibility of blood transfusion with the patient. d. Send the patient to the holding area when the operating room calls.

D The CBC count results are normal. With normal results, the patient can go to the holding area when the operating room is ready for the patient. There is no need to notify the surgeon or anesthesiologist, discuss blood transfusion, or ask about recent infection. DIF: Cognitive Level: Apply (application)

N/A TOP: Client Needs Category: Psychosocial Integrity (Therapeutic Communication) MSC: Integrated Process: Teaching/Learning 18. A client tells the nurse that he has an advance directive with durable power of attorney for health care. The client asks how the advance directive will affect the surgery. What is the nurses best response? a. You will not be intubated during general anesthesia for the surgery. b. There will be no effect on your surgery. c. The surgical staff will resuscitate only if your heart stops during the operation. d. If you are unable to make a decision, your designee will be asked.

D The advance directive with durable power of attorney indicates whom the client wishes to designate for medical decisions if he is unable to make decisions for himself. An advance directive with power of attorney does not eliminate the need for intubation during surgery. Although the document does not affect the procedure, simply acknowledging that fact does not help the client understand. If the clients heart stops during the operation and the client has not made his or her wishes known about that situation, the power of attorney would be consulted. DIF: Cognitive Level: Comprehension/Understanding

68 OBJ: 4 (clinical) TOP: Obtaining Consent KEY: Nursing Process Step: Assessment MSC: NCLEX: Safe, Effective Care Environment: Coordinated Care 11. The nurse explains that the person responsible for verifying that the consent form is signed and that the surgical site is marked is the: a. scrub nurse. b. surgeon. c. anesthesiologist. d. circulating nurse.

D The circulating nurse is responsible for confirming a signature on the consent form and marking the site for surgery. DIF: Cognitive Level: Comprehension

N/A TOP: Client Needs Category: Physiological Integrity (Reduction of Risk PotentialPotential for Complications From Surgical Procedures and Health Alterations) MSC: Integrated Process: Nursing Process (Assessment) 21. The nurse is conducting preoperative assessments. Which client does the nurse teach about the possibility of developing a venous thromboembolism (VTE)? a. Client with a latex allergy b. Client with body mass index (BMI) of 19 c. Client with an international normalized ratio (INR) of 2.2 d. Client undergoing hip replacement surgery

D The client will have limited mobility following hip replacement surgery, increasing the risk of postoperative venous thromboembolism (VTE). The other conditions will not increase the risk of VTE. DIF: Cognitive Level: Application/Applying or higher

321 TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity 18. The nurse interviews a patient scheduled to undergo general anesthesia for a hernia repair. Which information is most important to communicate to the surgeon and anesthesiologist before surgery? a. The patient drinks 3 or 4 cups of coffee every morning before going to work. b. The patient takes a baby aspirin daily but stopped taking aspirin 10 days ago. c. The patient drank 4 ounces of apple juice 3 hours before coming to the hospital. d. The patients father died after receiving general anesthesia for abdominal surgery.

D The information about the patients father suggests that there may be a family history of malignant hyperthermia and that precautions may need to be taken to prevent this complication. Current research indicates that having clear liquids 3 hours before surgery does not increase the risk for aspiration in most patients. Patients are instructed to discontinue aspirin 1 to 2 weeks before surgery. The patient should be offered caffeinated beverages postoperatively to prevent a caffeine-withdrawal headache, but this does not have preoperative implications. DIF: Cognitive Level: Apply (application)

320 OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity 20. A patient who takes a diuretic and a b-blocker to control blood pressure is scheduled for breast reconstruction surgery. Which patient information is most important to communicate to the health care provider before surgery? a. Hematocrit 36% b. Blood pressure 144/82 c. Pulse rate 58 beats/minute d. Serum potassium 3.2 mEq/L

