BRUNNER 19 & 20: intra op &Postop

24. You are the circulating nurse for several surgeries today. What would be one of your major goals for each of these patients? A) Latex-allergy symptoms treated rapidly B) Surgery unsuccessful C) Maintenance of the patient's dignity D) Complications treated rapidly

Ans: C Feedback: The major goals for care of the patient during surgery include reduced anxiety, absence of latex exposure, absence of positioning injuries, freedom from injury, maintenance of the patient's dignity, and absence of complications. Options A, B, and D are incorrect. A goal would never be for the surgery to be unsuccessful.

21. Which of the following events subjects the surgical patient to possible injury in the intraoperative phase of the surgical experience? (Mark all that apply.) A) Reflexes B) Ability to communicate C) Loss of pain sense D) Consciousness E) Normal vital signs

Ans: A, B, C Feedback: Loss of pain sense, reflexes, and ability to communicate subjects the intraoperative patient to possible injury. Options D and E are incorrect as they are not risk factors for the surgical patient.

32. You are a new nurse in the operating room. Your preceptor is teaching you about malignant hyperthermia. Which symptom is often the earliest sign of malignant hyperthermia? A) Increased temperature B) Oliguria C) Tachycardia D) Hypotension Ans: C

Feedback: The initial symptoms of malignant hyperthermia are related to cardiovascular and musculoskeletal activity. Tachycardia (heart rate greater than 150 beats per mimute) is often the earliest sign. Oliguria, hypotension, and increased temperature are later signs of malignant hyperthermia.

2. You are the circulating nurse. Which task are you solely responsible for? A) Monitoring the patient and documents B) Estimating the patient's blood loss C) Setting up the sterile tables D) Keeping track of drains and sponges

Ans: A Feedback: Main responsibilities include verifying consent; coordinating the team; and ensuring cleanliness, proper temperature, humidity, lighting, safe function of equipment, and the availability of supplies and materials. The circulating nurse monitors aseptic practices to avoid breaks in technique while coordinating the movement of related personnel (medical, x-ray, and laboratory), as well as implementing fire safety precautions. The circulating nurse also monitors the patient and documents specific activities throughout the operation to ensure the patient's safety and well-being. Estimating the patient's blood loss is the surgeon's responsibility, setting up the sterile tables is the responsibility of the first scrub, and keeping track of the drains and sponges is the joint responsibility of the circulating nurse and the scrub.

4. You are the circulating nurse in an operating room that has several surgeries scheduled. You would know to monitor which patient during the intraoperative period because he or she is at increased risk for hypothermia? A) A 72-year-old woman B) A 17-year-old boy C) A 45-year-old woman D) A 12-year-old girl

Ans: A Feedback: Elderly patients are at greatest risk during surgical procedures because they have an impaired ability to increase their metabolic rate and impaired thermoregulatory mechanisms, which increase susceptibility to hypothermia. This makes options B, C, and D incorrect.

1. The nursing student is preparing an elderly patient for surgery. The patient is scheduled for a general anesthetic. Which side effect should the nurse monitor the patient for? A) Hypothermia B) Pulmonary edema C) Cerebral ischemia D) Increased ability to resist stress

Ans: A Feedback: Inadvertent hypothermia may occur as a result of a low temperature in the OR, infusion of cold fluids, inhalation of cold gases, open body wounds or cavities, decreased muscle activity, advanced age, or the pharmaceutical agents used (eg, vasodilators, phenothiazines, general anesthetics). The anesthetist monitors for pulmonary edema and cerebral ischemia. The increased ability to resist stress is not monitored.

34. You have a 72-year-old female patient who is scheduled for a left total knee replacement. Which complication is this patient at increased risk for because of her aging cardiovascular system? A) Hypovolemia B) Hypopnea C) Hyperkalemia D) Hyperphosphatemia

Ans: A Feedback: The aging heart and blood vessels have decreased ability to respond to stress. Reduced cardiac output and limited cardiac reserve make the elderly patient vulnerable to changes in circulating volume and blood oxygen levels. There is not an increased risk for hypopnea, hyperkalemia, or hyperphosphatemia because of an aging cardiovascular system.

