Perioperative

35. Which problem should the nurse identify as priority for client who is one (1) day postoperative? 1. Potential for hemorrhaging. 2. Potential for injury. 3. Potential for fluid volume excess. 4. Potential for infection.

1. All clients who undergo surgery are at risk for hemorrhaging, which is the priority problem.

24. The nurse is planning the care of the surgical client having procedural sedation. Which intervention has highest priority? 1. Assess the client's respiratory status. 2. Monitor the client's urinary output. 3. Take a 12-lead ECG prior to injection. 4. Attempt to keep the client focused.

1. Assessing the respiratory rate, rhythm, and depth is the most important action.

45. Which nursing intervention is priority for the client experiencing acute pain? 1. Assess the client's verbal and nonverbal behavior. 2. Wait for the client to request pain medication. 3. Administer the pain medication on a scheduled basis. 4. Teach the client to use only imagery every hour for the pain.

1. Assessing verbal and nonverbal cues is the priority intervention because pain is subjective.

47. The nurse clears the PCA pump and discovers the client has used only a small amount of medication during the shift. Which intervention should the nurse implement? 1. Determine why the client is not using the PCA pump. 2. Document the amount and take no action. 3. Chart the client is not having pain. 4. Contact the HCP and request oral medication.

1. Assessing why the client is not using the medication is a priority and then, based on the client's response, a plan of care can be determined.

173. The nurse assesses a client's surgical incision for signs of infection. Which finding by the nurse would be interpreted as a normal finding at the surgical site? 1. Red, hard skin 2. Serous drainage 3. Purulent drainage 4. Warm, tender skin

173. 2 Rationale: Serous drainage is an expected finding at a surgical site. The other options indicate signs of wound infection. Signs and symptoms of infection include warm, red, and tender skin around the incision. Wound infection usually appears 3 to 6 days after surgery. The client also may have a fever and chills. Purulent material may exit from drains or from separated wound edges. Infection may be caused by poor aseptic technique or a contaminated wound before surgical exploration; existing client conditions such as diabetes mellitus or immunocompromise may place the client at risk.

5. The nurse is interviewing a surgical client in the holding area. Which information should the nurse report to the anesthesiologist? Select all that apply. 1. The client has loose, decayed teeth. 2. The client is experiencing anxiety. 3. The client smokes two (2) packs of cigarettes a day. 4. The client has had a chest x-ray which does not show infiltrates. 5. The client reports using herbs.

1. Loose teeth or caries need to be reported to the anesthesiologist so he or she can make provisions to prevent breaking the teeth and causing the client to possibly aspirate pieces. 2. The nurse should report any client who is extremely anxious, but the nurse can address the needs of a client experiencing expected surgical anxiety. 3. Smokers are at a higher risk for complications from anesthesia. 5. Herbs—for example, St. John's wort, licorice, and ginkgo—have serious interactions with anesthesia and with bodily functions such as coagulation.

38. The nurse is caring for a client in acute pain as a result of surgery. Which intervention should the nurse implement? 1. Administer pain medication as soon as the time frame allows. 2. Use nonpharmacological methods to replace medications. 3. Use cryotherapy after heat therapy because it works faster. 4. Instruct family members to administer medication with the PCA.

1. Pain medications should be administered at the frequency ordered by the HCP, not just when the client requests them, especially for acute pain.

31. The nurse and the unlicensed assistive personnel (UAP) are working on the surgical unit. Which task can the nurse delegate to the UAP? 1. Take routine vital signs on clients. 2. Check the Jackson Pratt insertion site. 3. Hang the client's next IV bag. 4. Ensure the client obtains pain relief.

1. Taking the vital signs of the stable client may be delegated to the UAP.

25. The PACU nurse is receiving the client from the OR. Which intervention should the nurse implement first? 1. Assess the client's breath sounds. 2. Apply oxygen via nasal cannula. 3. Take the client's blood pressure. 4. Monitor the pulse oximeter reading.

1. The airway should be assessed first. When caring for a client, the nurse should follow the ABCs: airway, breathing, and circulation.

46. The nurse is conducting an interview with a 75-year-old client admitted with acute pain. Which question would have priority when assisting with pain management? 1. "Have you ever had difficulty getting your pain controlled?" 2. "What types of surgery have you had in the last 10 years?" 3. "Have you ever been addicted to narcotics?" 4. "Do you have a list of your prescription medications?"

1. The answer to this request would indicate if the client has had a negative experience which may influence the client's pain management.

13. Which activities are the circulating nurse's responsibilities in the operating room? 1. Monitor the position of the client, prepare the surgical site, and ensure the client's safety. 2. Give preoperative medication in the holding area and monitor the client's response to anesthesia. 3. Prepare sutures; set up the sterile field; and count all needles, sponges, and instruments. 4. Prepare the medications to be administered by the anesthesiologist and change the tubing for the anesthesia machine.

1. The circulating nurse has many responsibilities in the OR, including coordinating the activities in the OR; keeping the OR clean; ensuring the safety of the client; and maintaining the humidity, lighting, and safety of the equipment.

1. The nurse requests the client to sign a surgical informed consent form for an emergency appendectomy. Which statement by the client indicates further teaching is needed? 1. "I will be glad when this is over so I can go home today." 2. "I will not be able to eat or drink anything prior to my surgery." 3. "I can practice relaxing by listening to my favorite music." 4. "I will need to get up and walk as soon as possible."

1. The client will be in the hospital for a few days. This is not a day-surgery procedure. The client needs more teaching.

8. The 68-year-old client scheduled for intestinal surgery does not have clear fecal contents after three (3) tap water enemas. Which intervention should the nurse implement first? 1. Notify the surgeon of the client's status. 2. Continue giving enemas until clear. 3. Increase the client's IV fluid rate. 4. Obtain STAT serum electrolytes.

1. The nurse should contact the surgeon because the client is at risk for fluid and electrolyte imbalance after three (3) enemas. Clients who are NPO, elderly clients, and pediatric clients are more likely to have these imbalances.

37. The client is complaining of left shoulder pain. Which intervention should the nurse implement first? 1. Assess the neurovascular status of the left hand. 2. Check the medication administration record (MAR). 3. Ask if the client wants pain medication. 4. Administer the client's pain medication.

