Test 3

After receiving change of shift report about theses postop patients, which patient should the nurse assess first?

Obese patient who had abdominal surgery 3 days ago and whose wound edges are separating

Which statement best describes the role of the CRNA on the surgical care team?

Releases or discharges patients from the PACU

The nurse assesses a patient on the second postoperative day after abdominal surgery to repair a perforated duodenal ulcer. Which finding is most important for the nurse to report to the surgeon?

200 mL sanguineous fluid in the wound drain

On the second postoperative day, the patients NG tube is removed and the patient begins drinking clear liquids. Four hour later, the patient reports frequent, cramping gas pains. What action by the nurse is the most appropriate?

Assist the patient to ambulate

The surgical unit nurse has just received a patient with a history of smoking from the PACU. Which action is most important at this time?

Auscultate for adventitious breath sounds

Which action by the nurse will be most helpful to a patient who is expected to ambulate, deep breathe and cough on the first postoperative day?

Administer prescribed analgesic medications before the activities

A patient who had knee surgery received IV ketorolac 30 minutes ago and continues to complain of pain 7/10. Which action should the nurse do next?

Administer the PRN IV morphine sulfate

Which finding would indicate to the nurse that a postop patient is at increased risk for poor wound healing?

Albumin level 2.2 g/dL

While in the holding area, a patient reveals to the nurse that his father had a high fever after surgery. What action by the nurse is a priority?

Alert the anesthesia care provider of the family member's reaction to surgery

A patient who has not had any prior surgeries tells the nurse doing the preoperative assessment about allergies to avocados and bananas. Which action is most important for the nurse to take?

Alert the surgery center about a possible latex allergy

A patient who has begun to awaken after 30 minutes in the PACU is restless and shouting at the nurse. The patient's oxygen is 96% and recent lab results are all normal. Which action by the nurse is most appropriate?

Assess for bladder distention

Which action describes how the scrub nurse protects the patient with aseptic technique during surgery?

Changes gloves after touching the upper arm of the surgeons gown

A patient who is just waking up after having hip replacement surgery is agitated and confused. Which action should the nurse take first?

Check the O2 sat

The outpatient surgery nurse reviews the complete blood cell (CBC) count results for a patient who is scheduled for surgery in a few days. The results are white blood cell (WBC) count 10.2 × 103/µL; hemoglobin 15 g/dL; hematocrit 45%; platelets 150 × 103/µL. Which action should the nurse take?

Continue to prepare the patient for the surgical procedure

A patient is admitted to the PACU with a BP 122/72. Thirty minutes after admission the BP is 114/62, with a pulse of 74 and warm, dry skin. Which action by the nurse is most appropriate?

Continue to take vital signs every 15 minutes

Which topic should the nurse discuss preoperatively with a patient who is scheduled for an open cholecystectomy?

Deep breathing and coughing

An older adult patient is being discharged from the ambulatory surgical unit after left eye surgery. The patient tells the nurse, "I don't know if I can take care of myself once I'm home." Which action by the nurse is most appropriate to implement first?

Discuss patient concerns regarding self care

The nurse obtains a health history from a patient who is scheduled for elective hip surgery in 1 week. The patient reports use of garlic and Ginkgo Bilboa. Which action by the nurse is appropriate?

Discuss the herb and supplement use with the patient's health care provider

A patient's T-tube is draining dark green fluid after gallbladder surgery. What action by the nurse is the most appropriate?

Document the drainage characteristics

In the PACU, a patient's vital signs are 116/72, 74 bpm, respirations 12 and 91%. The patient is sleepy but awakens easily. Which action should the nurse take first?

Encourage the patient to take deep breaths

Which action should the perioperative nurse take to protect the patient from burn injury during surgery?

Ensure correct placement of the grounding pad

A patient has received atropine before surgery and reports a dry mouth. Which action by the nurse is appropriate?

Explain that dry mouth is an expected side effect

Which actions will the nurse include in the surgical time-out procedure before surgery?

Have the patient state name and date of birth, verify the patient identification band number, ask the patient to state the surgical procedure

On the second postoperative day after abdominal surgery for removal of a large pancreatic cyst, a patient has an oral temperature of 100.8. Which action should the nurse take next?

Have the patient use the incentive spirometer

Which action could the PACU nurse delegate to UAP who help to transport a patient to the clinical unit?

Help to transfer the patient onto a stretcher

Which data identified during the preop assessment alerts the nurse that special protection techniques should be implemented during surgery?

History of spinal and hip arthritis

Which statement by a patient scheduled for knee surgery is most important to report to the health care provider before surgery?

I had a heart valve replacement last year

Which statement if made by a new circulating nurse, reflects understanding for the circulating nurse role?

I will assist in preparing the OR for the patient

A patient scheduled to undergo total knee replacement surgery under general anesthesia asks the nurse, "Will the doctor put me to sleep with a mask over my face?" Which response by the nurse is most appropriate?

I will check with the anesthesia care provider to find out what is planned

A patient's blood pressure in the postanesthesia care unit (PACU) has dropped from an admission blood pressure of 140/86 to 102/60 with a pulse change of 70 to 96. SpO2 is 92% on 3 L of oxygen. In what order should the nurse take these action?

Increase the IV infusion rate, increase the oxygen flow rate, assess the patient's dressing, check the patient's temperature

A patient undergoing an emergency appendectomy has been using St. John's wort to prevent depression. Which complications should the nurse expect in the postanesthetia care unit?