10. You are the circulating nurse in an outpatient surgery center. Your patient is scheduled to receive moderate sedation. You know that a patient receiving this form of anesthesia should what? A) Never be left unattended by the nurse B) Receive an anti-emetic C) Remember most of the procedure D) Be able to maintain his or her own airway

Ans: A Feedback: The patient receiving moderate sedation should never be left unattended. The patient's ability to maintain his or her airway depends on the level of sedation. The administration of moderate sedation is not a counterindication for giving an anti-emetic. The patient receiving moderate sedation does not remember most of the procedure.

3. You are discharging your patient home from day surgery after a general anesthetic. What instruction would you give the patient prior to the patient leaving the hospital? A) The patient is not to drive a vehicle B) The patient should have a glass of brandy the first night home to help him or her sleep C) Eat a large meal at home D) Do not sign important papers for the first 12 hours after surgery

Ans: A Feedback: Although recovery time varies depending on the type and extent of surgery and the patient's overall condition, instructions usually advise limited activity for 24 to 48 hours. During this time, the patient should not drive a vehicle, drink alcoholic beverages, or perform tasks that require energy or skill. Eat only as tolerated.

5. You admit a patient to the PACU who has undergone a surgical procedure that required the use of general anesthesia. What is the patient most at risk for following general anesthesia? A) Atelectasis B) Anemia C) Dehydration D) Peripheral edema

Ans: A Feedback: Atelectasis occurs when the postoperative patient fails to move, cough, and breathe deeply. With good nursing care, this is an avoidable complication. Anemia occurs rarely and usually in situations where the patient loses a significant amount of blood or if he continues bleeding postoperatively. Fluid shifts postoperatively may result in dehydration and peripheral edema, but the patient is most at risk for atelectasis.

7. As an OR nurse, you have an increased awareness regarding asepsis. You know that a basic guideline for maintaining surgical asepsis is what? A) Sterile surfaces or articles may touch other sterile surfaces. B) Sterile supplies can be used on another patient if the packages are intact. C) The outer lip of a sterile solution is considered sterile. D) The scrub nurse may pour a sterile solution from a nonsterile bottle.

Ans: A Feedback: Basic guidelines for maintaining sterile technique include the fact that sterile surfaces or articles may touch other sterile surfaces only. The other distracters are examples of how to break sterile technique.

39. Your patient is asleep on the operating table. As the circulating nurse, you are aware of the potential environmental hazards to your patient. What is an environmental hazard in the operating room? A) Lasers B) Needlestick injuries C) Exposure to sterile fluids D) Exposure to bodily fluids

Ans: A Feedback: Faulty equipment, improper use of equipment, exposure to toxic substances, as well as infectious waste, cuts, needlestick injuries, and lasers are some of the associated hazards in the surgical environment. The patient is not at risk of a needlestick injury or exposure to bodily fluids, the members of the operative team are. There is no risk in being exposed to sterile fluids.

15. A 38-year-old patient has just been admitted to the PACU following abdominal surgery. As the patient begins to awaken, he is restless and asking for "a drink of water." The nurse checks his skin and it is cold, moist, and pale. What is the nurse concerned the patient may be at risk for? A) Hemorrhage and shock B) Loss of airway and hypotension C) Pain and anxiety D) Hypertension and dysrhythmias

Ans: A Feedback: Hemorrhage is a complication of surgery that can result in death; when blood loss is extreme, the patient usually presents apprehensive, restless, and thirsty; and the skin is cold, moist, and pale. Option B is incorrect; the patient is asking for "a drink of water" so loss of airway is unlikely, and there is no evidence provided in the question that is related to hypotension such as blood pressure. Options C and D are incorrect; there is no evidence based on the information provided in the question that the patient is in pain or having anxiety, hypertension, or dysrhythmias.