1. The nurse should first assess the client for potential complications to determine if this is expected pain or pain requiring notifying the health-care provider.

20. The circulating nurse is planning the care for an intraoperative client. Which statement is the expected outcome? 1. The client has no injuries from the OR equipment. 2. The client has no postoperative infection. 3. The client has stable vital signs during surgery. 4. The client recovers from anesthesia.

1. This expected outcome addresses the safety of the client while in the OR.

43. The nurse is administering an opioid narcotic to the client. Which interventions should the nurse implement for client safety? Select all that apply. 1. Compare the hospital number on the MAR to the client's bracelet. 2. Have a witness verify the wasted portion of the narcotic. 3. Assess the client's vital signs prior to administration. 4. Determine if the client has any allergies to medications. 5. Clarify all pain medication orders with the health-care provider.

1. This procedure ensures client safety by preventing medication from being given to the wrong client. 3. This intervention would prevent giving a narcotic to a client who is unstable or compromised. 4. Determining allergies addresses client safety.

23. The circulating nurse assesses tachycardia and hypotension in the client. Which interventions should the nurse implement? 1. Prepare ice packs and mix dantrolene sodium. 2. Request the defibrillator be brought into the OR. 3. Draw a PTT and prepare a heparin drip. 4. Obtain finger stick blood glucose immediately.

1. Unexplained tachycardia, hypotension, and elevated temperature are signs of malignant hyperthermia, which is treated with ice packs and dantrolene sodium.

166. The nurse has just reassessed the condition of a postoperative client who was admitted 1 hour ago to the surgical unit. The nurse plans to monitor which parameter most carefully during the next hour? 1. Urinary output of 20 mL/hour 2. Temperature of 37.6 ° C (99.6 ° F) 3. Blood pressure of 100/70 mm Hg 4. Serous drainage on the surgical dressing

166. 1 Rationale: Urine output should be maintained at a minimum of 30 mL/hour for an adult. An output of less than 30 mL for each of 2 consecutive hours should be reported to the health care provider. A temperature higher than 37.7 ° C (100 ° F) or lower than 36.1 ° C (97 ° F) and a falling systolic blood pressure, lower than 90 mm Hg, are usually considered reportable immediately. The client's preoperative or baseline blood pressure is used to make informed postoperative comparisons. Moderate or light serous drainage from the surgical site is considered normal.

167. A postoperative client asks the nurse why it is so important to deep-breathe and cough after surgery. When formulating a response, the nurse incorporates the understanding that retained pulmonary secretions in a postoperative client can lead to which condition? 1. Pneumonia 2. Hypoxemia 3. Fluid imbalance 4. Pulmonary embolism

167. 1 Rationale: Postoperative respiratory problems are atelectasis, pneumonia, and pulmonary emboli. Pneumonia is the inflammation of lung tissue that causes productive cough, dyspnea, and lung crackles and can be caused by retained pulmonary secretions. Hypoxemia is an inadequate concentration of oxygen in arterial blood. Fluid imbalance can be a deficit or excess related to fluid loss or overload. Pulmonary embolus occurs as a result of a blockage of the pulmonary artery that disrupts blood flow to one or more lobes of the lung; this is usually due to clot formation.

168. The nurse is developing a plan of care for a client scheduled for surgery. The nurse should include which activity in the nursing care plan for the client on the day of surgery? 1. Avoid oral hygiene and rinsing with mouthwash. 2. Verify that the client has not eaten for the last 24 hours. 3. Have the client void immediately before going into surgery. 4. Report immediately any slight increase in blood pressure or pulse.

168. 3 Rationale: The nurse would assist the client to void immediately before surgery so that the bladder will be empty. Oral hygiene is allowed, but the client should not swallow any water. The client usually has a restriction of food and fluids for 6 to 8 hours before surgery instead of 24 hours. A slight increase in blood pressure and pulse is common during the preoperative period and is usually the result of anxiety.

169. A client with a perforated gastric ulcer is scheduled for surgery. The client cannot sign the operative consent form because of sedation from opioid analgesics that have been administered. The nurse should take which most appropriate action in the care of this client? 1. Obtain a court order for the surgery. 2. Have the charge nurse sign the informed consent immediately. 3. Send the client to surgery without the consent form being signed. 4. Obtain a telephone consent from a family member, following agency policy.

169. 4 Rationale: Every effort should be made to obtain permission from a responsible family member to perform surgery if the client is unable to sign the consent form. A telephone consent must be witnessed by two persons who hear the family member's oral consent. The two witnesses then sign the consent with the name of the family member, noting that an oral consent was obtained. Consent is not informed if it is obtained from a client who is confused, unconscious, mentally incompetent, or under the influence of sedatives. In an emergency, a client may be unable to sign and family members may not be available. In this situation, a health care provider is permitted legally to perform surgery without consent, but in this case it is not an emergency. Options 1 and 3 are not appropriate in this situation. Also, agency policies regarding informed consent should always be followed.

170. A preoperative client expresses anxiety to the nurse about upcoming surgery. Which response by the nurse is most likely to stimulate further discussion between the client and the nurse? 1. "If it's any help, everyone is nervous before surgery." 2. "I will be happy to explain the entire surgical procedure to you." 3. "Can you share with me what you've been told about your surgery?" 4. "Let me tell you about the care you'll receive after surgery and the amount of pain you can anticipate."

170. 3 Rationale: Explanations should begin with the information that the client knows. By providing the client with individualized explanations of care and procedures, the nurse can assist the client in handling anxiety and fear for a smooth preoperative experience. Clients who are calm and emotionally prepared for surgery withstand anesthesia better and experience fewer postoperative complications. Option 1 does not focus on the client's anxiety. Explaining the entire surgical procedure may increase the client's anxiety. Option 4 avoids the client's anxiety and is focuses on postoperative care.

171. The nurse is conducting preoperative teaching with a client about the use of an incentive spirometer. The nurse should include which piece of information in discussions with the client? 1. Inhale as rapidly as possible. 2. Keep a loose seal between the lips and the mouthpiece. 3. After maximum inspiration, hold the breath for 15 seconds and exhale. 4. The best results are achieved when sitting up or with the head of the bed elevated 45 to 90 degrees.

