2900/1 ATI & PrepU

A nurse is caring for a client who is experiencing anaphylactic shock in response to the administration of penicillin. Which of the following medications should the nurse administer first?

Epinephrine

A nurse is caring for a client who is bradycardia following a surgical procedure using spinal anesthesia. The nurse should plan to administer which of the following medications to the client?

Epinephrine epinephrine, a vasopressor, to increase the client's heart rate and prevent cardiac arrest.

A nurse is providing teaching for a client who is scheduled to undergo moderate sedation for bronchoscopy. Which of the following client statements indicates an understanding of the teaching?

"I can expect to feel sleepy for several hours after the procedure". The nurse should instruct the client to expect to feel drowsy for several hours following moderate sedation and to avoid any activities which require concentration.

A nurse is providing discharge teaching for a client who is post-op following rhinoplasty using general anesthesia. Which of the following instructions should the nurse include?

"Use cool compresses on your eyes, nose, and face". The nurse should instruct the client to place cool compresses on his face to reduce swelling and ecchymosis.

What measurement should the nurse report to the physician in the immediate postoperative period?

A systolic blood pressure lower than 90 mm Hg. A systolic blood pressure of less than 90 mm Hg is usually considered immediately reportable. However, the patient's preoperative or baseline blood pressure is used to make informed postoperative comparisons.

A nurse is monitoring a client who received succinylcholine during a surgical procedure. Which of the following actions should the nurse take if the client develops manifestations of malignant hyperthermia?

Administer dantrolene The nurse should administer dantrolene by IV bolus at 2 to 5 mg/kg to reverse the manifestations for a client who has malignant hyperthermia.

Which is the priority, collaborative, nursing intervention to treat malignant hyperthermia in the surgical site?

Administer dantrolene IV push over one minute.

A patient presents to the ED with BP 86/40, HR 140, RR 24, temp 98.1, and O2 sats on room air at 92%. The patient is anxious and denies any pain. The provider prescribes a half liter bolus of 0.9% Normal Saline to be administered 30 minutes. Which is the correct action by the nurse?

Administer fluid at a rate of 1000 mL per hour.

A nurse is caring for a client who is postop following abdominal surgery. Which of the following interventions should the nurse perform to prevent respiratory complications?

Advise patient to splint the surgical incision when coughing and deep breathing. Splinting the incision supports the surgical site and decreases pain during coughing and deep breathing.

A nurse is caring for a client who is preop and is asking multiple questions about the risks of the procedure. Which of the following actions should the nurse take?

Ask the surgeon to speak to the client for clarification. The nurse should notify the surgeon that the client has questions about the procedure. It is the responsibility of the surgeon to explain the risks and benefits of the surgery.

A client is at postoperative day 1 after abdominal surgery. The client is receiving 0.9% normal saline at 75 mL/h, has a nasogastric tube to low wall suction with 200 mL every 8 hours of light yellow fluid, and a wound drain with 50 mL of dark red drainage every 8 hours. The 24-hour urine output total is 2430 mL. What action by the nurse is most appropriate?

Assess for signs and symptoms of fluid volume deficit.

The nurse is performing the shift assessment of a postsurgical client. The nurse finds the client's mental status, level of consciousness, speech, and orientation are intact and at baseline, but the client appears unusually restless. What should the nurse do next?

Assess the client's oxygen levels. The nurse assesses the client's mental status and level of consciousness, speech, and orientation and compares them with the preoperative baseline. Although a change in mental status or postoperative restlessness may be related to anxiety, pain, or medications, it may also be a symptom of oxygen deficit or hemorrhage.

A nurse is caring for an older adult client who has a terminal illness and is ventilator dependent. The client is alert and oriented and he wants to discontinue use of the ventilator. The nurse should be aware that continued treatment against the client's wished is a violation of which ethical principle?

Autonomy

Which of the following actions by the nurse is appropriate?

Discarding an object that comes in contact with the 1-inch border. The 1-inch border of a sterile field is considered unsterile.

A nurse is assessing a client who is 2 days postop following a total prostatectomy. The nurse notes that the client's right calf is red, edematous, and warm to the touch. Which of the following actions should the nurse take?

Elevate the client's right extremity. These findings suggest the client has deep-vein thrombosis. The nurse should keep the client's right extremity elevated to promote venous return.

The nurse is caring for a client who is receiving moderate (conscious) sedation with midazolam. The client's respiratory rate decreases from 16 to 6/min, and their oxygen saturation from 92 to 85%. Which of the following medications should the nurse administer?