40. You are caring for an 88-year-old patient who is recovering from an ileac-femoral bypass graft. The patient is 2 days post-op and has been mentally intact. When you assess the patient, you find he is confused and has disturbed sleep patterns and impaired psychomotor skills. What would you suspect is the problem with the patient? A) Postoperative delirium B) Postoperative dementia C) Senile dementia D) Senile confusion

Ans: A Feedback: Postoperative delirium, characterized by confusion, perceptual and cognitive deficits, altered attention levels, disturbed sleep patterns, and impaired psychomotor skills, is a significant problem for older adults. Options B and C are incorrect; dementia does not have a sudden onset. Senile confusion is only a distractor, so option D is incorrect.

26. What position used for surgery can cause irreparable nerve damage? A) Trendelenburg B) Prone C) Dorsal recumbent D) Lithotomy

Ans: A Feedback: Shoulder braces must be well padded to prevent irreparable nerve injury, especially when the Trendelenburg position is necessary. Options B, C, and D are incorrect.

9. What is the best rationale for intubation during a surgical procedure? A) The tube provides an airway for ventilation. B) The tube protects the esophagus. C) The patient may receive an anti-emetic through the tube. D) The patient's heart rate can be monitored with the tube.

Ans: A Feedback: The anesthetic is administered and the patient's airway is maintained through an intranasal intubation, oral intubation, or a laryngeal mask airway. The tube also helps protect aspiration of stomach contents. The tube does not protect the esophagus. Because the tube goes into the lungs, no medications are given through the tube. The patient's heart rate is not monitored through the tube.

30. You are performing your shift assessment of your patient. You find his mental status, level of consciousness, speech, and orientation are intact and at baseline. Your patient tells you he is very anxious. What would you do next? A) Assess oxygen levels B) Give anti-anxiety medications C) Notify the physician D) Make a social services consult

Ans: A Feedback: The nurse assesses the patient's mental status and level of consciousness, speech, and orientation and compares them with the preoperative baseline. Although a change in mental status or postoperative restlessness may be related to anxiety, pain, or medications, it may also be a symptom of oxygen deficit or hemorrhage. Anti-anxiety medications are not given until the cause of the anxiety is known. The physician is only notified if the reason for the anxiety is serious or if an order for medication is needed. A social services consult is inappropriate at this time.

34. Your patient has just returned to the unit from PACU with patient-controlled anesthesia (PCA). You know that the requirements for PCA include what? A) An understanding of the need to self-dose B) An understanding of how to adjust the medication dosage C) A caregiver who can administer the medication as ordered D) An understanding of the medication that is ordered

Ans: A Feedback: The two requirements for PCA are an understanding of the need to self-dose and the physical ability to self-dose. This makes options B, C, and D incorrect.

26. You are discharging a patient home from a same-day surgery center. You have gone over all of the discharge instructions with the patient and her caregiver. What else should you do before letting the patient leave the facility? (Mark all that apply.) A) Provide all discharge instructions in writing B) Provide the nurse's or surgeon's telephone number C) Give prescriptions to the patient D) Give advice on nutrition to the caregiver E) Provide dates and times of new appointments

Ans: A, B, C Feedback: Before discharging the patient, the nurse provides written instructions covering each of those points. Prescriptions are given to the patient. The nurse's or surgeon's telephone number is provided, and the patient and caregiver are encouraged to call with questions and to schedule follow-up appointments. When discharging a patient from an ambulatory surgery center, advice on nutrition and dates and times of new appointments are not given, making options D and E incorrect.