171. 4 Rationale: For optimal lung expansion with the incentive spirometer, the client should assume the semi-Fowler's or high Fowler's position. The mouthpiece should be covered completely and tightly while the client inhales slowly, with a constant flow through the unit. The breath should be held for 5 seconds before exhaling slowly.

172. The nurse has conducted preoperative teaching for a client scheduled for surgery in 1 week. The client has a history of arthritis and has been taking acetylsalicylic acid (aspirin). The nurse determines that the client needs additional teaching if the client makes which statement? 1. "Aspirin can cause bleeding after surgery." 2. "Aspirin can cause my ability to clot blood to be abnormal." 3. "I need to continue to take the aspirin until the day of surgery." 4. "I need to check with my health care provider about the need to stop the aspirin before the scheduled surgery."

172. 3 Rationale: Anticoagulants alter normal clotting factors and increase the risk of bleeding after surgery. Aspirin has properties that can alter the clotting mechanism and should be discontinued at least 48 hours before surgery. However, the client should always check with his or her health care provider regarding when to stop taking the aspirin when a surgical procedure is scheduled. Options 1, 2, and 4 are accurate client statements.

44. Which technique would be most appropriate for the nurse to implement when assessing a four (4)-year-old client in acute pain? 1. Use words a four (4)-year-old child can remember. 2. Explain the 0-to-10 pain scale to the child's parent. 3. Have the child point to the face which describes the pain. 4. Administer the medication every four (4) hours.

3. The Faces Scale is the best way to assess pain in a four (4)-year-old child.

174. The nurse is monitoring the status of a postoperative client. The nurse would become most concerned with which sign that could indicate an evolving complication? 1. Increasing restlessness 2. A pulse of 86 beats/minute 3. Blood pressure of 110/70 mm Hg 4. Hypoactive bowel sounds in all four quadrants

174. 1 Rationale: Increasing restlessness is a sign that requires continuous and close monitoring because it could indicate a potential complication, such as hemorrhage, shock, or pulmonary embolism. A blood pressure of 110/70 mm Hg with a pulse of 86 beats/minute is within normal limits. Hypoactive bowel sounds heard in all four quadrants are a normal occurrence.

175. A client who has had abdominal surgery complains of feeling as though "something gave way" in the incisional site. The nurse removes the dressing and notes the presence of a loop of bowel protruding through the incision. Which nursing interventions should the nurse take? Select all that apply. 1. Contact the surgeon. 2. Instruct the client to remain quiet. 3. Prepare the client for wound closure. 4. Document the findings and actions taken 5. Place a sterile saline dressing and ice packs over the wound. 6. Place the client in a supine position without a pillow under the head.

175. 1, 2, 3, 4 Rationale: Wound dehiscence is the separation of the wound edges. Wound evisceration is protrusion of the internal organs through an incision. If wound dehiscence or evisceration occurs, the nurse should call for help, stay with the client, and ask another nurse to contact the surgeon and obtain needed supplies to care for the client. The nurse places the client in a low Fowler's position, and the client is kept quiet, and instructed not to cough. Protruding organs are covered with a sterile saline dressing. Ice is not applied because of its vasoconstrictive effect. The treatment for evisceration is usually immediate wound closure under local or general anesthesia. The nurse also documents the findings and actions taken.

176. A client who has undergone preadmission testing has had blood drawn for serum laboratory studies, including a complete blood count, coagulation studies, and electrolytes and creatinine levels. Which laboratory result should be reported to the surgeon's office by the nurse, knowing that it could cause surgery to be postponed? 1. Sodium, 141 mEq/L 2. Hemoglobin, 8.0 g/dL 3. Platelets, 210,000/mm3 4. Serum creatinine, 0.8 mg/dL

176. 2 Rationale: Routine screening tests include a complete blood count, serum electrolyte analysis, coagulation studies, and a serum creatinine test. The complete blood count includes the hemoglobin analysis. All these values are within normal range except for hemoglobin. If a client has a low hemoglobin level, the surgery likely could be postponed by the surgeon.

177. The nurse receives a telephone call from the postanesthesia care unit stating that a client is being transferred to the surgical unit. The nurse plans to take which action first on arrival of the client? 1. Assess the patency of the airway. 2. Check tubes or drains for patency. 3. Check the dressing to assess for bleeding. 4. Assess the vital signs to compare with preoperative measurements.

177. 1 Rationale: The first action of the nurse is to assess the patency of the airway and respiratory function. If the airway is not patent, the nurse must take immediate measures for the survival of the client. The nurse then takes vital signs followed by checking the dressing and the tubes or drains. The other nursing actions should be performed after a patent airway has been established.

178. The nurse is reviewing a health care provider's (HCP's) prescription sheet for a preoperative client that states that the client must be NPO after midnight. The nurse would telephone the HCP to clarify that which medication should be given to the client and not withheld? 1. Prednisone 2. Ferrous sulfate 3. Cyclobenzaprine (Flexeril) 4. Conjugated estrogen (Premarin)

178. 1 Rationale: Prednisone is a corticosteroid. With prolonged use, corticosteroids cause adrenal atrophy, which reduces the ability of the body to withstand stress. When stress is severe, corticosteroids are essential to life. Before and during surgery, dosages may be increased temporarily. Ferrous sulfate is an oral iron preparation used to treat iron deficiency anemia. Cyclobenzaprine (Flexeril) is a skeletal muscle relaxant. Conjugated estrogen (Premarin) is an estrogen used for hormone replacement therapy in postmenopausal women. These last three medications may be withheld before surgery without undue effects on the client.

28. The PACU nurse administers Narcan, an opioid antagonist, to a postoperative client. Which client problem should the nurse include to the plan of care based on this medication? 1. Alteration in comfort. 2. Risk for depressed respiratory pattern. 3. Potential for infection. 4. Fluid and electrolyte imbalance.

2. A client with respiratory depression treated with Narcan can have another episode within 15 minutes after receiving the drug as a result of the short half-life of the medication.

40. Which statement should the nurse identify as the expected outcome for a client experiencing acute pain? 1. The client will have decreased use of medication. 2. The client will participate in self-care activities. 3. The client will use relaxation techniques. 4. The client will repeat instructions about medications.

2. Clients experiencing acute pain will not be involved in self-care because of their reluctance to move, which increases the pain; therefore, participation indicates the client's pain is tolerable.