Increases anesthesia recovery time

The operating room nurse is providing orientation to a student nurse. Which action would the nurse describe as a routine responsibility of a scrub nurse?

Keep both hands above the OR table level

Postoperatively, the nurse should monitor the patient who received inhalation anesthesia for which complication?

Laryngospasm

Which nursing action should the OR nurse manager delegate to the registered nurse first assistant when caring for a surgical patient?

Make surgical incisions and suture as needed

When caring for a patient who has received a general anesthetic, the circulating nurse notes red, raised wheals on the patient's arms. Which action should the nurse take?

Notify the ACP

The nurse is preparing to witness the patient signing the operative consent form when the patient says "I don't understand what the doctor said about the surgery." Which action should the nurse take next?

Notify the surgeon that the informed consent process is not complete

A patient who has diabetes and uses insulin to control blood glucose has been NPO since midnight before having a knee replacement surgery. Which action should the nurse take?

Obtain a blood glucose measurement before any insulin administration

When caring for a preoperative patient on the day of surgery, which actions can the nurse delegate to the UAP?

Obtain and document baseline VS, Remove nail polish and apply pulse ox, transport the patient by stretcher to the OR

Five minutes after receiving a preoperative sedative medication by IV injection, a patient asks the nurse to get up to go to the bathroom to urinate. Which of the following is the most appropriate action for the nurse to take?

Offer the patient a urinal or bedpain

Which action in the perioperative patient plan of care can the charge nurse delegate to a surgical technologist?

Pass sterile instruments and supplies to the surgeon and scrub tech

A postoperative patient has ineffective airway clearance. Which data would indicate to the nurse that interventions for this patient problem have been successful?

Patient's breath sounds are clear to auscultation

An unconscious patient who was transferred from surgery to the PACU 15 minutes ago has an oxygen saturation of 89%. Which action should the nurse take first?

Perform the jaw-thrust maneuver

Which action will the perioperative nurse take after surgery is completed for a patient who received Ketamine as an aesthetic agent?

Provide a quiet environment in the PACU

The nurse plans to provide preoperative teaching to an alert older man who has hearing and vision deficits. His wife usually answers most questions that are directed to the patient. Which action should the nurse take when doing the teaching?

Provide additional time for the patient to understand preoperative instructions and carry out procedures

Monitored anesthesia care is going to be used for a closed, manual reduction of a patient's dislocated shoulder. What action does the nurse anticipate?

Starting an IV in the patient's unaffected arm

The nurse is preparing a patient on the morning of surgery. The patient prefers not to remove a wedding ring, saying, "I've never taken it off since the day I was married." How should the nurse respond?

Suggest that the patient give the ring to a family member to hold

A patient is transferred from the postanesthesia care unit (PACU) to the clinical unit. Which action by the nurse on the clinical unit should be performed first?

Take the patient's vital signs

The nurse is caring for a patient the first postoperative day following a laparotomy for a small bowel obstruction. The nurse notices new bright-red drainage about 5 cm in diameter on the dressing. Which action should the nurse take first?

Take the patient's vital signs

A patient scheduled for an elective hysterectomy tells the nurse, "I am afraid that I will die in surgery like my mother did!" Which response by the nurse is most appropriate?

Tell me more about what happened to your mother.

An experienced nurse orients a new nurse to the PACU. Which action by the new nurse, if observed by the experienced nurse, indicates that the orientation was successful?

The new nurse positions an unconscious patient on the side upon arrival in the PACU

A patient arrives at the outpatient surgical center for a scheduled laparoscopy under general anesthesia. Which information requires the nurse's preoperative intervention to maintain patient safety?

The patient is planning to drive home after surgery

The nurse assesses a patient who had a total abdominal hysterectomy 2 days ago. Which information about the patient is most important to communicate to the provider?

The patient's calf is swollen and warm to touch

A 38-year old woman is admitted for an elective surgical procedure. Which information obtained by the nurse during the preoperative assessment must be communicated to the anesthesiologist and surgeon before surgery?

The patient's report that her last menstrual period was 8 weeks ago

The nurse facilitates student clinical experiences in the surgical suite. Which action, if performed by a student would require the nurse to intervene?

The student wears street clothes in the semi-restricted area

A patient who is scheduled for a therapeutic abortion tells the nurse, "having an abortion is wrong." Which functional health pattern should the nurse further assess?

Value-belief

A patient in the surgical holding area is being prepared for a spinal fusion. Which action by a member of the surgical team requires immediate intervention by the charge nurse?

Walking into the hallway outside the OR with hair uncovered

A patient in surgery receives a neuromuscular blocking agent as an adjunct to general anesthesia. While in the postanesthesia care unit (PACU), what assessment finding is most important for the nurse to report?

weak chest movement

A postoperative patient has not voided for 8 hours after return to the unit. Which action should the nurse take first?

bladder scan

A patient that has just been transferred from the OR to the PACU has a body temperature of 96.5 and is shivering, what action should the nurse take next?

cover the patient with a warm blanket

An older patient who had knee replacement surgery 2 days ago can only tolerate being out of bed with PT twice a day. Which initial complication should the nurse identify as priority for this patient?

venous thromboembolism

While ambulating in the room, a patient complains of feeling dizzy. In what order will the nurse accomplish the following activities?

have the patient sit down in a chair, take the BP, give the patient something to drink, inform the patient's HCP