Flumazenil The client's respiratory rate and oxygen saturation level indicate increased sedation caused by a benzodiazepine. The nurse should administer flumazenil, a benzodiazepine agonist, to reverse the sedative effects of the medication.

The nurse admits a client to the postanesthesia care unit with a blood pressure of 132/90 mm Hg and a pulse of 68 beats per minute. After 30 minutes, the client's blood pressure is 94/47 mm Hg, and the pulse is 110. The nurse documents that the client's skin is cold, moist, and pale. This client is showing signs of what potential issue?

Hypovolemic shock. The client is exhibiting symptoms of hypovolemic shock; therefore, the nurse should notify the client's health care provider and anticipate orders for fluid and/or blood product replacement.

The intraoperative nurse is implementing a care plan that addresses the surgical client's risk for vomiting. Interventions that address the potential for vomiting reduce the risk of what subsequent surgical complication?

Hypoxia If the client aspirates vomitus, an asthma-like attack with severe bronchial spasms and wheezing is triggered. Pneumonitis and pulmonary edema can subsequently develop, leading to extreme hypoxia. Vomiting can cause choking, but the question asks about aspirated vomitus.

A nurse is caring for a client who had an open transverse colectomy 5 days ago. The nurse enters the client's room and recognizes that the wound has eviscerated. After coveting the wound with sterile, saline soaked dressing, which of the following actions should the nurse take?

Obtain VS to assess shock. The nurse should obtain vital signs to assess the client's current status.

During the care of a preoperative client, the nurse has given the client a preoperative benzodiazepine. The client is now requesting to void. What action should the nurse take?

Offer the client a bedpan or urinal. If a preanesthetic medication is given, the client is kept in bed with the side rails raised because the medication can cause lightheadedness or drowsiness. If a client needs to void following administration of a sedative, the nurse should offer the client a urinal.

Following admission of the postoperative client to the clinical unit, which of the following assessment data requires the most immediate attention?

Oxygen saturation of 82%. Normal pulse oximetry is 95% to 100%. An oxygen saturation of 82% indicates respiratory compromise and requires immediate attention.

A patient on a psychiatric unit has experienced a sudden shift in mood from being withdrawn and depressed too happy and talkative. The patient has also been giving away various personal items to other patients. What is the nurse's priority action?

Perform a suicide, or lethality assessment on the patient.

You are physically preparing a client for surgery and instruct the person to remove any jewelry. The client refuses to remove a wedding band. What should you do in this situation with approval from your facility?

Place gauze under and over the ring and apply adhesive tape over it. If the client is reluctant to remove a wedding band, the nurse may slip gauze under the ring, then loop the gauze around the finger and wrist or apply adhesive tape over a plain wedding band.

A nurse is caring for a client who has returned to the unit following a surgical procedure. The client's oxygen saturation is 85%. Which of the following actions should the nurse take first?

Raise the head of the bed.

A nurse is reviewing the medical record for a client who has prescription for a general anesthesia prior to surgery.

Potassium 2.8 The nurse should identify that the client's potassium level is below the expected reference range of 3.5 to 5 mEq/L, which places the client at risk for cardiac dysrhythmias. Therefore, the nurse should report this finding to the provider.

What is the major purpose of withholding food and fluid before surgery?

Prevent aspiration

Which action should a nurse perform to prevent deep vein thrombosis when caring for a postsurgical client?

Reinforce the need to perform leg exercises every hour when awake The nurse should reinforce the need to perform leg exercises every hour when awake. If signs and symptoms of thrombophlebitis appear, the client should maintain bed rest.

Once the operating team has assembled in the room, the circulating nurse calls for a "time out." What action should the nurse take during the time out?

Review the scheduled procedure, site, and client.. According to the 2016 National Patient Safety Goals, accurate identification of the client, procedure, and operative site is essential.

A nurse is working as a registered nurse first assistant as defined by the state's nurse practice act. This nurse practices under the direct supervision of which surgical team member?

Surgeon. - The registered nurse first assistant practices under the direct supervision of the surgeon. - The circulating nurse works in collaboration with other members of the health care team to plan the best course of action for each patient. - The scrub nurse assists the surgeon during the procedure as well as setting up sterile tables and preparing equipment. - The anesthetist administers the anesthetic medications.

A nurse is caring for a client who is at risk for hypovolemic shock. Which findings is the earliest indicator that this complication is developing?

Tachycardia

Following a surgical procedure, who is generally responsible for moving the client to the recovery area?