38. As an intraoperative nurse, what is your responsibility to your patient in relation to malignant hyperthermia? (Mark all that apply.) A) Recognize the signs and symptoms B) Be knowledgeable about the protocol C) Know how to call a code in the OR D) Have the appropriate medication available E) Direct the surgeon and anesthesiologist through the protocol

Ans: A, B, D Feedback: Although malignant hyperthermia is uncommon, the nurse must identify patients at risk, recognize the signs and symptoms, have the appropriate medication and equipment available, and be knowledgeable about the protocol to follow. This preparation may be lifesaving for the patient. Options C and E are incorrect. Codes are not called in the operating room. The circulator does not direct the treatment protocol for malignant hyperthermia.

30. Which nursing diagnosis would a circulating nurse use on her intraoperative patients who have a general anesthetic? (Mark all that apply.) A) Disturbed sensory perception B) Risk for hypovolemia C) Risk of latex allergy response D) Disturbed body image E) Anxiety

Ans: A, C, E Feedback: Based on the assessment data, some major nursing diagnoses may include the following: anxiety related to surgical or environmental concerns, risk of latex allergy response due to possible exposure to latex in OR environment, risk for perioperative positioning injury related to positioning in the OR, risk for injury related to anesthesia and surgical procedure, or disturbed sensory perception (global) related to general anesthesia or sedation. Options B and D are incorrect; they would not be nursing diagnoses used for every surgical patient who has a general anesthesia.

21. You are the PACU nurse caring for a 45-year-old male patient who had a left lobectomy. You assess your patient frequently for airway patency and cardiovascular status. You know that the most common cardiovascular complications seen in the PACU include what? (Mark all that apply.) A) Hypotension B) Hypervolemia C) Heart murmurs D) Dysrhythmias E) Hypertension

Ans: A, D, E Feedback: The primary cardiovascular complications seen in the PACU include hypotension and shock, hemorrhage, hypertension, and dysrhythmias. Heart murmurs are not adverse reactions to surgery. Hypervolemia is not a common cardiovascular complication seen in the PACU.

5. The anesthetist is coming to the unit to see a patient prior to surgery that is scheduled for tomorrow morning. What information, obtained during the admission assessment, should be given to the anesthetist during the visit? A) Last bowel movement B) Latex allergy C) Number of pregnancies D) Difficulty falling asleep

Ans: B Feedback: Due to the increased number of patients with latex allergies, it is essential to identify the allergy early on so precautions can be taken in the operating room. The anesthetist should be informed of any allergies.

27. The patient's surgery is nearly finished. The surgeon has decided to use tissue adhesives to close the surgical wound. As the nurse, you know that this puts the patient at increased risk for what? A) Hypothermia B) Anaphylaxis C) Infection D) Malignant hyperthermia

Ans: B Feedback: Fibrin sealants are used in a variety of surgical procedures, and cyanoacrylate tissue adhesives are used to close wounds without the use of sutures. These sealants have been implicated in allergic reactions and anaphylaxis. Options A, C, and D are incorrect; none of these detractors are an increased risk because of the use of tissue adhesives.

8. Your patient is a 35-year-old female who has been administered general anesthesia. The patient is in stage II (the excitement stage) of anesthesia. Which intervention might you need to implement during this stage? A) Rub the patient's back B) Restrain the patient C) Encourage the patient to express feelings D) Stroke the patient's hand

Ans: B Feedback: In stage II, the patient may struggle, shout, or laugh. The movements of the patient may be uncontrolled so it is essential the nurse help to restrain the patient for safety.

23. You are preparing to take your patient into the operating room. As the circulating nurse, one of your responsibilities is to review the patient's record. What are you reviewing the record for? A) Progress notes B) History and physical C) Admission papers signed by patient D) Intake and output record

Ans: B Feedback: It is important to review the patient's record for the following: correct informed surgical consent, with patient's signature; completed records for health history and physical examination; results of diagnostic studies; and allergies (including latex). Options A, C, and D are incorrect; progress notes, admission papers, and the I&O record are not reviewed by the circulating nurse.

14. The operating room nurse is taking the patient into the OR when the patient informs the operating nurse that his grandmother spiked a 104°F temperature in the operating room and nearly died 15 years ago. What relevance does this information have regarding your patient? A) The patient may be nervous. B) The patient may be at risk for developing malignant hyperthermia. C) The grandmother's surgery has no relevance to the patient's surgery. D) The patient may be at risk for hypothermia.

