Exam 2 practice test Theory
A preoperative patient asks when to stop eating and drinking before surgery. Based on the most recent practice guidelines established by the American Society of Anesthesiologists, which response would the nurse provide? "Stay NPO after midnight." "Maintain NPO status until after breakfast." "You may drink clear liquids up to 2 hours before surgery." "You may drink clear liquids up until you are moved to the OR."
"You may drink clear liquids up to 2 hours before surgery." Rationale: Practice guidelines for preoperative fasting state the minimum fasting period for clear liquids is 2 hours. Evidence-based practice no longer supports the long-standing practice of requiring patients to be NPO after midnight.
A nurse in a provider's office is reviewing the laboratory results of a client who takes furosemide for hypertension. The nurse notes that the client's potassium level is 3.3 mEq/L. The nurse should monitor the client for which of the following complications? A. Cardiac dysrhythmias B. Hypoglycemia C. Seizures D. Neurogenic shock
A
A client's stools are light gray in color. What additional information should the nurse obtain from the client? Select all that apply. A. intolerance to fatty foods B. fever C. jaundice D. respiratory distress E. pain at McBurney's point F. bleeding ulcer
A,B,C
A client with Crohn's disease has concentrated urine; decreased urinary output; dry skin with decreased turgor; hypotension; and weak, thready pulses. What should the nurse do first? A. Encourage the client to drink at least 1,000 mL/day. B. Provide parenteral rehydration therapy as prescribed. C. Turn and reposition every 2 hours. D. Monitor vital signs every shift.
B
A nurse is caring for a client who has hypernatremia and requires IV fluid therapy due to his NPO status. Which of the following solutions should the nurse prepare to infuse for this client? A. Lactated Ringer's B. Dextrose 5% in 0.9% sodium chloride C. 0.45% sodium chloride D. Dextrose 10% in water
C
When reviewing the preoperative forms, the nurse notices that the informed consent form is not signed. Which action would the nurse take? A. Have the patient sign the consent form. B. Have the family sign the form for the patient. C. Call the surgeon to obtain consent for surgery. D. Teach the patient about the surgery and get verbal permission.
C. Call the surgeon to obtain consent for surgery. Rationale: The informed consent for the surgery must be obtained by the physician. The nurse can witness the signature on the consent form and verify that the patient (or caregiver if patient is a minor, unconscious, or mentally incompetent to sign) understands the informed consent. Verbal consents are not enough. The state nurse practice act and agency policies must be followed.
A patient requests that the nurse give his hearing aid to a family member so it will not be lost in surgery. Which action would the nurse take? A. Give the hearing aid to the wife as he wishes. B. Tape the hearing aid to his ear to prevent loss. C. Encourage the patient to wear it for the surgery. D. Tell the surgery nurse that he has his hearing aid out.
C. Encourage the patient to wear it for the surgery. Rationale: Although jewelry is removed before surgery, hearing aids should be left in place to allow the patient to better follow instructions given in the surgical suite and the postanesthesia care unit (PACU), as well as the dismissal instructions that will be given before he returns home for recovery.
A client has undergone a laparoscopic cholecystectomy. Which instruction should the nurse include in the discharge teaching? A. Empty the bile bag daily B. Breathe deeply into a paper bag when nauseated. C. Keep adhesive dressings in place for 6 weeks. D. Report bile-colored drainage from any incision
D
A patient being admitted to the same-day surgery unit reports taking kava last evening to sleep. Which action would the nurse take? Tell the patient that using kava to help sleep is often helpful. Inform the anesthesia care provider of the patient's recent use of kava. Tell the patient that the kava should continue to help the patient to relax before surgery. Inform the patient about the dangers of taking herbal medicines without consulting a health care provider.
Inform the anesthesia care provider of the patient's recent use of kava. Rationale: Kava may prolong the effects of certain anesthetics. Thus, the anesthesiologist needs to be informed of recent ingestion of this herbal supplement. Patients should not take anything before surgery without the health care provider's knowledge.
At 0600, the anesthesiologist prescribes preoperative medications for a patient who is scheduled for surgery at 0730: cefazolin IV to be infused 30 minutes before surgery; midazolam before surgery, and scopolamine patch behind the ear. Which medication would the nurse administer first? Cefazolin Fentanyl Midazolam Scopolamine
Scopolamine Rationale: The scopolamine patch will be administered first to allow enough time for the serum level to become therapeutic. The cefazolin will be given at 0700 to allow infusion 30 minutes before surgery. Fentanyl is an opioid and was not ordered preoperatively. Midazolam, a short-acting benzodiazepine, is used as a sedative.
