Final exam- Perioperative
Which nursing action will best promote pain management for a client in the postoperative phase? 1) Breathing into a paper bag 2) Performing relaxation techniques 3) Dimming the lights 4) Providing food and medication
Answer: 2) Performing relaxation techniques
What complication is the nurse aware of that is associated with deep venous thrombosis? 1) Immobility because of calf pain 2) Pulmonary embolism 3) Marked tenderness over the anteromedial surface of the thigh 4) Swelling of the entire leg owing to edema
Answer: 2) Pulmonary embolism
Which client's fracture will need the shortest healing time? 1) 9-year-old client with a simple wrist fracture 2) 25-year-old with a compound fracture of ankle 3) 39-year-old with diabetes mellitus and rib fractures 4) 64-year-old with rheumatoid arthritis and a hip fracture
Answer: 1) 9-year-old client with a simple wrist fracture
What measurement should the nurse report to the physician in the immediate postoperative period? 1) A systolic blood pressure lower than 90 mm Hg 2) A temperature reading between 97°F and 98°F 3) Respirations between 20 and 25 breaths/min 4) A hemoglobin of 13.6
Answer: 1) A systolic blood pressure lower than 90 mm Hg
A nurse is caring for a client who is three hours post op from open abdominal surgery. During routine assessment, the nurse notes the previously stable client now appears anxious, apprehensive, and has a blood pressure of 90/56. What does the nurse consider is the most likely cause of the client's change in condition? 1) The client is displaying early signs of hypovolemic shock. 2) The client is showing signs of a medication reaction. 3) The client is displaying late signs of hypovolemic shock. 4) The client is showing signs of an anesthesia reaction.
Answer: 1) The client is displaying early signs of hypovolemic shock.
A perioperative nurse is conducting an in-service education program about maintaining surgical asepsis during the intraoperative period. Which of the following would the nurse emphasize? 1) The edges of a sterile package, once opened, are considered unsterile. 2) A distance of 3 feet must be maintained when moving around a sterile field. 3) If a tear occurs in a sterile drape, a new sterile drape is applied on top of it. 4) Circulating nurses may come in contact with the sterile field without contaminating it.
Answer: 1) The edges of a sterile package, once opened, are considered unsterile.
A client is brought to the operating room for an elective surgery. What is the priority action by the circulating nurse? 1) Verify consent. 2) Document the start of surgery. 3) Acquire ordered blood products. 4) Count sponges and syringes.
Answer: 1) Verify consent
A 17-year-old client is having same-day surgery. Solely during the intraoperative phase of perioperative care, the nurse: 1) continuously monitors the sedated client. 2) performs a complete assessment of the client. 3) obtains a surgical consent from the client's mother. 4) assesses how well the client is recovering from anesthesia.
Answer: 1) continuously monitors the sedated client.
The RICE acronym is helpful for remembering treatment interventions for musculoskeletal injuries. Which of the following are components of the RICE acronym? Select all that apply. 1) Rest 2) Compression 3) Edema 4) Elevation 5) Corticosteroids 6) Ice 7) Relaxation
Answer: 1, 2, 4,7 R- Rest I- Ice C- Compression E- Elevation
A presurgical client asks, "Why will I go to the PACU instead of just going straight up to the postsurgical unit?" What is the nurse's best response? 1) "The PACU allows you to recover from anesthesia in a stimulating environment to facilitate awakening and reorientation." 2) "The PACU allows you to recover from the effects of anesthesia, and you'll stay in the PACU until you're oriented, have stable vital signs, and are without complications." 3) "Frequently, clients are placed in the medical-surgical unit to recover, but hospitals are usually short of beds, and the PACU is an excellent place to triage clients." 4) "You'll remain in the PACU for a predetermined time because the surgeon will often need to reinforce or alter the patient's incision in the hours following surgery."
Answer: 2) "The PACU allows you to recover from the effects of anesthesia, and you'll stay in the PACU until you're oriented, have stable vital signs, and are without complications."
In a client with a dislocation, the nurse should initially perform neurovascular assessments a minimum of every 15 minutes until stable. Which complication does the assessments help the nurse to monitor? 1) Gastrointestinal bleeding 2) Compartment syndrome 3) Carpal tunnel syndrome 4) Ganglion cysts
Answer: 2) Compartment syndrome
The nurse is performing wound care on a 68-year-old postsurgical client. Which of the following practices violates the principles of surgical asepsis? 1) Holding sterile objects above the level of the nurse's waist 2) Considering a 1 inch (2.5 cm) edge around the sterile field as being contaminated 3) Pouring solution onto a sterile field cloth 4) Opening the outermost flap of a sterile package away from the body
Answer: 2) Considering a 1 inch (2.5 cm) edge around the sterile field as being contaminated
A nurse is assisting a postsurgical patient with effective coughing. How often should this exercise be performed? 1) Every hour 2) Every 2 hours 3) Every 4 hours 4) Every shift
Answer: 2) Every 2 hours
A client has been administered ketamine for moderate sedation. What is the priority nursing intervention? 1) Assessing for hallucinations 2) Frequently monitoring vital signs 3) Administering oxygen 4) Providing a quiet dark room for recovery
Answer: 2) Frequently monitoring vital signs
A client has sustained a long bone fracture and the nurse is preparing the client's care plan. Which of the following should the nurse include in the care plan? 1) Administer vitamin D and calcium supplements as prescribed. 2) Monitor temperature and pulses of the affected extremity. 3) Perform passive range of motion exercises as tolerated. 4) Administer corticosteroids as prescribed.
