Final Exam Concept Competency Peri-op

As a part of an informed consent, a surgeon explains the details of the surgery and related care to the client. The nurse leader witnesses the complete process. The nurse leader would ensure the surgeon provided which information to the client? Select all that apply. -surgical procedure -name of the surgeon -explanation of the possible risks -anesthetic medication used during preoperation -name of the staff members who will be in the surgery

-surgical procedure -name of the surgeon -explanation of the possible risks

The nurse is caring for a child who has undergone laparoscopic appendectomy. Which interventions would the nurse document on the child's clinical record? Select all that apply. -intake and output -measurement of pain -tolerance of low-residue diet -frequency of dressing changes -presence or absence of bowel sounds

-intake and output -measurement of pain -presence or absence of bowel sounds

A client is likely to undergo reconstructive surgery for which purpose? -to restore function and/or appearance -to replace an organ or tissue -to relieve or reduce symptoms -to remove or excise an organ or tissue

-to restore function and/or appearance

Which nurse would be best for the nurse manager to assign to give a unit of packed red blood cells to a client who is experiencing postoperative bleeding after abdominal surgery? -an experienced LPN who works regularly on the postoperative unit -a RN who is currently starting IV chemotherapy on another client -a RN who is on-call and will be able to arrive on the unit in about 30 minutes -a RN who has floated from the PACU for the day

-a RN who has floated from the PACU for the day

Which assessment finding would be important for the nurse to report to the health care provider when caring for a client who is in the PACU after receiving general anesthesia? -attempting to push the airway out -unresponsive to verbal stimulation -respirations at 16 breaths/minute and unlabored -systolic blood pressure decrease from 130 mmHg to 90 mmHg

-a systolic blood pressure decrease from 130 mmHG to 90 mmHg

The nurse is preparing an intraoperative care plan for a client. Which intervention would be excluded from the care plan? -ensuring the client's skin integrity -reviewing the preoperative instructions -administering a general anesthetic to the client -placing the client in the correct position on the operating table

-administering a general anesthetic to the client

A client diagnosed recently with early dementia is admitted for acute pain of the hip, and a total hip replacement surgery is scheduled. The client is oriented, alert, and responds appropriately when interviewed. The client says, "I don't want to have the surgery." The client's spouse asks that the team proceed with the surgery to provide pain relief for the client. Which action would the nurse take? -discuss feelings about having surgery with the client -ask the client if a power of attorney for health care has been established -continue with preparation for surgery as the spouse has requested -continue with teaching, ensuring that the client understands the process

-ask the client if a power of attorney for health care has been established

Which action would the nurse take when the client asks the nurse how long she should wait to become pregnant after the surgery when preparing to sign her abdominal hysterectomy with a bilateral oophorectomy surgical consent? -have the client sign the informed consent form -ask the client if she understands what the surgery entails -tell the client that she will not be able to get pregnant after the surgery -call the primary health care provider immediately and hold preoperative medications

-call the primary health care provider immediately and hold preoperative medications

Which important points would the nurse keep in mind when witnessing consent forms? Select all that apply. -confirm that the client's signature is authentic -ensure that the client has given the consent voluntarily -refrain from asking the student nurse to witness consent forms -instruct the family member to assist if the client denies understanding of the procedure -check if the client's caregiver has understood the procedures written in the consent form

-confirm that the client's signature is authentic -ensure that the client has given the consent voluntarily -refrain from asking the student nurse to witness consent forms

The nurse is providing preoperative education to a client scheduled for orthopedic surgery at 8:00 AM the next day. Which instruction would the nurse include? -have your dinner completed by 6:00 PM tonight and then no food or fluids after that -drink whatever liquids you want tonight and then only clear liquids tomorrow morning -consume a light evening meal tonight and then no food or fluids after midnight -eat lunch today and then don't drink or eat anything until after your surgery

-consume a light evening meal tonight and then no food or fluids after midnight

Which response would the nurse give to the older female client diagnosed with a cystocele who is reluctant to have surgical repair of the condition? -you should have the surgery done, although it's not harmful to avoid surgery -depending on the degree of the cystocele, there may be other options -you are risking bowel obstruction if you don't do the surgery -you are risking kidney failure if you don't do the surgery

-depending on the degree of the cystocele, there may be other options

Which initial action would the nurse take when obtaining consent for surgery? -describe the risks involved in the surgery -explain that obtaining the signature is routine for any surgery -witness the client's signature, which the nurse's signature will document -determine whether the client's knowledge level is sufficient to give consent

-determine whether the client's knowledge level is sufficient to give consent

The nurse finds that the surgical mask being worn has become moist before going into surgery. Which would the nurse do? -dispose of the mask and put on a new one -wait until the mask gets dry and then enter the operating room -don't cough or sneeze while wearing the mask -talk less after wearing the mask to minimize respiratory airflow

-dispose of the mask and put on a new one

Which characteristic of O-negative blood explains why people with this blood type are classified as "universal donors"? -it doesn't have any of the antigens that can cause a reaction -the donor can donate blood more frequently than other people -more people have this blood type, so it's more universally available -it's more frequently administered when compared with other blood types

-it doesn't have any of the antigens that can cause a reaction

Which action would the nurse include in the preoperative plan of care for a client admitted to the hospital for cranial surgery? -helping the client put on a wig before the client's visitors arrive -obtaining the client's consent for shaving the client's head -braiding the client's hair to keep it restrained during surgery -telling the client that the head is shaved after anesthesia begins