An older adult patient has come to the ambulatory surgery center for surgery. After reviewing the assessment record, which test would the nurse recommend be prescribed by the HCP before surgery? Blood glucose Pregnancy test Serum albumin Serum potassium
Serum potassium Rationale: The nurse should seek a serum potassium level because the patient takes hydrochlorothiazide. An ECG would also be appropriate to seek with the history of hypertension and cigarette smoking. There are not indications for the need of a blood glucose, pregnancy, or serum albumin test.
Which goal for the client's care should take priority during the first days of hospitalization for an exacerbation of ulcerative colitis? A. promoting self-care and independence B. managing diarrhea C. maintaining adequate nutrition D. promoting rest and comfort
B
Which instruction should the nurse include in the teaching plan for a client who is experiencing gastroesophageal reflux disease? A. Limit caffeine intake to two cups of coffee per day. B. Do not lie down for 2 hours after eating. C. Follow a low-protein diet. D. Take medications with milk to decrease irritation.
B
Which is a priority focus of care for a client experiencing an exacerbation of Crohn's disease? A. encouraging regular ambulation B. promoting bowel rest C. maintaining current weight D. decreasing episodes of rectal bleeding
B
A client who has ulcerative colitis has persistent diarrhea and has lost 12 lb (5.5 kg) since the exacerbation of the disease. Which approach will be most effective in helping the client meet nutritional needs? A. continuous enteral feedings B. following a high-calorie, high protein diet C. total parenteral nutrition (TPN) D. eating six small meals a day
C
The client with gastroesophageal reflux disease (GERD) has a chronic cough. The nurse should further assess the client for which other possible problem? A. development of laryngeal cancer B. irritation of the esophagus C. esophageal scar tissue formation D. aspiration of gastric contents
D
A client who has been scheduled to have a choledocholithotomy expresses anxiety about having surgery. Which nursing intervention would be the most appropriate to achieve the outcome of anxiety reduction? A. providing the client with information about what to expect postoperatively B. telling the client not to be afraid C. reassuring the client by saying that surgery is a common procedure D. stressing the importance of following the health care provider's (HCP's) instructions after surgery
A
Which dietary measure would be useful in preventing esophageal reflux? A. eating small, frequent meals B. increasing fluid intake C. avoiding air swallowing with meals D. adding a bedtime snack to the dietary plan
A
The nurse is doing a preoperative assessment on a patient who has type 2 diabetes; weighs 146 kg; and is 5 feet 8, inches tall. Which finding is a priority related to preparing for anesthesia? Hemoglobin A1C of 8.5% Several seasonal allergies A body mass index of 48.8 kg/m2 A history of postoperative vomiting
A body mass index of 48.8 kg/m2 Rationale: The patient's body mass index is the priority because it indicates the patient is severely obese. The patient's size may impair the anesthesiologist's ability to ventilate and medicate the patient properly, as well as the surgery room staff's ability to position the patient safely. The other factors are not the priority.
Which preoperative patient has the greatest risk of bleeding as a result of prescribed medication? A man who takes metoprolol for the treatment of hypertension A man who is taking clopidogrel after the placement of a coronary artery stent A man whose type 1 diabetes is controlled with insulin injections four times daily A man who recently started taking finasteride for the treatment of benign prostatic hyperplasia
A man who is taking clopidogrel after the placement of a coronary artery stent Rationale: Any drug that inhibits platelet aggregation, such as clopidogrel, represents a bleeding risk. Insulin, metoprolol, and finasteride are less likely to contribute to a risk for bleeding.
Five minutes after receiving a preoperative sedative medication by IV injection, a patient asks to get up to go to the bathroom to urinate. Which action would the nurse take? A. Offer the patient a urinal or bedpan after explaining the need to maintain safety. B. Assist the patient to the bathroom and stay next to the door to assist the patient back to bed. C. Allow the patient to go to the bathroom since the onset of the medication will be more than 5 minutes. D. Ask the patient to hold the urine for a short period since a urinary catheter will be placed in the operating room.
A. Offer the patient a urinal or bedpan after explaining the need to maintain safety. Rationale: The prime issue after administration of either sedative or opioid analgesic medications is safety. Because the medications affect the central nervous system, the patient is at risk for falls and should not be allowed out of bed, even with assistance. The other options would not be safe for the patient.