9. The nurse is caring for a male client scheduled for abdominal surgery. Which interventions should the nurse include in the plan of care? Select all that apply. 1. Perform passive range-of-motion exercises. 2. Discuss how to cough and deep breathe effectively. 3. Tell the client he can have a meal in the PACU. 4. Teach ways to manage postoperative pain. 5. Discuss events which occur in the postanesthesia care unit.

2. Coughing effectively aids in the removal of pooled secretions, which can cause pneumonia. Deep-breathing exercises keep the alveoli inflated and prevent atelectasis. 4. The client's postoperative pain should be kept within a tolerable range. 5. These interventions help decrease the client's anxiety.

29. The 26-year-old male client in the PACU has a heart rate of 110 and a rising temperature and complains of muscle stiffness. Which interventions should the nurse implement? Select all that apply. 1. Give a back rub to the client to relieve stiffness. 2. Apply ice packs to the axillary and groin areas. 3. Prepare an ice slush for the client to drink. 4. Prepare to administer dantrolene, a smooth muscle relaxant. 5. Reposition the client on a warming blanket.

2. Ice packs should be applied to the axillary and groin areas for a client experiencing malignant hyperthermia. 4. Dantrolene is the drug of choice for treatment.

17. The nurse identifies the nursing diagnosis "risk for injury related to positioning" for the client in the operating room. Which nursing intervention should the nurse implement? 1. Avoid using the cautery unit which does not have a biomedical tag on it. 2. Carefully pad the client's elbows before covering the client with a blanket. 3. Apply a warming pad on the OR table before placing the client on the table. 4. Check the chart for any prescription or overthe- counter medication use.

2. Padding the elbows decreases pressure so nerve damage and pressure ulcers are prevented. This addresses the etiology of the nursing diagnosis.

33. Which statement would be an expected outcome for the postoperative client who had general anesthesia? 1. The client will be able to sit in the chair for 30 minutes. 2. The client will have a pulse oximetry reading of 97% on room air. 3. The client will have a urine output of 30 mL per hour. 4. The client will be able to distinguish sharp from dull sensations.

2. The anesthesia machine takes over the function of the lungs during surgery, so the expected outcome should directly reflect the client's respiratory status; the alveoli can collapse, causing atelectasis.

22. The nursing manager is making assignments for the OR. Which case should the manager assign to the inexperienced nurse? 1. The client having open-heart surgery. 2. The client having a biopsy of the breast. 3. The client having laser eye surgery. 4. The client having a laparoscopic knee repair.

2. The case of a client having a biopsy of the breast would be a good case for an inexperienced nurse because it is simple.

18. The circulating nurse is positioning clients for surgery. Which client has the greatest potential for nerve damage? 1. The 16-year-old client in the dorsal recumbent position having an appendectomy. 2. The 68-year-old client in the Trendelenburg position having a cholecystectomy. 3. The 45-year-old client in the reverse Trendelenburg position having a biopsy. 4. The 22-year-old client in the lateral position having a nephrectomy.

2. The client's age, along with positioning with increased weight and pressure on the shoulders, puts this client at higher risk.

2. The nurse in the holding area of the surgery department is interviewing a client who requests to keep his religious medal on during surgery. Which intervention should the nurse implement? 1. Notify the surgeon about the client's request to wear the medal. 2. Tape the medal to the client and allow the client to wear the medal. 3. Request the family member take the medal prior to surgery. 4. Explain taking the medal to surgery is against the policy.

2. The medal should be taped and the client should be allowed to wear the medal because meeting spiritual needs is essential to this client's care.

21. Which nursing intervention has the highest priority when preparing the client for a surgical procedure? 1. Pad the client's elbows and knees. 2. Apply soft restraint straps to the extremities. 3. Prepare the client's incision site. 4. Document the temperature of the room.

2. This action would prevent the client from falling off the table, which is the highest priority.

42. Which intervention is appropriate for the nurse to delegate to the unlicensed assistive personnel (UAP) when caring for the female client experiencing acute pain? 1. Take the pain medication to the room. 2. Apply an ice pack to the site of pain. 3. Check on the client 30 minutes after she takes the pain medication. 4. Observe the client's ability to use the PCA.

2. This task does not require teaching, evaluating, or nursing judgment and therefore can be delegated.

3. The nurse must obtain surgical consent forms for the scheduled surgery. Which client would not be able to consent legally to surgery? 1. The 65-year-old client who cannot read or write. 2. The 30-year-old client who does not understand English. 3. The 16-year-old client who has a fractured ankle. 4. The 80-year-old client who is not oriented to the day.

3. A 16-year-old client is not legally able to give permission for surgery unless the adolescent has been given an emancipated status by a judge. This information was not given in the stem.

48. Which problem would be most appropriate for the nurse to identify for the client experiencing acute pain? 1. Ineffective coping. 2. Potential for injury. 3. Alteration in comfort. 4. Altered sensory input.

3. Alteration in comfort is addressing the client's acute pain.

34. The postoperative client is transferred from the PACU to the surgical floor. Which action should the nurse implement first? 1. Apply antiembolism hose to the client. 2. Attach the drain to 20 cm suction. 3. Assess the client's vital signs. 4. Listen to the report from the anesthesiologist.

3. Assessing the client's status after transfer from the PACU should be the nurse's first intervention.

27. The surgical client's vital signs are T 98˚F, P 106, R 24, and BP 88/40. The client is awake and oriented times three (3) and the skin is pale and damp. Which intervention should the nurse implement first? 1. Call the surgeon and report the vital signs. 2. Start an IV of D5RL with 20 mEq KCl at 125 mL/hr. 3. Elevate the feet and lower the head. 4. Monitor the vital signs every 15 minutes.

3. By lowering the head of the bed and raising the feet, the blood is shunted to the brain until volume-expanding fluids can be administered, which is the first intervention for a client who is hemorrhaging.

36. The unlicensed assistive personnel (UAP) reports the vital signs for a first-day postoperative client as T 100.8˚F, P 80, R 24, and BP 148/80. Which intervention would be most appropriate for the nurse to implement? 1. Administer the antibiotic earlier than scheduled. 2. Change the dressing over the wound. 3. Have the client turn, cough, and deep breathe every two (2) hours. 4. Encourage the client to ambulate in the hall.