Answer: 2) Monitor temperature and pulses of the affected extremity.
The OR nurse is taking the client into the OR when the client informs the operating nurse that his grandmother spiked a very high temperature in the OR and nearly died 15 years ago. What relevance does this information have regarding the client? 1) The client may be experiencing presurgical anxiety. 2) The client may be at risk for malignant hyperthermia. 3) The grandmother's surgery has minimal relevance to the client's surgery. 4) The client may be at risk for a sudden onset of postsurgical infection.
Answer: 2) The client may be at risk for malignant hyperthermia.
Which intervention should the nurse plan to implement to decrease the client's risk for injury during the intraoperative period? 1) Allow the client to verbalize fears. 2) Verify the client's preoperative vital signs. 3) Assess the client for allergies. 4) Keep the family informed of the client's status.
Answer: 3) Assess the client for allergies
A nurse is monitoring a client post cardiac surgery. What action would help to prevent cardiovascular complications for this client? 1) Position the client in bed with pillows placed under his knees to hasten venous return. 2) Keep the client from ambulating until the day after surgery. 3) Implement leg exercises and turn the client in bed every 2 hours. 4) Keep the client cool and uncovered to prevent elevated temperature.
Answer: 3) Implement leg exercises and turn the client in bed every 2 hours.
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? 1) Obtain an emesis basin. 2) Ask the client for more clarification. 3) Position the client in the side-lying position. 4) Administer an anti-emetic.
Answer: 3) Position the client in the side-lying position.
The dressing surrounding a mastectomy client's Jackson-Pratt drain has scant drainage on it. The nurse believes that the amount of drainage on the dressing may be increasing. How can the nurse best confirm this suspicion? 1) Describe the appearance of the dressing in the electronic health record. 2) Photograph the client's abdomen for later comparison using a smartphone. 3) Trace the outline of the drainage on the dressing for future comparison. 4) Remove and weigh the dressing, reapply it, and then repeat in 8 hours.
Answer: 3) Trace the outline of the drainage on the dressing for future comparison.
The nurse is caring for a client who anticipates pain and anxiety following his prostatectomy. Which intervention will likely best assist in decreasing the client's pain and anxiety? 1) Administration of NSAIDs rather than opioids 2) Allowing the client to increase activity 3) Use of guided imagery along with pain medication 4) Use of deep breathing and coughing exercises
Answer: 3) Use of guided imagery along with pain medication
When an older adult client is brought to the recovery room and presents with irregular, loud respirations, the nurse determines that this is most likely a result of: 1) the effects of anesthesia. 2) the normal return of reflexes. 3) a partial airway obstruction. 4) the type of surgery.
Answer: 3) a partial airway obstruction
When integrating the principles for maintaining surgical asepsis during surgery, which of the following would be most appropriate? 1) Considering the gown sterile from mid-thigh to neck 2) Positioning the sterile drape on a table from back to front 3) Allowing circulating nurses to contact sterile equipment 4) Ensuring gown sleeves remain sterile 2 inches above the elbow to cuff
Answer: 4) Ensuring gown sleeves remain sterile 2 inches above the elbow to cuff
The nurse is creating the care plan for a 70-year-old obese client who has been admitted to the postsurgical unit following a colon resection. This client's age and increased body mass index mean that she is at increased risk for what complication in the postoperative period? 1) Hyperglycemia 2) Azotemia 3) Falls 4) Infection
Answer: 4) Infection
A patient stepped on an acorn while walking barefoot in the backyard and developed an infection progressing to osteomyelitis. What microorganism does the nurse understand is most often the cause of the development of osteomyelitis? 1) Proteus 2) Pseudomonas 3) Salmonella 4) Staphylococcus aureus
Answer: 4) Staphylococcus aureus
The nurse is caring for a client during an intra operative procedure. When assessing vital signs, which result indicates a need to alert the anesthesiologist immediately? 1) Pulse rate of 110 beats/min 2) Respiratory rate of 18 breaths/min 3) Blood pressure of 104/62 mm Hg 4) Temperature of 40° c
Answer: 4) Temperature of 40° c
The nurse is admitting a client to the postanesthesia care unit (PACU) who received general anesthesia for the removal of a bunion. The nurse should prioritize what assessments? 1) lung auscultation and apical heart rate 2) pain and temperature 3) skin integrity and peripheral perfusion 4) respirations and airway
Answer: 4) respirations and airway