When measuring gastric residual volume in a client receiving continuous tube feeding through a gastrostomy tube, the nurse attaches a large syringe to the tube and withdraws all fluid remaining in the stomach. After noting the amount of fluid, what should the nurse do? A. Discard the aspirated fluid down the toilet B. Readminister the aspirated fluid through the feeding tube C. Add the aspirated fluid to the bag of formula D. Discard the aspirated fluid into a biohazard container
B
A nurse is assigned to provide preoperative teaching to a patient scheduled for coronary artery bypass surgery who only speaks Spanish. Which is the best method for teaching the patient to use an incentive spirometer? A. Give the patient a pamphlet written in Spanish with directions on the use of the incentive spirometer. B. Ask another Spanish-speaking patient in the preoperative area to translate as the nurse describes the procedure. C. Notify the postoperative unit to have a Spanish-speaking nurse provide teaching on the incentive spirometer after surgery. D. Have the hospital interpreter available while the nurse demonstrates the procedure and the patient returns the demonstration.
D. Have the hospital interpreter available while the nurse demonstrates the procedure and the patient returns the demonstration. Rationale: If the patient does not speak English, it is essential that the services of a competent interpreter be obtained. Hospitals are required to provide interpreters for common languages other than English. Demonstration and return demonstration is the most effective teaching method for use of equipment such as the incentive spirometer and should be done in the preoperative period if possible.
The patient is having a mole removed that has changed appearance. What does the nurse teach the patient is the reason for this surgical procedure? A. It will prevent cancer. B. It will alleviate symptoms. C. It will cure the patient's cancer. D. It will provide cosmetic improvement.
A. It will prevent cancer. Rationale: Removing a mole that is changing is to prevent as well as diagnose cancer. There are no symptoms to alleviate mentioned or cosmetic problems for this patient.
A nurse is assessing an older adult client who is receiving IV therapy. The nurse should recognize that which of the following findings indicates fluid volume excess? (Select all that apply.) A. Bounding pulse B. Pitting edema C. Swelling at the IV site D. Urine-specific gravity greater than 1.030 E. Crackles upon auscultation
A, B, E
The nurse is developing a care management plan with a client who has been diagnosed with gastroesophageal reflux disease. What should the nurse instruct the client to do? Select all that apply. A. Avoid a diet high in fatty foods. B. Avoid beverages that contain caffeine. C. Eat three meals a day, with the largest meal being at dinner in the evening. D. Avoid all alcoholic beverages. E. Lie down after consuming each meal for 30 minutes. F. Use over-the-counter (OTC) antisecretory agents rather than prescriptions.
A,B,D
A client is admitted to the hospital with a diagnosis of cholecystitis. The client has severe abdominal pain and nausea and has vomited 120 mL. Based on these data, which nursing action would have the highest priority at this time? A. Manage anxiety. B. Restore fluid loss. C. Manage the pain. D. Replace nutritional loss.
C
An older adult patient has been admitted before having surgery for a bilateral mastectomy and breast reconstruction. Which information would the nurse include in the patient's preoperative teaching? (Select all that apply.) Various options for reconstructive surgery The risks and benefits of her particular surgery Risk factors for breast cancer and the role of screening Where in the hospital she will be taken after surgery is over How to perform postoperative deep-breathing and coughing exercises
Where in the hospital she will be taken after surgery is over How to perform postoperative deep-breathing and coughing exercises Rationale: During preoperative teaching, it is important to introduce the role of deep-breathing and coughing exercises and to inform the patient about the different locations involved in her hospital stay. The surgeon would address specific risks and benefits of surgery and reconstruction options. Teaching about breast cancer screening would be inappropriate, and insensitive at this point in her disease trajectory.
A client with acute cholecystitis has severe pain. Which prescription will be most effective in relieving the pain? A. infusing normal saline solution at 100 mL/h B. administering morphine sulfate 10 mg IM every 3 to 4 hours C. receiving nothing by mouth (NPO) D. having a nasogastric tube connected to low intermittent suction
B
A client who has been diagnosed with gastroesophageal reflux disease (GERD) has heartburn. To decrease the heartburn, the nurse should instruct the client to eliminate which item from the diet? A. lean beef B. air-popped popcorn C. hot chocolate D. raw vegetables
C
A client refuses to look at or care for their colostomy. Which statement by the nurse would be most appropriate? A. It's been 4 days since your surgery, and you'll soon be discharged. You have to learn to care for your colostomy before you leave the hospital." B. "I think we will need to teach your husband to care for your colostomy if you are not going to be able to do it." C. "I understand how you are feeling. It is important for you to feel attractive, and you think having a colostomy changes your attractiveness." D. "I can see that you are upset. Would you like to share your concerns with me?"