The anesthesiologist, circulating nurse, and surgeon. After the intraoperative phase of the surgical procedure has been completed, the circulating nurse, the anesthesia provider, and the surgeon safely transport the client to the PACU, taking care to maintain the client's airway during this critical time.

The nurse is caring for a patient after abdominal surgery in the PACU. The patient's blood pressure has increased and the patient is restless. The patient's oxygen saturation is 97%. What cause for this change in status should the nurse first suspect?

The patient is in pain. An increase in blood pressure and restlessness are symptoms of pain.

Why do nurses act to influence policy regarding mental health?

To improve the holistic welfare of the patient.

A nurse is assessing a client who is recovering from spinal anesthesia. Which of the following sensation should the nurse expect to return to the client first?

Touch. Following spinal anesthesia, the first sensation the nurse should expect the client to feel is the sense of touch.

When a client with a history of chronic alcoholism is admitted to the hospital for surgery, the nurse anticipates that the client may show signs of alcohol withdrawal delirium during which time period?

Up to 72 hours after alcohol withdrawal. Alcohol withdrawal delirium is associated with a significant mortality rate when it occurs postoperatively. Onset of symptoms depends on when alcohol was last consumed. Twenty-four hours is too short a time frame to consider alcohol withdrawal delirium as no longer a threat to a chronic alcoholic.

A nurse in an acute care mental health facility is sitting with a client who has schizophrenia. The client whispers to the nurse, "I'm being kept in this prison against my will. Please try to get me out." Which response should the nurse make?

You feel that you don't belong here?

It is important for the nurse to assist a postsurgical client to sit up and turn the head to one side when vomiting in order to

avoid aspiration.

A term used to describe a partial or complete separation of wound edges is

dehiscence. Dehiscence is the partial or complete separation of wound edges.

A client develops malignant hyperthermia. What client symptom would the nurse most likely observe as the first indicator of the disorder?

heart rate over 150 beats per minute. With malignant hyperthermia, tachycardia with a heart rate greater than 150 beats per minute is often the earliest sign because of an increase in end-tidal carbon dioxide.

A nurse is teaching a client who is in the immediate post-op period about the use of PCA pump. Which of the following statements should the nurse include in the teaching?

"Do not allow visitors to push the PCA button if you are sleeping." The nurse should instruct the client that they should be awake when receiving a dose of the medication and that they are the only authorized user of the PCA pump. Allowing visitors to push the button is a safety risk for the client.

A nurse is providing discharge instructions for a client who is postop following abdominal surgery. which of the following client statements indicate an understanding of the teaching?

"I will eat foods that are high in protein an vitamin C during my recovery" The nurse should instruct the client to increase intake of foods with protein and vitamin C to promote wound healing.

A client asks why a drain is in place to pull fluid from the surgical wound. What is the best response by the nurse?

"It assists in preventing infection." A wound drain assists in preventing infection by removing the medium in which bacteria could grow.

A nurse is preparing to administer morphine sulfate 2 mg IV bolus. Available is morphine sulfate 10 mg/mL. How many mL should the nurse administer per dose?

0.2

In the immediate postoperative period, vital signs are taken at least every

15 minutes. Pulse rate, blood pressure, and respiration rate are recorded at least every 15 minutes for the first hour and every 30 minutes for the next 2 hours.

The circulating nurse must be vigilant in monitoring the surgical environment. Which of the following actions by the nurse is inappropriate?

Allow unnecessary personnel to enter the OR environment. The circulating nurse restricts the admittance of unnecessary personnel in the OR environment.

After undergoing a thyroidectomy, a client develops hypocalcemia and tetany. Which electrolyte should the nurse anticipate administering?

Calcium gluconate Immediate treatment for a client who develops hypocalcemia and tetany after thyroidectomy is calcium gluconate.

The nurse is caring for a client who has been diagnosed with deep vein thrombosis. When assessing the client's vital signs, the nurse notes an apical pulse of 150 bpm, a respiratory rate of 46 breaths/minute, and blood pressure of 100/60 mm Hg. The client appears anxious and restless. What should be the nurse's first course of action?

Call the rapid response team. Pulmonary embolism is a potentially life-threatening complication of deep vein thrombosis. The client's change in mental status, tachypnea, and tachycardia indicate a possible pulmonary embolism. The nurse should promptly call the rapid response team.

A registered nurse who is responsible for coordinating and documenting client care in the operating room is a

Circulating Nurse A circulating nurse is a registered nurse who coordinates and documents client care.