Ans: B Feedback: Malignant hyperthermia is an inherited muscle disorder chemically induced by anesthetic agents. Identifying patients at risk is imperative because the mortality rate is 50%. Options A, C, and D are incorrect; the patient's nervousness is not relevant, the grandmother's surgery is very relevant, and all patients are at risk for hypothermia.

6. Surgical asepsis is a requirement in the restricted zone of the operating suite. What personal protective equipment should the nurse wear at all times in the restricted zone of the operating room? A) Reusable shoe covers B) Mask covering the nose and mouth C) Goggles D) Gloves

Ans: B Feedback: Masks are worn at all times in the restricted zone of the operating room. Shoe covers are worn one time only; goggles and gloves are worn as required but not necessarily at all times.

40. A part of the intraoperative nurse's role is being a patient advocate. What is an advocacy activity of the intraoperative nurse? A) Checking the patient's armband against his or her medical record B) Respecting the patient's cultural values C) Dehumanizing the patient D) Maintaining the patient's privacy while he or she is awake

Ans: B Feedback: Other advocacy activities include minimizing the clinical, dehumanizing aspects of being a surgical patient by making sure the patient is treated as a person; respecting cultural and spiritual values; providing physical privacy; and maintaining confidentiality. Therefore options C and D are incorrect. Option A is incorrect; verifying the patient's identity is a nursing function prior to any procedure or test.

35. The nurse knows that elderly patients are at higher risk for complications and adverse outcomes during the intraoperative period. What is the best rationale for this phenomenon? A) The elderly patient has more boney prominences than a younger person. B) The elderly patient has reduced ability to adjust rapidly to emotional and physical stress. C) The elderly patient has impaired thermoregulatory mechanisms, which increase susceptibility to hyperthermia. D) The elderly patient has an impaired ability to decrease his or her metabolic rate.

Ans: B Feedback: Other factors that affect the elderly surgical patient in the intraoperative period include the following: impaired ability to increase metabolic rate and impaired thermoregulatory mechanisms increase susceptibility to hypothermia. Bone loss (25% in women, 12% in men) necessitates careful manipulation and positioning during surgery. Reduced ability to adjust rapidly to emotional and physical stress influences surgical outcomes and requires meticulous observation of vital functions. Option A is incorrect because the elderly have the same amount of bony prominences as a younger person, they are just more exposed.

15. You note a colleague making an inappropriate remark about the patient's weight. The patient is unconscious at the time. What should you do? A) Ignore the comment because the patient is unconscious. B) Discourage the comments. C) Report the comment to the supervisor. D) Realize humor is needed in the workplace.

Ans: B Feedback: Patients, whether conscious or unconscious, should not be subjected to excess noise, inappropriate conversation, or, most of all, derogatory comments. The nurse must act as an advocate on behalf of the patient and discourage any such remarks. Therefore, options A, C, and D are incorrect.

12. You are the nurse caring for a patient who will receive a transsacral block. In what surgeries would a transsacral block be useful for pain control? A) Thoracotomy B) Inguinal hernia repair C) Breast reduction D) Closed reduction of a right humerus

Ans: B Feedback: A transsacral block produces anesthesia for the perineum and lower abdomen. Options A, C, and D are incorrect. Both a thoracotomy and breast reduction are in the chest region, and a transsacral block would not provide pain control for these procedures. A closed reduction of a right humerus is a procedure on the right arm, and a transsacral block would not provide pain control.

31. As a nurse, you know that one of the risks for a surgical patient is vomiting. What can aspirated vomitus lead to? A) Choking B) Hypoxia C) Malignant hyperthermia D) Hypothermia

Ans: B Feedback: If the patient aspirates vomitus, an asthma-like attack with severe bronchial spasms and wheezing is triggered. Pneumonitis and pulmonary edema can subsequently develop, leading to extreme hypoxia. Vomiting can cause choking, but the question asks about aspirated vomitus. Malignant hyperthermia is an allergic reaction to anesthesia. Aspirated vomitus does not cause hypothermia.