3. Having the client turn, cough, and deep breathe is the best intervention for the nurse to implement because, if a client has a fever within the first day, it is usually caused by a respiratory problem.

26. Which assessment data indicate the postoperative client who had spinal anesthesia is suffering a complication of the anesthesia? 1. Loss of sensation at the lumbar (L5) dermatome. 2. Absence of the client's posterior tibial pulse. 3. The client has a respiratory rate of eight (8). 4. The blood pressure is within 20% of the client's baseline.

3. If the effects of the spinal anesthesia move up rather than down the spinal cord, respirations can be depressed and even blocked.

11. The nurse is completing a preoperative assessment on a male client who states, "I am allergic to codeine." Which intervention should the nurse implement first? 1. Apply an allergy bracelet on the client's wrist. 2. Label the client's allergies on the front of the chart. 3. Ask the client what happens when he takes the codeine. 4. Document the allergy on the medication administration record.

3. The nurse should first assess the events which occurred when the client took this medication because many clients think a side effect, such as nausea, is an allergic reaction.

14. The circulating nurse observes the surgical scrub technician remove a sponge from the edge of the sterile field with a clamp and place the sponge and clamp in a designated area. Which action should the nurse implement? 1. Place the sponge back where it was. 2. Tell the technician not to waste supplies. 3. Do nothing because this is the correct procedure. 4. Take the sponge out of the room immediately.

3. The technician followed the correct procedure. Sponges are counted to maintain client safety, so all sponges must be kept together to repeat the count before the incision site is sutured. The sponge must be removed, not used, and placed in a designated area to be counted later.

7. The nurse is assessing a client in the day surgery unit who states, "I am really afraid of having this surgery. I'm afraid of what they will find." Which statement would be the most therapeutic response by the nurse? 1. "Don't worry about your surgery. It is safe." 2. "Tell me why you're worried about your surgery." 3. "Tell me about your fears of having this surgery." 4. "I understand how you feel. Surgery is frightening."

3. This statement focuses on the emotion which that the client identified and is therapeutic.

19. Which situation demonstrates the circulating nurse acting as the client's advocate? 1. Plays the client's favorite audio book during surgery. 2. Keeps the family informed of the findings of the surgery. 3. Keeps the operating room door closed at all times. 4. Calls the client by the first name when the client is recovering.

3. This would keep the client's dignity by maintaining privacy. With this action, the nurse is speaking for the client while the client cannot speak as a result of anesthesia; this is an example of client advocacy.

39. Which situation is an example of the nurse fulfilling the role of client advocate? 1. The nurse brings the client pain medication when it is due. 2. The nurse collaborates with other disciplines during the care conference. 3. The nurse contacts the health-care provider when pain relief is not obtained. 4. The nurse teaches the client to ask for medication before the pain gets to a "5."

3. When the nurse contacts the HCP about unrelieved pain, the nurse is speaking when the client cannot, which is the definition of a client advocate.

15. The circulating nurse and the scrub technician find a discrepancy in the sponge count. Which action should the circulating nurse take first? 1. Notify the client's surgeon. 2. Complete an occurrence report. 3. Contact the surgical manager. 4. Recount all sponges.

4. A recount of sponges may lead to the discovery of the cause of the presumed error. Usually it is just a miscount or a result of a sponge being placed in a location other than the sterile field, such as the floor or a lower shelf.

16. Which violation of surgical asepsis would require immediate intervention by the circulating nurse? 1. Surgical supplies were cleaned and sterilized prior to the case. 2. The circulating nurse is wearing a longsleeved sterile gown. 3. Masks covering the mouth and nose are being worn by the surgical team. 4. The scrub nurse setting up the sterile field is wearing artificial nails.

4. According to the Centers for Disease Control and Prevention (CDC), the Association of Operating Room Nurses (AORN), and the Association for Practitioners in Infection Control, artificial nails harbor microorganisms, which increase the risk for infection.

32. The charge nurse is making shift assignments. Which postoperative client should be assigned to the most experienced nurse? 1. The 4-year-old client who had a tonsillectomy and is able to swallow fluids. 2. The 74-year-old client with a repair of the left hip who is unable to ambulate. 3. The 24-year-old client who had an uncomplicated appendectomy the previous day. 4. The 80-year-old client with small bowel obstruction and congestive heart failure.

4. An older client with a chronic disease would be a complicated case, requiring the care of a more experienced nurse.

4. The nurse is preparing a client for surgery. Which intervention should the nurse implement first? 1. Check the permit for the spouse's signature. 2. Take and document intake and output. 3. Administer the "on call" sedative. 4. Complete the preoperative checklist.

4. Completing the preoperative checklist has the highest priority to ensure all details are completed without omissions.

30. Which data indicate to the nurse the client who is one (1) day postoperative right total hip replacement is progressing as expected? 1. Urine output was 160 mL in the past eight (8) hours. 2. Paralysis and paresthesia of the right leg. 3. T 99.0˚F, P 98, R 20, and BP 100/60. 4. Lungs are clear bilaterally in all lobes.

4. Lung sounds which are clear bilaterally in all lobes indicate the client has adequate gas exchange, which prevents postoperative complications and indicates effective nursing care.

6. Which task would be most appropriate for the nurse to delegate to the unlicensed assistive personnel (UAP)? 1. Complete the preoperative checklist. 2. Assess the client's preoperative vital signs. 3. Teach the client about coughing and deep breathing. 4. Assist the client to remove clothing and jewelry.

4. The UAP can remove clothing and jewelry.

10. The nurse is caring for a client scheduled for total hip replacement. Which behavior indicates the need for further preoperative teaching? 1. The client uses the diaphragm and abdominal muscles to inhale through the nose and exhale through the mouth. 2. The client demonstrates dorsiflexion of the feet, flexing of the toes, and moves the feet in a circular motion. 3. The client uses the incentive spirometer and inhales slowly and deeply so the piston rises to the preset volume. 4. The client gets out of bed by lifting straight upright from the waist and then swings both legs along the side of the bed.

4. The correct way to get out of bed postoperatively is to roll onto the side, grasp the side rail to maneuver to the side, and then push up with one hand while swinging the legs over the side. The client needs further teaching.

41. Which nursing intervention is the highest priority when administering pain medication to a client experiencing acute pain? 1. Monitor the client's vital signs. 2. Verify the time of the last dose. 3. Check for the client's allergies. 4. Discuss the pain with the client.