D The low potassium level may increase the risk for intraoperative complications such as dysrhythmias. Slightly elevated blood pressure is common before surgery because of anxiety. The lower heart rate would be expected in a patient taking a b-blocker. The hematocrit is in the low normal range but does not require any intervention before surgery. DIF: Cognitive Level: Apply (application)

N/A TOP: Client Needs Category: Safe and Effective Care Environment (Safety and Infection ControlAccident/Injury Prevention) MSC: Integrated Process: Nursing Process (Implementation) 11. When examining an adult clients preoperative laboratory results, the nurse notes that the potassium level is 2.9 mEq/mL. What is the nurses priority action? a. Document the finding. b. Alter the clients diet to include fruit. c. Increase the IV flow rate. d. Notify the surgeon.

D The normal range for serum potassium is 3.5 to 5.0 mEq/L or mmol/L. A value of 2.9 represents hypokalemia, which must be corrected before surgery. The surgeon should be notified of this finding. The finding should be documented; however, notifying the surgeon is the priority. DIF: Cognitive Level: Application/Applying or higher

N/A TOP: Client Needs Category: Physiological Integrity (Reduction of Risk PotentialPotential for Complications From Surgical Procedures and Health Alterations) MSC: Integrated Process: Nursing Process (Analysis) 3. The nurse is completing preoperative teaching for a client, and it becomes apparent that the client does not understand the surgery that will be performed. What is the priority action for the nurse? a. Obtain informed consent from the client. b. Continue teaching the client about the surgery. c. Revise the teaching plan for the client. d. Notify the surgeon and document the finding.

D The surgeon should be notified right away so that the client can be instructed about the surgery to be performed. The client cannot give informed consent unless he or she understands the procedure. DIF: Cognitive Level: Application/Applying or higher

64 OBJ: 1 (theory) TOP: Bloodless Surgery KEY: Nursing Process Step: Planning MSC: NCLEX: Health Promotion and Maintenance 2. The nurse is performing a preoperative assessment on a patient scheduled for surgery today. The patient reports a history of drinking 2 glasses of wine daily, smoking cigarettes for 20 years, completing a round of corticosteroids for asthma control 2 days ago, and taking the last dose of passion flower extract yesterday. The nurses best action is: a. supply the patient with information on a smoking cessation class. b. warn the patient regarding the dangers of drinking alcohol on a daily basis. c. provide the patient with information regarding the use of herbal medications. d. notify the physician immediately regarding the recent use of corticosteroids.

D The use of corticosteroids reduces the bodys response to infection and delays healing. Surgery may need to be delayed until the patient has been off the drug approximately 7 days. Providing the patient with information regarding smoking cessation is advisable but is not a priority at this time. Drinking 2 glasses of wine daily may not be a problem if not contraindicated by the patients health status. Passion flower extract does not interfere with the surgery and poses no apparent problems. DIF: Cognitive Level: Analysis

76 OBJ: 5 (theory) TOP: Types of Anesthesia KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Basic Care and Comfort 15. During the course of surgery, a patient exhibits tachycardia, diaphoresis, and rising body temperature. The priority intervention by the circulating nurse is to: a. continue to monitor the patient for any further changes in condition. b. note the patients oxygen saturation and blood pressure. c. ask the scrub nurse to verify the assessment findings. d. alert the anesthesiologist and surgeon immediately.

D These are signs of malignant hyperthermia, along with arrhythmias, muscle rigidity, and hypotension. The anesthesiologist and surgeon should be notified immediately because malignant hyperthermia is a medical emergency. DIF: Cognitive Level: Application

72 | Safety Alert OBJ: 4 (clinical) TOP: Preoperative Medication KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Reduction of Risk Potential 6. The nurse is aware that the 82-year-old patient returning from surgery will need special attention relative to: a. combating thirst. b. maintaining respiratory status. c. stabilizing blood pressure. d. maintaining core body temperature.

