ATI perioperative
A nurse is receiving evening shift report on four clients who returned from the PACU that morning. The nurse should assess which of the following clients first? A- A client who is postoperative following a thoracotomy and and has a chest tube with 150 mL of bright-red blood in the collection chamber from the past 1 hr B- A client who is postoperative following a small bowel resection and has a temporary colostomy along with absent bowel sounds in all four quadrants C- A client who is postoperative following a tonsillectomy and has had one episode of coffee-ground emesis D- A client who is postoperative following a total knee arthroplasty and is reporting a knee pain level of 7 on a scale from 0 to 10
A- A client who is postoperative following a thoracotomy and and has a chest tube with 150 mL of bright-red blood in the collection chamber from the past 1 hr When using the airway, breathing, circulation approach to client care, the nurse should first assess the client who has 150 mL of blood in the collection chamber because this finding is above the expected reference range and can be an indication of hemorrhage.
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 hyperthemia? A- Administer dantrolene B- Institute seizure precautions C- Remove endotracheal tube D- Give IV atropine
A- 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.
A nurse is reviewing the medication administration record for a client who is scheduled for surgery the next day. The nurse should identify that which of the following medications places the client at risk for complications during surgery and should be reported to the provider? A- Clopidogrel B- Atorvastatin C- Ranitidine D- Alendronate
A- Clopidogrel The nurse should identify that clopidogrel is an oral antiplatelet medication used to prevent coronary artery stenosis and other vascular incidents. Therefore, the mediation should be discontinued 5 days prior to surgery because it acts similarly to aspirin and can cause the client to experience increased bleeding during and after surgery.
A nurse is caring for a client who is 12 hours postoperative from a gastrectomy and has an NG tube set to continuous low suction. Which of the following findings requires intervention by the nurse? A- Gastric distention B- Absent bowel sounds C- Urine output of 150 mL over the last 4 hr D- Yellow drainage in the NG tube
A- Gastric distention Gastric 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. The nurse should avoid removing or irrigating the tube unless directed to do so by the surgeon.
A nurse is reviewing the medical record of a client who is to undergo eneral anesthesia for surgery. The nurse should report which of the following findings to the provider? A- Serum Potassium 2.8 mEq/L B- Serum Sodium 140 mEq/L C- INR 1.5 D- Bun 12 mEq/L
A- Serum Potassium 2.8 mEq/L The nurse should recognize 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, this finding should be reported to the provider immediately.
A surgical nurse enters a surgical suite to ensure surgical asepsis is maintained. Which of the following findings requires intervention by the nurse? A- The scrub tech is wearing a watch under his scrubs B- The circulating nurse opens dressing packages before applying sterile gloves C- The surgeon has her hands folded 5 cm above her waist D- The holding area nurse is performing client education
A- The scrub tech is wearing a watch under his scrubs Finger and wrist jewelry are likely contaminated with microorganisms and bacteria. Therefore, the scrub technologist should remove jewelry before handling sterile objects.
A nurse is assessing a client who is 2 hr postoperative following an appendectomy. Which of the following findings should the nurse report to the provider? A- Urine output of 20 mL/hr B- Temp of 36.5 C (97.7° F) C- A 2 cm X 2 cm area of bloody drainage on the dressing D- WBC 9,000 MM
A- 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 output can indicate hypovolemia and decreased perfusion of the kidneys.
A nurse is providing teaching for a client who is in the immediate postoperative period and has a PCA pump. Which of the following statements should the nurse include in the teaching? A- "You will receive a dose of medication every time you push the button" B- "Do not allow your family to push the PCA button if you are sleeping" C- "You cannot receive too much medication by pushing the button." D- "Do not push the PCA button until your pain reaches a severe level"
B- "Do not allow your family to push the PCA button if you are sleeping" The nurse should instruct the client that she should be awake when receiving a dose of the medication and that she is the only authorized user of the PCA pump. Therefore, allowing a family member to push the button is unauthorized and a safety risk for the client.