A nurse is planning care for a client who is postop and has a closed-wound drainage system in place. Which of the following interventions should the nurse plan to include?

Cleanse the drain plug with alcohol after emptying. After emptying the drain, the nurse should compress the top and bottom of the device together with one hand, while cleansing the plug with the other.

A nurse in a PACU is assessing a client who is postop. Which of the following finding should the nurse report to the provider?

Presence of inspiratory stridor The nurse should report inspiratory stridor to the provider because it is a manifestation of tracheal edema and requires intervention.

A nurse is caring for a client with a postoperative wound evisceration. Which action should the nurse perform first?

Cover the protruding internal organs with sterile gauze moistened with sterile saline solution. Immediately covering the wound with moistened gauze prevents the organs from drying. The gauze and the saline solution must be sterile to reduce the risk of infection.

A nurse is caring for a child who is 2 hr postoperative following a tonsillectomy. Which o the following fluid items should the nurse offer the child at this time?

Crushed Ice

A nurse is teaching a client who has septic shock about the development of disseminated intravascular coagulation (DIC). Which of the following statements should the nurse make?

DIC is caused by abnormal coagulation involving fibrinogen.

The perioperative nurse is preparing to discharge a client home from day surgery performed under general anesthetia. Which instruction should the nurse give the client prior to the client leaving the hospital?

Do not drive yourself home. During this time, the client should not drive a vehicle and should eat only as tolerated. Although recovery time varies depending on the type and extent of surgery and the client's overall condition, instructions usually advise limited activity for 24 to 48 hours

Which term refers to the protrusion of abdominal organs through the surgical incision?

Evisceration Evisceration is a surgical emergency. Evisceration occurs when organs protrude through the surgical incision.

A nurse is caring for a client who is 12 hr post-op from a gastrectomy and has NG tube set to continuous low suction. Which of the following requires intervention by the nurse?

Gastric distention astric distention is an indication that the NG tube is not patent. The nurse should check the tubing for kinks, blockages, and loose connections. The nurse should also reposition the client to facilitate drainage and avoid removing or irrigating the tube unless directed to do so by the provider.

Guided imagery can be used to manage postoperative pain. What is true about this statement?

Guided imagery is recommended as an adjunct for postoperative pain management.

Which would be included as a responsibility of the scrub nurse?

Handing instruments to the surgeon and assistants. The responsibilities of a scrub nurse are to assist the surgical team by handing instruments to the surgeon and assistants, preparing sutures, receiving specimens for laboratory examination, and counting sponges and needles.

A patient is newly admitted with difficulty breathing, It would be most important to consider which piece of history data when planning care for this patient?

History of recurrent pneumonia

A patient with uncontrolled diabetes is scheduled for a surgical procedure. What chief life-threatening hazard should the nurse monitor for?

Hypoglycemia The patient with diabetes who is undergoing surgery is at risk for both hypoglycemia and hyperglycemia. Hypoglycemia may develop during anesthesia or postoperatively from inadequate carbohydrates or excessive administration of insulin. Hyperglycemia, which can increase the risk of surgical wound infection, may result from the stress of surgery, which can trigger increased levels of catecholamine.

A nurse in the ED is assessing a client who has internal injuries from a car crash. The client is disoriented to time and place, diaphoretic, and his lips are cyanotic. The nurse should anticipate which of the findings as an indication of hypovolemic shock?

Increased heart rate

Nursing assessment findings reveal a temperature of 35.6 C (96.2°F), pulse oximetry 90%, shivering, and client complains of chilling. The findings are indicative of which nursing diagnosis?

Ineffective thermoregulation. Clinical manifestations of hypothermia include a low body temperature, shivering, chilling, and hypoxia.

A circulating nurse is monitoring the temp in the surgical suite. The nurse should identify that cool temp reduce client's risk for which of the following potential complications of surgery?

Infection. The nurse should identify that a cool room temperature with humidity between 30% and 60%, along with a proper air exchange and filtering system, reduces the risk of infection for clients during surgery.

A patient on the mental health unit tells the nurse "The voices are telling me to kill the doctor". Which action should the nurse take first?

Initiate one-on-one observation of the patient.

A nurse is assessing a client who is preop. The nurse should identify that which of the following factors reported by the client increased the risk for postop wound infection?

Long-term use of corticosteroids. The nurse should identify that the use of corticosteroids inhibits leukocyte response, which increases the client's risk for infection.