D Thirst, respiratory status, and blood pressure are all important considerations when caring for the postsurgical patient; however, maintaining core body temperature is a major concern with the older adult postsurgical patient. DIF: Cognitive Level: Application

N/A TOP: Client Needs Category: Physiological Integrity (Reduction of Risk PotentialPotential for Complications From Surgical Procedures and Health Alterations) MSC: Integrated Process: Nursing Process (Assessment) 22. The nurse applies antiembolism stockings to a client preoperatively. When the client says that they are uncomfortably tight, what is the nurses best action? a. Remove the stockings for an hour to relieve the pressure. b. Pull the stockings down so that they are not constricting. c. Measure the clients calf to ensure that they are the correct size. d. Teach the client the purpose of wearing the stockings.

D Thromboembolic disease (TED) stockings should feel slightly tight on the legs to promote venous return and prevent the client from developing venous thromboembolism (VTE). The nurse should not remove the stockings nor pull them down. The calf would have been measured before the stockings were obtained. DIF: Cognitive Level: Application/Applying or higher

221 KEY: Preoperative nursing| infection| older adult MSC: Integrated Process: Nursing Process: Assessment NOT: Client Needs Category: Health Promotion and Maintenance 2. A preoperative nurse is assessing a client prior to surgery. Which information would be most important for the nurse to relay to the surgical team? a. Allergy to bee and wasp stings b. History of lactose intolerance c. No previous experience with surgery d. Use of multiple herbs and supplements

D Some herbs and supplements can interact with medications, so this information needs to be reported as the priority. An allergy to bee and wasp stings should not affect the client during surgery. Lactose intolerance should also not affect the client during surgery but will need to be noted before a postoperative diet is ordered. Lack of experience with surgery may increase anxiety and may require higher teaching needs, but is not the priority over client safety. DIF: Applying/Application

62 OBJ: 1 (theory) TOP: Laparoscopic Surgery KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Basic Care and Comfort 27. A(n) ________________ allows a patient to donate her own blood to be used during or after surgery.

autologous transfusion An autologous transfusion is one in which the patient has donated her own blood to be used during or after surgery. DIF: Cognitive Level: Comprehension

p. 242 TOP: Client Needs Category: Physiological Integrity (Reduction of Risk PotentialPotential for Complications From Surgical Procedures and Health Alterations) MSC: Integrated Process: Communication and Documentation OTHER 1. The nurse is preparing to transfer a client to the operating room for surgery. Put the interventions in order for the nurse to perform. (List in order of priority.) a. Take a full set of vital signs. b. Have the client go to the bathroom to void. c. Ask the client to state his or her name and check the ID band. d. Administer ordered preoperative sedation.

c, b, a, d First, the nurse should identify the client using two identifiers to ensure that the correct client is being prepped for surgery. Next, the nurse should assist the client to the bathroom, then take vital signs, then finally administer preoperative sedation once the client is in bed. DIF: Cognitive Level: Application/Applying or higher TOP: Client Needs Category: Safe and Effective Care Environment (Safety and Infection ControlAccident/Injury Prevention) MSC: Integrated Process: Nursing Process (Implementation) 1. An older client is hospitalized after an operation. When assessing the client for postoperative infection, the nurse places priority on which assessment? a. Change in behavior b. Daily white blood cell count c. Presence of fever and chills d. Tolerance of increasing activity ANS: A Older people have an age-related decrease in immune system functioning and may not show classic signs of infection such as increased white blood cell count, fever and chills, or obvious localized signs of infection. A change in behavior often signals an infection or onset of other illness in the older client. DIF: Applying/Application

63 | Table 4-1 OBJ: 3 (theory) TOP: Preoperative Teaching KEY: Nursing Process Step: Evaluation MSC: NCLEX: Health Promotion and Maintenance COMPLETION 26. The nurse reminds the patient that in laparoscopic surgery, with the small incision and less tissue trauma, there is less pain because of the diminished ______________.

inflammatory response There is less trauma, therefore less inflammatory response, which reduces pain. DIF: Cognitive Level: Comprehension