D
A client undergoes a laparoscopic cholecystectomy. Which instructions should the nurse give the client about a diet immediately after surgery? A. "You can't eat or drink anything for 24 hours." B. "You may resume your normal diet the day after your surgery." C. "Start with liquids and see how you feel." D. "You can progress from a liquid to a bland diet as tolerated."
D
A client who has been vomiting for 2 days has a nasogastric tube inserted. The nurse notes that over the past 10 hours, the tube has drained 2 L of fluid. The nurse should further assess the client for which electrolyte imbalance? A. hypermagnesemia B. hypernatremia C. hypokalemia D. hypocalcemia
C
Lorazepam 1 mg IV is ordered for a patient before surgery. Which action would the nurse take before administering the medication? A. Ask the patient about an allergy to iodine or shellfish. B. Encourage or assist the patient to the bathroom to void. C. Explain that the medication is used to prevent postoperative nausea. D. Check the laboratory results for the most recent serum potassium level.
B. Encourage or assist the patient to the bathroom to void.
A patient with a recent diagnosis of prostate cancer is scheduled for a radical prostatectomy. Before signing the consent, the patient tells the nurse, "I am not sure if this surgery is safe." Which response would the nurse provide? A. "Tell me what you know about your surgery and the risks involved." B. "Any surgery has risks, but we will be here to take good care of you." C. "You seem anxious. After you sign the consent, I can give you a sedative." D. "You do not need to be concerned. Your surgeon has not had any complaints."
A. "Tell me what you know about your surgery and the risks involved." Rationale: The health care provider performing the surgery is responsible for obtaining the patient's consent. The nurse may witness the patient's signature on the consent form. As a patient advocate, the nurse should verify that the patient understands the surgery and the risks involved. If the nurse determines that the patient is unclear about operative plans, the nurse should contact the health care provider about the patient's need for more information. The other options provide false reassurance or do not respond to the patient's concern.
An alert patient does not want to have a tracheostomy inserted because of the potential for extended endotracheal intubation, although family members state that they want it done. Which action would the nurse take? A. Advocate for the patient's rights. B. Try to change the patient's mind. C. Call surgery to cancel the procedure. D. Tell the family they cannot interfere.
A. Advocate for the patient's rights. Rationale: The nurse must act as the patient's advocate and assist the patient with fulfilling his wishes. However, as the patient's advocate, the nurse must be sure he knows the risks and benefits of refusing a tracheostomy. Trying to change the patient's mind is unethical because it is contrary to acting as an advocate. As long as the patient is lucid, he retains the right of self-determination. Canceling the procedure is not indicated until discussion with the patient and surgeon has occurred. Telling the family they cannot interfere can aggravate or escalate the situation.
A patient informs the nurse prior to surgery that she is very nervous about the procedure. She had to take alprazolam last night, but it did not relieve the anxiety. Which action would the nurse take first? A. Ask the patient about the concerns. B. Administer another dose of alprazolam. C. Review the details of the surgery with the patient. D. Tell the patient that outcomes for this surgery are generally very good.
A. Ask the patient about the concerns. Rationale: The nurse should assess the cause of the anxiety or fear the patient is experiencing, then notify the anesthesia care provider (ACP). The patient may only need to talk about the surgery related to the situation, concerns with the unknown or body image, or past experiences to relieve the anxiety, but the nurse cannot assume that lack of knowledge is the cause of the anxiety. Medication administration will be prescribed by the ACP if needed, but medications can also be administered during surgery. Simply reassuring the patient is not taking the patient's needs into account unless the patient expresses that topic as a specific concern.
An older adult patient is being prepared for surgery. What assessment data would be obtained from the patient? (Select all that apply.) A. Fluid balance history B. Attitude about surgery C. Foods the patient dislikes D. Current mobility problems E. Current cognitive function F. Patient's opinion about the surgeon
A. Fluid balance history D. Current mobility problems E. Current cognitive function Rationale: Preoperative fluid balance history is especially critical for older adults because they have reduced adaptive capacity that puts them at greater risk for over- and underhydration. Mobility problems must be assessed to assist with intraoperative and postoperative positioning and ambulation. Preoperative assessment of the older person's baseline cognition function is especially crucial for intraoperative and postoperative evaluation because they are more prone to adverse outcomes during and after surgery from the stressors of the surgery, dehydration, hypothermia, and anesthesia. Attitude about surgery and opinion or faith in the surgeon are important for all patients. Foods the patient dislikes are not important unless the patient is allergic to them, but this is no more important for older patients than it is for all patients.