A nurse is assessing a client who received a preop IV dose of metoclopramide 1 hr ago. For which of the following findings should the nurse notify the provider?

Muscle rigidity Muscle rigidity is a manifestation of neuroleptic malignant syndrome, which is a potentially life-threatening adverse effect of metoclopramide. Other manifestations include hyperthermia, blood pressure irregularities, tachycardia, and diaphoresis. The nurse should report this finding to the provider.

A client has terminal cancer and is being cared for at home. The family member calls 911 emergency services when the client suddenly becomes unconscious. When paramedics arrive a POLST is visibly posted on the refrigerator. What is the purpose of this form?

Provide Emergency medical system (EMS) personnel (e.g., paramedics) the ability to rapidly determine whether the client wishes to have cardiopulmonary resuscitation (CPR) or receive any type of emergency interventions that may sustain life.

A nurse is providing pre-op teaching to a client who is scheduled for gastrectomy in 1 week. the client express anxiety about the upcoming surgery. Which of the following actions should the nurse take?

Provide concise, factual information. Providing concise, factual information allows for open communication and gives the nurse the opportunity to address the client's anxiety.

The nurse is caring for a client who has returned to the postsurgical unit following abdominal surgery. The client is unable to ambulate and is now refusing to wear external pneumatic compression stockings. The nurse should explain that refusing to wear external pneumatic compression stockings increases the risk of which postsurgical complication?

Pulmonary embolism Clients who have surgery that limits mobility are at an increased risk for pulmonary embolism secondary to deep vein thrombosis. he use of external pneumatic compression stockings significantly reduces the risk by increasing venous return to the heart and limiting blood stasis.

Which action should a nurse perform to prevent deep vein thrombosis when caring for a client postsurgical client?

Reinforce the need to perform leg exercises every hour when awake.

The nurse is taking the client into the operating room (OR) when the client informs the nurse that the client's grandparent spiked a very high temperature in the OR and nearly died 15 years ago. What relevance does this information have regarding the client?

The client may be at risk for malignant hyperthermia. Malignant hyperthermia is an inherited muscle disorder chemically induced by anesthetic agents. Identifying clients at risk is imperative because the mortality rate is 50%.

A nurse is teaching a client about deep venous thrombosis (DVT) prevention. What teaching would the nurse include about DVT prevention?

Report early calf pain.

A nurse is witnessing a client sign the consent form for surgery. After signing the consent form, the client starts asking questions regarding the risks and benefits of a surgical procedure. What action by the nurse is most appropriate?

Request that the surgeon come and answer the questions. It is the physician's responsibility to provide information pertaining to risks and benefits of surgery.

A client receiving moderate sedation for a minor surgical procedure begins to vomit. What should the nurse do first?

Roll the client onto his or her side. The client must be rolled to the side to prevent aspiration.

Which method of wound healing is one in which wound edges are not surgically approximated and integumentary continuity is restored by granulation?

Second-intention healing. - When wounds dehisce, they are allowed to heal by secondary intention. - Primary or first-intention healing is the method of healing in which wound edges are surgically approximated and integumentary continuity is restored without granulation. - Third-intention healing is a method of healing in which surgical approximation of wound edges is delayed and integumentary continuity is restored by bringing apposing granulations together.

A 25-year-old male patient has been admitted with a severe crushing injury and acute kidney injury after an industrial accident. Which laboratory result will be most important to report to the health care provider?

Serum potassium level 6.5 mEq/L

A patient is receiving a transfusion of packed red blood cells (PRBCs) and a transfusion reaction is suspected. What is the priority nursing intervention?

Stop the transfusion.

The nurse is preparing a patient for surgery. The patient is to undergo a hysterectomy without oophorectomy, and the nurse is witnessing the patient's signature on a consent form. Which comment by the patient would best indicate informed consent?

The health care provider is going to remove my uterus and told me about the risk of hemorrhage." The surgeon must also inform the patient of the benefits, alternatives, possible risks, complications, disfigurement, disability, and removal of body parts as well as what to expect in the early and late postoperative periods.

A surgical nurse enter a surgical suite to ensure surgical asepsis is maintained. For which of the following findings should the nurse intervene?

The scrub tech is wearing a watch under their scrubs. Finger and wrist jewelry are likely contaminated with micro-organisms and bacteria. Therefore, the scrub technologist should remove jewelry before handling sterile objects.

The nurse is providing preoperative teaching to a client scheduled for surgery. The nurse is instructing the client on the use of deep breathing, coughing, and the use of incentive spirometry when the client states, "I don't know why you're focusing on my breathing. My surgery is on my hip, not my chest." What rationale for these instructions should the nurse provide?