A nurse is caring for a client who is preoperative and is asking multiple questions about the risks of the procedure. Which of the following actions should the nurse take? A- Explain the risks and benefits of the surgery to the client B- Ask the surgeon to speak to the client for clarification C- Reassure the client that the procedure is necessary for recovery D- Notify the circulating nurse that the client has questions about the procedure
B- 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 nurse is creating a plan of care for a client who is preoperative for a total hip arthroplasty, practices judaism, and adheres to a kosher diet. Which of the following interventions is the nurse's priority? A- Listen and allow the client to express feelings about the surgery B- Determine if the clients faith conflicts with the treatment plan. C- Ensure the client's meal plan serves only kosher food following surgery. D- Teach the client how to perform various relaxation exercises.
B- Determine if the clients faith conflicts with the treatment plan. The nurse's priority intervention when using the nursing process is assessment. By determining if the client's faith, religious practices, or views conflict with the current treatment plan or surgical procedure, the nurse can take the necessary steps to inform the provider and prevent an issue during or after the surgical procedure.
A nurse is assessing a client who is 2 days postoperative 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? A- Apply an ice pack to the clients right calf B- Elevate the clients right extremity C- Administer testosterone to the client D- Gently massage the clients right calf
B- Elevate the clients 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.
A nurse is providing discharge instructions for a client who is postoperative following abdominal surgery. Which of the following client statements indicates an understanding of the teaching? A- I will have an increase in yellow-colored drainage from my incision for 2 weeks B- I will eat foods that are high in protein and vitamin C during my recovery C- I should avoid taking over the counter pain medication if my pain is not severe D- I will remain on bed rest until my follow up appointment with my doc
B- I will eat foods that are high in protein and 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 nurse is caring for a client who is 2 days postoperative following a cholecystectomy. The client has been vomiting for the past 24 hr and reports a pain level of 8 on a scale on a scale from 0 to 10. The nurse notes a hard, distended abdomen and absent bowel sounds. After conferring with the provider, which of the following actions should the nurse take first? A- Draw the clients blood for electrolytes B- Insert an NG tube C- Administer pain meds D- Initiate intake and output
B- Insert an NG tube The greatest risk to the client is fluid and electrolyte imbalance as a result of accumulated fluid and gas in the gastrointestinal tract. The first action the nurse should take is to insert an NG tube to begin decompression of the bowel.
A nurse is assessing a client who is preoperative. The nurse should identify that which of the following factors reported by the client increases the risk for a postoperative wound infection? A- Frequent use of echinacea B- Long-term use of corticosteroids C- History of osteoporosis D- Diet high in vit C
B- 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 caring for a client who has a surgical wound with a Penrose drain in place. Which of the following interventions should the nurse plan to perform? A- Cut a slit in a 4-inch square gauze pad to place around the drain B- Use the sterile technique when performing dressing changes C- Establish a clamping schedule prior to removal D- Apply negative pressure when emptying the drain
B- Use the sterile technique when performing dressing changes The nurse should change the Penrose drain dressing using the surgical aseptic technique
A nurse is providing preoperative for a client who is about to have a below-the-knee amputation. Which of the following instructions should the nurse include? A- "You should avoid lying on your abdomen after surgery" B-"your surgeon might prescribe an antibiotic before surgery" C- "It is important for you to sit in a chair at the bedside for several hours every day to reduce the risk of pneumonia" D- "To promote wound healing, it is important for you to reduce your intake
B-"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.
A nurse in the PACU assessing a client who is postoperative. Which of the following findings should the nurse report to the provider? A- BP 10% lower than baseline B- Pain level of 4 on 0 to 10 scale C- Presence of inspiratory stridor D- Small amount of sanguinous drainage on dressing
C- 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 who is postoperative following abdominal surgery. Which of the following nursing interventions should the nurse perform to prevent respiratory complications? A- Instruct the client to exhale into the incentive spirometer every 1-2 hr B- Minimize the amount of pain medication the client receives to prevent sedation C- Advise the client to splint the surgical incision when coughing and deep breathing D- Reposition the client every 8 hr for the first 48 hr
C- Advise the client 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 planning care for a client who is postoperative and has a closed-wound drainage system in place. Which of the following interventions should the nurse plan to include? A- Check the patency of the drain every 12 hrs. B- Clamp the drain while the client is ambulating. C- Cleanse the drain plug with alcohol after emptying. D- Secure the drain to the client's bed sheet.