The nurse is providing preoperative teaching to a group of patients. Which patient would the nurse plan to teach coughing and deep breathing exercises? A. A 20-yr-old man who is scheduled for a tonsillectomy B. A 40-yr-old woman who is scheduled for an open cholecystectomy C. A 30-yr-old woman who is scheduled for a transsphenoidal hypophysectomy D. A 50-yr-old man who is scheduled for an evacuation of a subdural hematoma
B. A 40-yr-old woman who is scheduled for an open cholecystectomy Rationale: Patients with abdominal surgeries should be taught how to cough and deep breathe to prevent pulmonary complications such as atelectasis and pneumonia. Coughing and deep breathing is contraindicated in cranial surgeries (e.g., subdural hematoma evacuation or transsphenoidal hypophysectomy) and tonsillectomies
A client has been receiving total parenteral nutrition (TPN) for the last 5 days. Before discontinuing the infusion, the infusion rate is slowed. What complication of TPN infusion should the nurse assess the client for as the infusion is discontinued? A. dehydration B. essential fatty acid deficiency C. rebound hypoglycemia D. malnutrition
C
A client has had an exacerbation of ulcerative colitis with cramping and diarrhea persisting longer than 1 week. The nurse should assess the client for which complication? A. heart failure B. deep vein thrombosis C. hypokalemia D. hypocalcemia
C
A nurse is providing preoperative teaching for a client who will undergo surgery. The nurse explains that the client will wear antiembolism stockings during and after the procedure. When the client asks what the stockings do, which of the following responses should the nurse make? A. "They protect your legs and heels from skin breakdown." B. "They help keep you warm after your surgery." C. "They improve your circulation to keep blood from pooling in your legs." D. "They make it easier for you to do leg exercises after your surgery."
C
Which discharge instruction would be appropriate for a client who has had a laparoscopic cholecystectomy and has sutures covered by a dressing? A. Avoid showering for 1 week after surgery. B. Return to work within 1 week. C. Leave dressing in place until seeing the surgeon at the postoperative visit. D. Use acetaminophen to control any fever.
C
The nurse is performing a preoperative assessment for a patient scheduled for a surgical procedure. What is the rationale for the nurse's careful documentation of the patient's current medication list? A. Some medications may alter the patient's perceptions about surgery. B. Many anesthetics alter renal and hepatic function, causing toxicity of other drugs. C. Some medications may interact with anesthetics, altering the potency and effect of the drugs. D. Routine medications are withheld the day of surgery, requiring dosage and schedule adjustments after surgery.
C. Some medications may interact with anesthetics, altering the potency and effect of the drugs. Rationale: Drug interactions may occur between prescribed medications and anesthetic agents used during surgery. For this reason, it is important to take a careful medication history and check that it has been communicated to the anesthesia care provider. Routine medications may or may not be prescribed for use the day of surgery.
The nurse in an ambulatory surgery center has administered the following preoperative medications to a patient scheduled for general surgery: diazepam, cefazolin, and famotidine. Which mode of transportation to the operating room (OR) would the nurse arrange? A. Seated in a wheelchair accompanied by a responsible family member B. Ambulatory and accompanied by a hospital escort and a family member C. Stretcher with side rails up and accompanied by OR transportation personnel D. Ambulatory accompanied by an OR staff member or transportation personnel
C. Stretcher with side rails up and accompanied by OR transportation personnel Rationale: The patient has received a sedative (diazepam) and should be transported either by stretcher (with side rails raised) or wheelchair and accompanied by either OR staff, OR transport personnel, or the nurse.
A nurse is teaching a client who has acute kidney injury about dietary sources of potassium. Which of the following statements by the client indicates a need for clarification? A."I will enjoy eating cantaloupe for my morning snack." B."I can easily add baked potatoes to my diet." C. "Eating yogurt will be a new experience." D. "Adding pecans will be a change I can readily make."
D
After a cholecystectomy, the client is to follow a low-fat diet. Which food would be most appropriate to include in a low-fat diet? A. cheese omelet with onions B. peanut butter on wheat toast C. ham salad sandwich made with mayonnaise D. turkey sandwich with lettuce and tomato
D
The client with a major burn injury receives total parenteral nutrition (TPN). What is the expected outcome of TPN? A. Correct water and electrolyte imbalances B. Allow the gastrointestinal tract to rest C. Provide supplemental vitamins and minerals D. Ensure adequate caloric and protein intake
D
