Ch. 5 med surg 1
You are the nurse working in an ambulatory surgery center. A teenage son of your clients ask you why so many people have surgery. What would be your best reply?
"Many people have diagnostic or short therapeutic surgical procedures."
The circulating nurse is unsure whether proper technique was followed when an object was placed in the sterile field during a surgical procedure. What is the best action by the nurse? a. remove the item from the sterile field b. mark the client's chart for future review of infections c. remove the entire sterile field from use d. ask another nurse to review the technique used
Answer: C
The client is experiencing nausea and vomiting following surgery. What will the nurse expect the surgeon to order: a. chlorpromazine b. omeprazole c. ondansetron d. nizatidine
Answer: C
The nurse is concerned that a postoperative patient may have a paralytic ileus. What assessment data may indicate that the patient does have a paralytic ileus? a. abdominal tightness b. abdominal distention c. absence of peristalsis d. increased abdominal girth
Answer: C
The nurse positions the client in the lithotomy position in preparation for: a. renal surgery b. pelvic surgery c. perineal surgery d. abdominal surgery
Answer: C
A student nurse is scheduled to observe a surgical procedure. The nurse provides the student nurse with education on the dress policy and provides all attire needed to enter a restricted surgical zone. Which observation by the nurse requires immediate intervention? a. hair is pulled back and covered by cap b. scrub top and drawstring are tucked into pants c. shoe covers are used d. mask is placed over nose and extends to bottom lip
Answer: D
A nurse is caring for a client who underwent a skin biopsy and has 3 stitches in place. This wound is healing by: a. first intention b. second intention c. third intention d. fourth intention
Answer: first intention
A client asks why a drain is in place to pull fluid from the surgical wound. What is the best response by the nurse? a. "It assists in preventing infection" b. "it will cut down on the number of dressing changes needed" c. "The drain will remove necrotic tissue" d. "Most surgeons use wound drains now"
Answer:A
A nurse asks a client who had abdominal surgery 1 day ago if he has moved his bowels since surgery. The client states, "I haven't moved my bowels, but I am passing gas." How should the nurse intervene?
Encourage the client to ambulate as soon as possible after surgery.
Which action should be incorporated into the client teaching plan to prevent deep vein thrombosis?
Hourly leg exercises
You are admitting an insulin-dependent patient to the same-day surgical suite for carpal tunnel surgery. You know that this patient may be at risk for which metabolic disorder?
Hyperglycemia
Which stage of surgical anesthesia is also known as excitement?
II
When is the ideal time to discuss preoperative teaching
Preadmission visit
What action during a surgical procedure requires immediate intervention by the circulating nurse?
The scrub nurse calling the blood bank to obtain blood products
Which of the following is an inappropriate nursing action by the surgical nurse?
Wearing sterile gloves over artificial nails
Which statement by the client indicates further teaching about epidural anesthesia is necessary?
"I will become unconscious"
A nurse is teaching a client about pain management after surgery. Which client statement indicates the teaching was effective?
"I will support my incision with my hands when I cough and do my deep breathing exercises."
After teaching a patient scheduled for ambulatory surgery using moderate sedation, the nurse determines that the patient has understood the teaching based on which of the following statements?
"I'll be sleepy but able to respond to your questions."
Which of the following is the appropriate response to the statement, "I'm so nervous about my surgery"?
"You seem nervous about your surgery."
A client is undergoing a lumbar puncture. The nurse educates the client about surgical positioning. Which statement by the nurse is appropriate?
"You will be lying on your side with your knees to your chest."
The nurse expects informed consent to be obtained for insertion of:
A gastrostomy tube
For the client who is taking aspirin, it is important to stop taking this medication at least how many day(s) before surgery? a. 1 b. 3 c. 5 d. 7
Answer: 7 days before surgery
A nurse is caring for a client in the PACU after surgery requiring general anesthesia. The client tells the nurse, "I think I'm going to be sick." What is the primary action taken by the nurse? a. position in side - lying position b. administer an anti-emetic c. obtain an emesis basin d. ask client for more clarification
Answer: A
An anxious client being prepared for surgery is encouraged to concentrate on a pleasant experience or restful scene. What cognitive coping strategy would the nurse document as being used? a. imagery b. optimistic self - recitation c. distraction d. progressive muscular relaxation
Answer: A
During a procedure, a client's temperature begins to rise rapidly. This is likely the result of which complication: a. malignant hyperthermia b. hypothermia c. infection d. fluid volume excess
Answer: A
During the admission history the client reports to the nurse of taking the usual dose of warfarin the previous day. What is an appropriate nursing action? a. notify the surgeon that the client took warfarin the day before surgery b. no action is needed, b/c the client takes warfarin on a continuing basis c. put a note on the preoperative checklist before sending the client into surgery d. tell the client to inform the circulating nurse before the anesthesia is administered
Answer: A
The nurse in the preoperative area has just medicated her client according to the anesthesiologist's orders. What is the nurse's priority action at this time: a. place side rails in the up position and make sure call light is in reach b. take client to bathroom c. have the family go to waiting room d. take client's VS
Answer: A
What measurement should the nurse report to the physician in the immediate postoperative period? a. systolic bp lower than 90 b. a temperature b/w 97 and 98 c. respirations b/w 20-25 d. hemoglobin of 13.6
Answer: A
An OR nurse needs to assist a patient to the Trendelenburg position. Which of the following is the correct position? a. flat on back, arms next to sides b. on back, head lowered, plane of body meets the horizontal on an angle c. on back, legs and thighs flexed at right angles d. on side, uppermost leg adducted and flexed at knee