To promote optimal lung expansion. One goal of preoperative nursing care is to teach the client how to promote optimal lung expansion and consequent blood oxygenation after anesthesia.

A nurse is assessing a client who is 2 hr postop following an appendectomy. Which of the following findings should the nurse report to the provider?

Urine output of 20 ml/hr. The nurse should notify the provider if the client's urine output is less than 30 mL/hr. Decreased urine output can indicate hypovolemia and decreased perfusion of the kidneys.

A client is transferred from the surgical suit to the PACU following oral surgery. While monitoring the client's VS, the nurse finds that the client's tongue become swollen and is obstructing the airway. Which of the following actions should the nurse take first?

Use the head-tilt, chin-lift method to open the airway. The first action the nurse should take when using the airway, breathing, circulation approach to client care is to establish a patent airway by tilting the client's head back and pushing the lower jaw forward.

The nurse is caring for a client during the immediate postoperative period and is assessing for signs of shock. What signs and symptoms indicate that the client may be in shock?

Weak and rapid pulse rate. Signs and symptoms of shock include pallor, fall in blood pressure, weak and rapid pulse rate, restlessness, and cool, moist skin.

A nurse is providing pre-op teaching for a client who is scheduled to have a below-the-knee amputation. Which of the following instructions should the nurse include?

Your surgeon might prescribe an antibiotic before surgery. A client who has a surgical amputation of an extremity is at risk for infection. Therefore, the provider often prescribes a broad-spectrum, prophylactic antibiotic to reduce the risk of infection.

Prior to surgery a patient/costumer is diagnosed with thyroid storm. Which activities will the nurse do to care for this person? SELECT ALL THAT APPLY

a. Apply artificial tears. b. Change lines to often keep dry. c. Provide a calm, cool and quite room.

A patient admitted with a substance-induced psychosis is experiencing auditory hallucinations. The patient states, "The voices won't leave me alone!". Which statements would it be appropriate for the nurse to make? SELECT ALL THAT APPLY

a. Are the voices telling you to hurt yourself or others? b. It must be scary to hear voices. c. Do you plan to follow what the voices are telling you to do?

A nurse is caring for a 17-year-old pediatric client who is laboring with her first child. The obstetrician determines an emergent cesarean birth is necessary. Which of the following apply to this situation? SELECT ALL THAT APPLY.

a. The nurse assured the 17-year-old has been given the information needed to make a decision. b. A 17-year-old is legally allowed to give consent because she is pregnant.

During the surgical procedure, the client exhibits tachycardia, generalized muscle rigidity, and a temperature of 40 C. The nurse should prepare to administer:

dantrolene sodium (Dantrium). The client is exhibiting clinical manifestations of malignant hyperthermia. Dantrolene sodium, a skeletal muscle relaxant, is administered.

The primary objective in the immediate postoperative period is

maintaining pulmonary ventilation. The primary objective in the immediate postoperative period is to maintain pulmonary ventilation, which prevents hypoxemia.

The nurse is admitting a client to the medical-surgical unit from the PACU. In order to help the client clear secretions and help prevent pneumonia, the nurse should encourage the client to:

use the incentive spirometer every 2 hours. To clear secretions and prevent pneumonia, the nurse encourages the client to turn frequently, take deep breaths, cough, and use the incentive spirometer at least every 2 hours. These pulmonary exercises should begin as soon as the client arrives on the clinical unit and continue until the client is discharged.

A nurse is providing pre-op teaching to a client who is scheduled to have a mastectomy with reconstructive surgery. Which of the following statement by the client indicated an understanding of the teaching?

"I will be able to shower after the doctor removes the drain." A client who has had a mastectomy with reconstructive surgery can shower after the provider removes the drain.

A nurse is reviewing the medical record of a client who is scheduled for an elective surgery. Which of the following medications should the nurse expect the provider to discontinue prior to surgery to minimize the risk for complications?

Warfarin The nurse should anticipate that the provider will instruct the client to discontinue warfarin, an anticoagulant, because it increases the risk of bleeding during and following surgery.

An operating room (OR) nurse is participating in an interdisciplinary audit of infection control practices in the surgical department. The nurse should know that a basic guideline for maintaining surgical asepsis is which of the following?

Sterile surfaces or articles may touch other sterile surfaces. Basic guidelines for maintaining sterile technique include that sterile surfaces or articles may touch other sterile surfaces only.