C- Cleanse the drain plug with alcohol after emptying. After emptying the drain, the nurse should use one hand to compress the top and bottom of the device together and the other to cleanse the plug before replacing it.
A nurse is caring for a client who is receiving moderate (conscious) sedation with midazolam. The clients respiratory rate decreases from 16/min to 6/min, and the oxygen saturation decreases from 92% to 85%. Which of the following medications should the nurse administer? A- Atropine B- Acetylcysteine C- Flumazenil D- Protamine sulfate
C- Flumazenil The client's respiratory rate and oxygen saturation level indicate increased sedation caused from a benzodiazepine. The nurse should administer flumazenil, a benzodiazepine agonist, to reverse the sedative effects of the medication.
A nurse is assessing a clients recovery from spinal anesthesia. Which of the following sensations should the nurse expect to return to the client first? A- Pain B- Cold C- Touch D- Warmth
C- Touch Following spinal anesthesia, the first sensation the nurse should expect the client to feel is the sense of touch.
A nurse is providing discharge teaching for a client who is postoperative following a rhinoplasty using general anesthesia. Which of the following instructions should the nurse include? A- Lie on your side when resting for the first week after surgery B- Limit intake to clear liquids for the first 24 hours after surgery C- Use cool compresses on your eyes, nose, and face D- Close your mouth when you are about to sneeze
C- 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.
A circulating nurse is monitoring the temperature in a surgical suite. The nurse should identify that cool temperatures reduce a client's risk for which of the following potential complications of surgery? A- Malignant hyperthermia B-Blood clots C- Infection D-Hypoxia
C- 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 nurse is caring for a client who has bradycardia following a surgical procedure spinal anesthesia. The nurse should plan to administer which of the following medications to the client? A- Amiodarone B- Propranolol C- Methyldopa D- Epinephrine
D- Epinephrine The nurse should plan to administer 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 a bronchoscopy. The nurse should verify that the client inderstands the procedure when the client states which of the following? A-I will need to complete a bowel prep the day before B- I will drink plenty of fluids the morning of the procedure C- I can eat as soon as the procedure is over D- I can expect to feel sleepy for several hours after the procedure
D- I can expect to feel sleepy for several hours after the procedure Following moderate sedation, the client should expect to feel drowsy for several hours and should avoid all activities requiring concentration.
A nurse is providing preoperative teaching to a client who is scheduled to have a mastectomy with reconstructive surgery. Which of the following statements by the client indicates an understanding of the teaching? A- I should wait to take my pain meds until after I have completed my range-of-motion exercises B- I should wait a week after surgery to start my hand strengthening exercises C- I will be able to lift up an object that weighs 10 pounds 2 weeks after my surgery D- I will be able to shower after the doctor removes the drain
D- I will be able to shower after the doctor removes the drain A client who had a mastectomy with reconstructive surgery can shower after the provider removes the drain.
A client had an open transverse colectomy 5 days ago. The nurse enters the client's room and recognizes that the wound has eviscerated. After covering the wound with a sterile, saline-soaked dressing, which of the following actions should the nurse take? A- Go to the nurses station to seek assistance B- Reinsert the organs into the abdominal cavity C- Place the client in a reverse Trendelenburg position D- Obtain vital signs to assess for shock
D- Obtain vital signs to assess for shock The nurse should obtain vital signs to assess the client's current status.
A nurse is providing preoperative teaching to a client who is schedule for a gastrectomy in 1 week. The client is anxious about the upcoming surgery. Which of the following actions should the nurse take? A- Sympathize with the clients feelings B- Reassure the client that the surgery will go fine C- Change the topic of discussion D- Provide concise, factual information
D- Provide concise, factual information Providing concise, factual information allows for open communication and gives the nurse the opportunity to dispel the client's fears.
A client is transferred from the surgical suite to the PACU following oral surgery. While monitoring the client's vital signs, the nurse finds that the client's tongue has become swollen and is obstructing the airway. Which of the following actions should the nurse take first? A- Contact the anesthesiologist B- Assist the endotracheal intubation C- Increase the clients flow of oxygen D- Use the head-tilt, chin-life method to open the airway
D- Use the head-tilt, chin-life 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.
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 of complications? A- Cefazolin B- Digoxin C- Ondansetron D- Warfain
D- Warfain 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.