Answer: B
Despite advances in surgical techniques, surgery remains an activity that carries a significant risk of injury. What measure should the OR nurse take to minimize a patient's risk of intraoperative positioning injury: a. assess the pt IV access site at regular intervals during surgery b. ensure that no body part experiences undue pressure or restriction of blood supply c. reposition the patient every 20-30 minutes while the patient is under anesthetic d. perform light massage to pressure points during surgery if the procedure allows for this
Answer: B
How would the operating room nurse place a patient in the Trendelenburg position? a. flat on back w/ arms next to sides b. on back with head lowered so that the plane of body meets the horizontal on an angle c. on back with legs and thighs flexed at right angles d. on side with uppermost leg adducted and flexed at knee
Answer: B
The OR personnel responsible for maintaining the safety of the client and the surgical environment is the: a. anesthesiologist b. circulating nurse c. scrub nurse d. surgeon
Answer: B
The anesthesiologist administered a transsacral conduction block. Which documentation by the nurse is consistent with the anesthesia being administered? a. unresponsive to verbal or tactile stimuli b. denies sensation to perineum and lower ab c. yelling and pulling at equipment d. no movement in right lower leg
Answer: B
You are doing a preoperative assessment on a patient going to surgery. The patient informs you that he drinks six to eight beers each day and has for the last 15 years. What postoperative difficulties can the nurse anticipate for this patient: a. delirium tremens immediately following surgery b. delirium tremens w/in 72 hours after his last alcohol drink c. delirium tremens upon administration of general anesthesia d. delirium tremens 1 week after his last alcohol drink
Answer: B
A client undergoing coronary artery bypass surgery is subjected to intentional hypothermia. The client is ready for rewarming procedures. Which action by the nurse is appropriate?
Apply a warm air blanket, gradually increasing body temperature.
What are the circulating nurse's responsibilities, in contrast to the scrub nurse's responsibilities?
Coordinating the surgical team
A fractured skull would be classified under which category of surgery based on urgency?
Emergent
A nurse is caring for a postoperative client who started shivering. What is the best action for the nurse?
Ensure that the room temperature is set at 25°C to 26.6°C (78°F to 80°F).
An obese client is undergoing abdominal surgery. During the procedure a surgical resident states, "The amount of fat we have to cut through is disgusting." What is the best response by the nurse?
Inform the resident that all communication needs to remain professional.
A client is undergoing preoperative assessment. During admission paperwork, the client reports having enjoyed a hearty breakfast this morning to be ready for the procedure. What is the nurse's next action?
Notify the surgeon.
A nurse documents the presence of granulation tissue in a healing wound. Which of the following is the best description for the tissue?
Pink to red and soft, noting that it bleeds easily
What complication is the nurse aware of that is associated with deep venous thrombosis?
Pulmonary embolism
A client is placed on the operating room table for the surgical procedure. Which surgical team member is responsible for handing sterile instruments to the surgeon and assistants?
Scrub nurse
A nurse who is part of the surgical team is involved in setting up the sterile tables. The nurse is functioning in which role?
Scrub role
A nurse is planning care for a client scheduled to undergo a thoracotomy. After tolerating full liquids, which dietary recommendation will the nurse consider?
Small, frequent full-fat meals
A client is undergoing thoracic surgery. What priority education should the nurse provide to assist in preventing respiratory complications?
Splint the incision site using a pillow during deep breathing and coughing exercises.
A physician calls the nurse for an update on his client who underwent abdominal surgery 5 hours ago. The physician asks the nurse for the total amount of drainage collected in the Hemovac since surgery. The nurse reports that according to documentation, no drainage has been recorded. When the nurse finishes on the telephone, she goes to assess the client. Which assessment finding explains the absence of drainage?
The Hemovac drain isn't compressed; instead it's fully expanded.
A nurse is teaching a client with chronic bronchitis about breathing exercises. Which instruction should the nurse include in the teaching?
Use diaphragmatic breathing.
A client is brought to the operating room for an elective surgery. What is the priority action by the circulating nurse?
Verify consent.
The nurse would identify which vitamin deficiency to prevent hemorrhaging during surgery?
Vitamin K
A nurse is caring for a client with obesity and diabetes after abdominal surgery. What is the client at increased risk for?
Wound Dehiscence
A client had a nephrectomy 2 days ago and is now complaining of abdominal pressure and nausea. The first nursing action should be to:
auscultate bowel sounds
The nurse recognizes that the older adult is at risk for surgical complications due to:
decreased renal function
The nurse is caring for a postoperative client with a Hemovac. The Hemovac is expanded and contains approximately 25 cc of serosanguineous drainage. The best nursing action would be to:
empty and measure the drainage and compress the hemovac
A patient with uncontrolled diabetes is scheduled for a surgical procedure. What chief life-threatening hazard should the nurse monitor for?
hypoglycemia
What does the nurse recognize as one of the most common postoperative respiratory complications in elderly clients?
pneumonia
The nurse is caring for the postoperative client in the postanesthesia care unit. Which of the following is the priority nursing action?
position the client to maintain a patent airway
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
In which position would a client undergoing a lumbar puncture be placed?
side - lying, knees to chest
A client is scheduled for a prostatectomy, and the anesthesiologist plans to use a spinal (subarachnoid) block during surgery. In the operating room, the nurse positions the client according to the anesthesiologist's instructions. Why does the client require special positioning for this type of anesthesia?
to prevent cerebrospinal fluid (CSF) leakage