4. The nurse should question the client to rule out complications and to determine which medication and amount would be most appropriate for the client. This is assessment.

12. Which laboratory result would require immediate intervention by the nurse for the client scheduled for surgery? 1. Calcium 9.2 mg/dL. 2. Bleeding time two (2) minutes. 3. Hemoglobin 15 g/dL. 4. Potassium 2.4 mEq/L.

4. This potassium level is low and should be reported to the health-care provider because potassium is important for muscle function, including the cardiac muscle.

866. A nurse receives the written laboratory results of a positive pregnancy test for a client scheduled for an emergency appendectomy. The nurse should first: 1. call the lab to verify the results of the test. 2. inform the client of the positive results. 3. report the results immediately to the surgeon. 4. notify the client's primary physician of the results.

ANSWER: 3 The surgeon should be notified because a positive pregnancy test result could influence the choice of anesthetic agents, medications, and surgical approach.

864. Which client statement made during a presurgical admission assessment needs the most immediate follow-up? 1. "I haven't eaten foods or had any fluids for the past 12 hours." 2. "I donated my own blood in case I need a transfusion; the last donation was 4 days ago." 3. "I took my usual dose of warfarin (Coumadin®) and other cardiac meds this morning with a sip of water." 4. "I brought a copy of my Health Care Directives so others will know my wishes should my heart stop during surgery."

ANSWER: 3 Warfarin is an anticoagulant. Usually this is stopped a few days before surgery due to the increased risk of bleeding.

883. A nurse is reviewing a plan of care for a postoperative client with a history of sickle cell disease. Which nursing diagnosis, documented on the client's care plan, should the nurse address first? 1. Anxiety 2. Impaired skin integrity 3. Deficient fluid volume 4. Ineffective airway clearance

ANSWER: 4 An open airway is a physiological need that is priority. Ineffective airway clearance in a postoperative client is often due to an ineffective or absent cough and the accumulation of secretions that compromise the airway.

888. A nurse assesses that a client on the second postoperative day following abdominal surgery has diminished breath sounds in both lung bases, is taking shallow breaths, is able to achieve only 500 mL on an incentive spirometer, and has been smoking one pack of cigarettes per day prior to surgery. The nurse's best interpretation of these findings is that the client is experiencing: 1. atelectasis. 2. pneumonia. 3. a normal postoperative course. 4. chronic obstructive pulmonary disease (COPD).

ANSWER: 1 Atelectasis is a common finding in smokers after abdominal surgery due to the accumulation of secretions. It is caused from collapsed alveoli or mucus that prevents some alveoli from opening and manifests with diminished breath sounds, diminished vital capacity, and decreased oxygen saturation.

882. A nurse is planning the discharge of a client following recovery from an exploratory laparotomy. The client has a history of chronic back pain and limited ability to ambulate. The nurse plans for further discharge teaching when the client states: 1. "I can leave my elastic antiembolic (TEDS®) stockings off once I get home." 2. "I should be eating a diet high in protein, calories, and vitamin C now and when I get home." 3. "An alternative method to control pain and reduce swelling is applying ice to my incision." 4. "I use my incentive spirometer every 2 hours so I can reach my volume goal before discharge."

ANSWER: 1 Because the client has limited ability to ambulate, the client should continue to wear the TED stockings at home to prevent deep vein thrombosis until the client increases ambulation. The TEDS should be removed one to two times daily for skin care and inspection.

893. A nurse notifies a physician after assessing a client 5 days after an exploratory laparotomy and noting a distended abdomen, abdominal pain, absence of flatus, and absent bowel sounds. Which typical complication of abdominal surgery should the nurse conclude may be occurring? 1. Paralytic ileus 2. Silent peritonitis 3. Fluid volume excess 4. Malabsorption syndrome

ANSWER: 1 Paralytic ileus results from a neuromuscular disturbance and does not involve a physical obstruction in or outside the intestine. Peristalsis is decreased or absent, resulting in a slowing of the movement or a backup of intestinal contents. In addition to the symptoms the client is experiencing, nausea and vomiting may be present.

881. A nurse evaluates that a client has achieved an expected outcome for the second postoperative day following abdominal surgery under general anesthesia. Which finding supports the nurse's conclusion? 1. Passing flatus 2. Urine output 680 mL in 24 hours 3. Crackles in bilateral lung bases 4. Rates incisional pain at 4 out of 10 on a 0 to 10 rating scale 60 minutes after analgesic given

ANSWER: 1 Passing flatus indicates increased gastrointestinal motility and the return of bowel function.

876. A client in an operating room holding area, who is to receive general anesthesia, reports having a dry mouth because food and fluids have been withheld for 8 hours. Which action by a nurse is most appropriate? 1. Teach the client that the primary reason food and fluids have been withheld is to prevent vomiting and potential complications 2. Clarify that food and fluids should have been withheld only for 4 hours and offer a small sip of water 3. Explain to the client that a full stomach puts pressure on the diaphragm and prevents full lung expansion during surgery 4. Tell the client that the general anesthetic will soon make the client sleepy and unaware of the mouth dryness

ANSWER: 1 The client should have nothing by mouth (NPO) for 6 to 8 hours prior to general anesthesia to prevent vomiting and aspiration.

867. During a presurgical admission assessment, a client states, "I've told my surgeon that I am a Jehovah's Witness and I won't accept a blood transfusion." Which statement by the nurse would be most appropriate? 1. "Tell me about your fear of receiving a blood transfusion." 2. "Your request to not receive a transfusion would be honored. Your consent is needed to administer blood or blood products." 3. "You don't need to worry about getting a blood transfusion. We have newer equipment that causes less blood loss during surgery." 4. "Are you sure you wouldn't want a blood transfusion if one is needed during surgery? You can always change your mind after surgery."

ANSWER: 2 A client's consent is needed prior to administering blood or blood products. Even in a life-threatening situation, the client has the right to refuse blood and blood products for religious reasons.

886. A physician documents in a client's postoperative progress notes that the client is experiencing a respiratory infection with a shift to the left in the white blood cell (WBC) differential count. Which finding by a nurse reviewing the client's laboratory report would support the physician's documentation? 1. Decreased WBC count 2. Increased band cells 3. Decreased hemoglobin 4. Increased C-reactive protein

ANSWER: 2 An early indication of infection is an increase in the band cells, which are immature neutrophils in the WBC differential count. The increase is termed a shift to the left.