-obtaining the client's consent for shaving the client's head

Which assessment finding would the nurse report to the health care provider that will likely delay the surgery for a 4-day old infant with a cleft and palate? -hypotonia (diminished muscle tone) -oral candidiasis (thrush) -facial paralysis -cephalohematoma (collection of blood between skill bone and periosteum

-oral candidiasis

Which action would the circulating nurse classify as a priority during surgery? Select all that apply. -protecting client's privacy -assessing blood loss and urine -monitoring ventilation for nonintubated clients -monitoring the level of anesthesia provided to the client -providing supplies and equipment on the basis of the surgical team's needs

-protecting client's privacy -assessing blood loss and urine -providing supplies and equipment on the basis of the surgical team's needs

D5W is infusing intravenously when a 7-year-old child is returned to the pediatric unit from surgery. The postoperative prescription doesn't indicate the desired rate of infusion. Which is the most appropriate action for the nurse to take? -reduce the flow rate to keep the vein open and obtain a prescription -adjust the flow rate to the 5 ml/h that the child was receiving before surgery -maintain the current flow rate and call the nurse in the operating room to verify the rate -regulate the flow rate to 25 ml/h until the health care provider arrives for follow-up observation

-reduce the flow rate to keep the vein open and obtain a prescription

Which action would the nurse take first after observing serosanguineous drainage on the abdominal dressing of a client in the PACU who had an abdominal cholesysteceomy? -change the dressing -reinforce the dressing -replace the tape with montgomery ties -support the incision with an abdominal binder

-reinforce the dressing

Which nursing assessment is a priority after a client undergoes an endarterectomy in a lower extremity? -appetite -skin color -bowel habits -tissue turgor

-skin color

Which nursing action would be performed first in a client who reports chills and flank pain ten minutes after the initiation of a blood transfusion? -stop the transfusion -obtain the vital signs -notify the health care provider -maintain the flow with normal saline

-stop the transfusion

A client newly diagnosed with cancer of the pancreas is scheduled for surgery. The client asks the nurse, 'Don't you think that some other treatment would be better than surgery?' How would the nurse respond? -it's a good idea to explore other acceptable treatments for your cancer. There is information available for you -surgery is the recommended approach. Perhaps you should discuss this further with the health care provider. -maybe you will be more confident with a second opinion. I think you need a referral to another health care provider -with your disease, your prognosis will improve if you follow the suggestion to have the recommended surgery

-surgery is the recommended approach. perhaps you should discuss this further with the health care provider

Which site would the nurse assess first for the amount of drainage from a client discharged from the PACU? -foley catheter -NG tube -IV catheter -surgical incision

-surgical incision

Which finding on the first postoperative day after a client has an open reduction and internal fixation of a fractured hip will be most important to report to the health care provider? -client report of level 8 incisional pain (0 to 10 scale) -50 mL of deep red drainage in wound drainage device -swelling and redness in the calf of the operative leg -client oral temperature elevation to 100.2 F (37.9 C)

-swelling and redness in the calf of the operative leg

Which explanation is the rationale for performing sponge, needle, and instrument counts in the operating room? -the hospital isn't liable if a client is injured resulting from a retained sponge or instrument -the nursing student is liable for client injuries resulting from a retained sponge or instrument -the nurse is responsible for performing sponge and instrument counts as a part of routine surgical standards -the primary health care provider is responsible for providing an accurate count of sponges or instruments

-the nurse is responsible for performing sponge and instrument counts as a part of routine surgical standards

The nurse signs as a witness to informed consent provided by the client. Which concept does the signature of the nurse imply? Select all that apply. -the signature of the client is authentic -consent has been given voluntarily -the client appears to be competent to give consent -treatment cannot be refused after consent is given -the nurse has explained all procedures to the client

-the signature of the client is authentic -consent has been given voluntarily -the client appears to be competent to give consent

An informed consent has not yet been obtained for an unconscious client scheduled for surgery. Which course of action does the nurse expect to be taken to deal with the situation? -the client's spouse will give informed consent for the surgery -the procedure will be postponed until the client is able to give consent -the surrogate decision maker designated by the client will give consent -the primary health care provider will perform the procedure without waiting for consent

-the surrogate decision maker designated by the client will give consent

A client who wakes up after a surgery spits out the oral airway placed during the recovery from anesthesia. What would this behavior indicate to the nurse? -their gag reflex has returned -they're confused due to anesthesia -they are nauseated and want to vomit -their airway is becoming obstructed

-their gag reflex has returned

A client who was admitted to the hospital with metastatic cancer has a temperature of 100.4 F (38 C), a distended abdomen, and abdominal pain. The client asks the nurse, 'Do you think that I will need to have surgery?' How would the nurse respond? -you seem concerned about having surgery -some people with your problem do have surgery -i'll find out for you. your record will show if surgery is scheduled -i don't know about any surgery. you'll have to ask your health care provider

-you seem concerned about having surgery

Which situation will cause the nurse to legally delay signing the operative consent when a client is scheduled for skin cancer surgery? -ambivalent feelings are present and acknowledged -a sedative type of medication has been given recently -a complete history and physical has not been performed and recorded -a discussion of alternatives with two primary health care providers has not occured

=a sedative type of medication has been given recently