Nursing Chapter 37
A client is scheduled for lung resection surgery. What should the nurse keep in mind when determining this clients degree of risk for this major surgical procedure?
Age Medications General health Nutritional status
The nurse has just inserted a nasogastric tube for gastric suction. What is the most reliable test for confirming tube placement?
Aspirate stomach contents and check the acidity using a pH test strip
The nurse is preparing to apply antiembolic stockings to a postoperative client. What should be done first, before applying the stockings?
Assess for circulatory problems
The nurse is planning care for a client during the postoperative period. What should the nurse identify as the goal of care for this client?
Assist the client to achieve the most optimal health status possible
The nurse determines that interventions to prevent postoperative constipation have been effective in a client recovering from surgery. What did the nurse assess to make this clinical decision?
Bowel movement occurred 24 hours after resuming a normal diet
The nurse is planning a perioperative clients needs upon discharge. What should be included when determining these needs?
Clients abilities to provide self-care Financial resources Need for home health care services
During the assessment of a client recovering from surgery, the nurse notes decreased breath sounds in both lower lobes bilaterally. What should the nurse do?
Coach the client to deep-breathe and cough
The nurse is preparing a client for an upper GI endoscopy. For which type of anesthesia should the nurse prepare the client to receive?
Conscious sedation
The nurse is completing a preoperative assessment with a client. What should this assessment include?
Current health status Allergies Current medications Mental status
The nurse is obtaining preoperative assessment data. What should be included in this assessment?
Current health status Allergies Current medications Mental status
The nurse is assessing an abdominal wound in the postoperative period. Which sign should indicate to the nurse that an infection is present?
Edges warm to the touch
The nurse is caring for a client on the postoperative unit. Which nursing diagnosis is the priority for this client?
Ineffective Airway Clearance
The nurse is preparing to conduct preoperative teaching. What should be included in this teaching?
Information related to what will happen to the client
The nurse is caring for a client in the immediate postoperative period (PACU). Which intervention should the nurse implement to reduce the risk of thrombophlebitis?
Leg exercises
The nurse is admitting a client to the medical-surgical unit following a cholecystectomy. Which assessment should the nurse perform first?
Level of consciousness
The nurse has identified the goals of maintaining client safety and homeostasis during the intraoperative phase of client care. What nursing activities would support these goals?
Maintain the sterile field. Perform instrument counts Position the client appropriately for surgery Perform preoperative skin preparation
The nurse is preparing to complete a physical assessment before surgery. Which assessments should the nurse obtain?
Mini mental status Assessment of hearing Assessment of the respiratory system Gastrointestinal assessment
The nurse has removed the sutures from a clients surgical wound. What should the nurse document about this procedure?
Number of sutures removed Appearance of the incision Client teaching Client tolerance of the procedure
The nurse is preparing a 6-year-old child for a tonsillectomy. Which strategy should the nurse use for teaching this client?
Play
The nurse is preparing a 23-year-old female client for surgery. The nurse should anticipate which diagnostic test to be prescribed for this client?
Pregnancy test
The nurse is caring for a client who is having surgery and is currently being transported to the operating room suite. The nurse should document that the client is in which operative phase?
Preoperative phase
The nurse wants to ensure that a client recovering from surgery does not develop thrombophlebitis. Which action should the nurse take to reduce the clients risk of this postoperative complication?
Provide for early ambulation
The nurse is caring for a postoperative client with an abdominal wound and a drain. What can the nurse delegate to unlicensed assistive personnel?
Report if the dressing is soiled Report if the dressing is loose
A client is anxious about receiving general anesthesia for a surgical procedure. What should the nurse explain are the advantages of having this type of anesthesia?
Respiratory rate can be regulated easily The anesthesia can be adjusted to the length of the operation
The nurse is preparing a care plan for a client about to undergo surgery. Which nursing diagnosis would take priority during the intraoperative phase of surgery?
Risk for Aspiration
The nurse is caring for a client in the recovery area. In which position should the nurse place the unconscious client during the immediate postanesthesia phase?
Side-lying
The nurse is caring for an 80-year-old client preparing for surgery. The nurse realizes this client is at increased risk for which reason?
The physiological deficits of aging increase the surgical risk for older adults
A client in the postanesthesia care unit is to have suction applied through a nasogastric tube. When documenting, the nurse should include which information?
The time suction was started Pressure on the suction Color and consistency of drainage
The nurse is evaluating the effectiveness of preoperative instruction regarding leg exercises with a client recovering from surgery. Which observation indicates that the instructions were effective?
There is no cramping or pain with ambulation
A client recovering from surgery asks the nurse why turning, deep breathing, and coughing exercises need to be done. What should the nurse respond?
These exercises help prevent pneumonia
The nurse is preparing to instruct a client on leg exercises to be used when recovering from abdominal surgery. What should the nurse determine before beginning this teaching?
Type of surgery Time of surgery Preoperative orders Name of the surgeon
The nurse is planning to remove the sutures from a clients surgical wound. What should the nurse do before removing the sutures?
Verify the order for suture removal Read the order to determine whether a dressing is to be applied after removal Remove the dressing and clean the incision
A client is scheduled for a cholecystectomy. The nurse realizes that the purpose for this surgery is
ablative
The nurse is preparing the skin of a client for surgery. The nurse knows the purpose of the surgical skin preparation is to
reduce the risk of postoperative wound infection