878. Upon arrival to an operating room holding area, a client who is scheduled for abdominal surgery is noted to have replaced a tongue ring that was removed when the operative checklist was completed. Which is the most appropriate initial action by a nurse? 1. Document the findings on the client's medical record 2. Request that the client once again remove the tongue ring 3. Complete a variance report, noting that the client has replaced the tongue ring 4. Notify the surgeon and the anesthesiologist of the replacement of the tongue ring

ANSWER: 2 Because anesthesia and surgery have not yet started, it is safe to ask the client to remove the tongue ring. If the client refuses, then the surgeon and anesthesiologist should be notified.

887. In reviewing a physician's orders for a postoperative client who underwent gynecological surgery, which order should a nurse determine is specifically written with the intent to prevent postoperative thrombophlebitis and pulmonary embolism? 1. Have the client dangle the legs the evening of surgery 2. Administer enoxaparin (Lovenox®) 40 mg subcutaneously daily 3. Administer hydromorphone (Dilaudid®) 1 to 4 mg IV every 3 to 4 hours as needed (prn) 4. Encourage coughing and deep breathing (C&DB) every hour while awake

ANSWER: 2 Enoxaparin is an anticoagulant that potentiates the inhibitory effect of antithrombin on factor Xa and thrombin.

870. A physician writes an order to hold all medications the morning of surgery for a client with a history of type 1 diabetes mellitus and hypertension. A nurse should call the physician to clarify the hold order for what medication? 1. Acetylsalicylic acid (aspirin) 2. Ducosate sodium (Colace®) 3. Regular and NPH insulin (Humulin®) 4. Clonidine (Catapres®)

ANSWER: 3 The diabetic client who takes insulin should be given a reduced dose of intermediate or long-acting insulin based on the blood glucose levels. Regular insulin in divided doses on the day of surgery or an insulin drip may be initiated for tight glucose control.

871. Which client statement indicates that a client who is scheduled for a 3-hour surgery under general anesthesia needs further teaching? 1. "A breathing tube will be placed when I am in the operating room." 2. "I should shave the skin in the surgical area the evening prior to surgery." 3. "I should splint my incision with a pillow when coughing and deep breathing after surgery." 4. "I might need a urinary catheter inserted before surgery so my urine output can be monitored."

ANSWER: 2 If any shaving of the surgical area is to be done, it should be done immediately prior to surgery in a holding area, treatment room, operating suite, or the operating room by qualified personnel. The client should not shave the surgical area. Nicks increase the risk for infection.

894. Which statement should a nurse include when teaching a client prior to discharge following abdominal surgery? 1. "Return to work in about 4 weeks because working increases your physical activity gradually." 2. "The ordered iron and vitamins tablets will promote wound healing and red blood cell growth." 3. "Daily walking carrying 10-pound weights will help to strengthen your incision." 4. "Home-care nursing service is usually paid by insurance if you need help around the house."

ANSWER: 2 In addition to vitamins and iron, supplemental vitamin C and a diet high in protein and calories will promote wound healing.

892. A nurse evaluates that the drainage from a client's nasogastric (NG) tube, inserted for gastric decompression during emergency surgery, would be normal if it: 1. returns brown-liquid in color. 2. returns greenish-yellow in color. 3. has an alkalotic hydrogen level (pH). 4. measures less than 25 mL in volume.

ANSWER: 2 Normal NG drainage fluid is greenish yellow in color.

875. A nurse is teaching a client prior to surgery about the device illustrated. The nurse teaches the client that the primary purpose of the device illustrated is to: 1. improve circulation prior to surgery. 2. prevent intra- and postoperative deep vein thrombosis. 3. assist in keeping the client warm during surgery. 4. promote dehiscence and wound healing postoperatively.

ANSWER: 2 Sequential compression devices (SCDs) are used postoperatively to prevent deep vein thrombosis. The device promotes fluid movement by simulating leg muscles contraction. The stocking compartments inflate to 35 to 55 mm Hg, inflating from the ankle, to the calf, and finally the thigh.

874. A nurse evaluates that a preoperative client can properly use a volume incentive spirometer when which client action is noted? 1. Sits upright, inserts the mouthpiece, and blows until the lungs are emptied of air 2. Sits upright, exhales, seals lips around the mouthpiece, inhales, and holds breath for 5 seconds 3. Sits at the edge of the bed, coughs, inserts the mouthpiece, and blows slowly for 10 seconds 4. Sits at the edge of the bed, breathes deeply five times, inserts the mouthpiece, and inhales quickly

ANSWER: 2 Sitting upright promotes lung expansion. With all types of incentive spirometers, the client must be able to seal the lips tightly around the mouthpiece and inhale slowly. The client then holds the breath for 3 to 5 seconds for effective lung expansion.

885. A postoperative client who received a spinal anesthetic is experiencing a headache, photophobia, and double vision. A nurse's initial intervention should be to: 1. immediately notify the surgeon. 2. position the client flat in bed. 3. limit the client's fluid intake. 4. administer steroid medications.

ANSWER: 2 The client is experiencing a postdural puncture headache caused by leakage of cerebrospinal fluid (CSF) from the needle insertion made in the dura for the spinal anesthetic. Placing the client in the flat position minimizes the leakage of CSF.

891. A client is to receive a second dose of oxycodone/ acetaminophen (Percocet®) for postoperative incisional pain. When a nurse brings the medication to the client, the client says, "Why bring this medication again? It makes me feel sick." Which statement is the most appropriate initial nurse response? 1. "I can call the doctor to see what else can be ordered for your pain." 2. "Describe what you feel when you say that the medication makes you feel sick." 3. "The doctor has ordered an antacid. I can give you this along with the medication." 4. "Many people say the same thing. The aspirin in the medication is hard on your stomach."

ANSWER: 2 The nurse is using the therapeutic communication technique, known as clarifying, to determine the effects of the medication on the client. This focuses on the client's feelings.

890. Which outcome should indicate to a nurse that a postsurgical client's coughing and deep breathing (C&DB) is most effective? 1. Respirations are 16 per minute and unlabored. 2. Lung sounds are audible and clear on auscultation. 3. Coughs include small amount of clear secretions. 4. Cough effort is strong and productive.

ANSWER: 2 The purpose of postoperative C&DB is to expel secretions, keep the lungs clear, allow full aeration, and prevent pneumonia and atelectasis. Auscultating for clear and audible lung sounds is a definitive means for evaluating the effectiveness of C&DB.

869. A nurse is reviewing preoperative orders for a client who is to have surgery on the large intestine the next day. Which written orders should the nurse question? SELECT ALL THAT APPLY. 1. NPO after midnight 2. Erythromycin 500 mg bid 3. Tap water enemas until hard stool passed 4. Clear liquid diet the day before surgery 5. Begin incentive spirometer (IS) use prior to surgery

ANSWER: 2, 3 Tap water enemas would be administered until the returns are clear. Stool present in the colon could predispose the client to peritonitis and infection. Antibiotics are administered to sterilize the bowel prior to surgery but no route is prescribed.

889. A nurse notes redness, swelling, and warmth of and around the incision when assessing a client's leg incision 48 hours after femoral popliteal bypass surgery. The nurse's best analysis should be that the incision is: 1. healing normally for the second postoperative day. 2. showing signs of rejection of the suture materials. 3. inflamed and could indicate the presence of an infection. 4. infected and showing signs of wound dehiscence.

ANSWER: 3 Redness, swelling, and warmth are signs of inflammation and could indicate the presence of an infection. Other signs of an infection include excessive pain or tenderness on palpation and purulent or odorous drainage.

884. A nurse is caring for a postoperative client who reports an inability to void. Which initial action by the nurse is most appropriate? 1. Turning on running water 2. Inserting a urinary catheter 3. Palpating the client's bladder 4. Reviewing the client's chart for the time of the last voiding

ANSWER: 3 The bladder should be palpated for distention. The nurse should also observe for other signs of a full bladder such as restlessness or an elevated blood pressure. The nurse should first determine the underlying reason for the client's inability to void.

863. A nurse plans care for a client and notes that all of the following must be completed for a client being prepared for surgery. Which intervention should the nurse complete first? 1. Complete the preoperative checklist. 2. Assess the client's preoperative vital signs. 3. Remove the client's rings, gold chain, and wristwatch. 4. Administer 10 mEq KCL IV for a serum potassium level of 3.0 mEq/L.

ANSWER: 4 Intravenous potassium is ordered for low serum potassium levels. Low levels could induce cardiac dysrhythmias and delay surgery. Administering the potassium should be the nurse's priority because abnormalities must be corrected before surgery.

880. Which information is most important for a postanesthesia care unit nurse to include in a report on a postoperative client to a surgical unit nurse? 1. Location of the relatives 2. Review of the surgical consent 3. Placement of client belongings 4. Last dose and type of pain medication

ANSWER: 4 Pain is the fifth vital sign. Time and dose is the reference for implementing the pain protocol or developing a plan for the client's pain control. The hand-off of the client to another area is the ideal time to insure the continuation of care, as well as the transfer of responsibility.

879. A nurse is orienting a new nurse to a postanesthesia care unit (PACU). Which statement by the new nurse indicates further orientation is needed? 1. "Lactated Ringer's (LR) and 5% dextrose with LR are typical IV solutions administered in the PACU." 2. "If a client has an opioid overdose, I should expect to administer naloxone hydrochloride (Narcan®)." 3. "I should monitor vital signs and perform a pain assessment every 15 minutes or more often if necessary." 4. "Once a client responds verbally after a spinal anesthetic, the client can be transferred to the nursing unit."

ANSWER: 4 The client receiving a spinal anesthetic should remain in the PACU until feeling and voluntary motor movement of the lower extremities has begun to return. Because the client did not receive a general anesthetic that depressed the central nervous system, the client may be verbally responsive immediately after surgery

872. Which nursing action would be best when a preoperative client verbalizes fear of postoperative pain? 1. Providing diversional activities when client reports fear of pain 2. Encouraging the client to verbalize concerns regarding the fear of pain 3. Informing the client of experiences and the likelihood of pain pre- and postoperatively 4. Explaining the medications ordered for pain control, availability, and treatment goals

ANSWER: 4 The client should be reassured that there are medications available to prevent and treat pain.

865. A nurse is to witness the signature of a surgical consent for multiple clients scheduled for surgery the following day. In evaluating the health history of each client, the nurse should plan to obtain a signature from the next of kin for: 1. a 75-year-old client who is blind. 2. a 60-year-old client who does not understand English. 3. a 50-year-old client who is forgetful, but fully oriented. 4. a 16-year-old educated client who fully understands the surgery.

ANSWER: 4 The legal age for consent is 18 years unless the adolescent has emancipated status granted by a judge.

868. A nurse is analyzing serum laboratory results for a 73-year-old female client scheduled for surgery in 2 hours. The nurse concludes that which result would warrant the most immediate notification of the physician? 1. Hemoglobin 10 g/dL 2. Creatinine 1.0 mg/dL 3. Potassium 4.5 mEq/dL 4. Prothrombin time 22 seconds

ANSWER: 4 The normal prothrombin time is 11 to 12.5 seconds. Because it is prolonged, the client is at risk for bleeding.

877. A nurse is caring for a client who received conscious sedation during a surgical procedure. Which assessment of this client is most important for a nurse to make postoperatively? 1. Lung sounds 2. Amount of urine output 3. Ability to swallow liquids 4. Rate and depth of breathing

ANSWER: 4 The rate and depth of breathing should be assessed to determine the adequacy of air exchange. A respiratory rate of less than 10 breaths per minute indicates drug-induced respiratory depression.

873. Which statement by a nurse is most effective when collecting data about a preoperative client's recreational drug use? 1. "Describe the drugs you use and the frequency that you use these drugs." 2. "Do you use any over-the-counter medications or illegal substances?" 3. "Tell me about all medications and substances you take because complications can occur if you are taking something we do not know about." 4. "Because herbs, medications, and recreational drugs such as marijuana and cocaine affect the type and amount of anesthesia you need, list any of these you take and how often you use them."

ANSWER: 4 When clients are aware of the potential interactions of drugs with anesthetics, most clients respond honestly about their drug use. This statement is nonjudgmental and nonthreatening.