8. Your patient is 2 hours postoperative with a Foley catheter in situ. The last hourly urine output you recorded for this patient was 10 mL. The tubing of the Foley is patent. What should you do? A) Irrigate the Foley with 30 mL normal saline B) Notify the physician, and continue to closely monitor the hourly urine output C) Decrease the IV fluid rate D) Have the patient sit in high-Fowler's position

Ans: B Feedback: If the patient has an indwelling urinary catheter, hourly outputs are monitored and rates of less than 30 mL/h are reported. The urine output should continue to be monitored hourly by the nurse.

35. Wound assessment is an important part of the nursing care of the postoperative patient. What does ongoing assessment of the surgical site involve? A) Adherence of the dressing to the wound B) Discoloration C) Blanching D) Granulation of the wound

Ans: B Feedback: Ongoing assessment of the surgical site involves inspection for approximation of wound edges, integrity of sutures or staples, redness, discoloration, warmth, swelling, unusual tenderness, or drainage. The area around the wound should also be inspected for a reaction to tape or trauma from tight bandages. Materials used for dressings generally do not adhere to the wound. Blanching would only be possible if the area around the wound were reddened or discolored, which is a visual assessment and does not require touching the wound area. Granulation of the wound cannot be assessed without reopening the wound, so it is not done.

27. The nursing instructor is discussing the difference between ambulatory surgical centers and hospital-based surgical units. A student asks why some patients have surgery in the hospital and others are sent to ambulatory surgery centers. What is the instructor's best response? A) "Patients who go to ambulatory surgery centers have more family support than patients admitted to the hospital." B) "Patients admitted to the hospital for surgery have multiple needs." C) "Only emergency and trauma patients are admitted to the hospital." D) "Patients who have surgery in the hospital can't afford the added expense of ambulatory surgery centers."

Ans: B Feedback: Patients admitted to the clinical unit for postoperative care have multiple needs and stay for a short period of time. Options A, C, and D are incorrect. Patients who have surgery in ambulatory centers do not necessarily have more family support. It is not true that only trauma and emergency surgeries are done in the hospital. Ambulatory centers are generally less expensive than hospitals for surgery.

7. The nursing instructor is with a student nurse who is going to be changing an abdominal dressing. The first step is to provide the patient with information regarding the procedure. Which of the following is the best statement for completing this task? A) "The dressing change is often painful, and we will be giving you pain medication prior to the procedure so you do not have to worry." B) "During the dressing change, I will provide privacy at a time of your choosing, it should not be painful, and you can look at the incision and help with the procedure if you want to." C) "The dressing change should not be painful, but you can never be sure, and infection is always a concern." D) "The best time for doing a dressing change is during lunch so we are not interrupted. I will provide privacy, and it should not be painful."

Ans: B Feedback: When having dressings changed, the patient needs to be informed that the dressing change is a simple procedure with little discomfort, privacy will be provided, and the patient is free to look at the incision or even assist in the dressing change itself. If the patient decides to look at the incision, assurance is given that the incision will shrink as it heals and that the redness will likely fade. Option A is incorrect; dressing changes should not be painful, but giving pain medication prior to the procedure is always good preventive measure. Option C is incorrect; telling the patient that the dressing change "should not be painful, but you can never be sure, and infection is always a concern" does not offer the patient any real information or options and serves only to create fear. Option D is incorrect; the best time for dressing changes is when it is most convenient for the patient; nutrition is important so interrupting lunch is probably a poor choice.

16. The nursing instructor is discussing postoperative care with the junior nursing students. A student nurse asks, "Why does the patient go to the PACU prior to the medical-surgical unit?" What is the nursing instructor's best response? A) "The PACU allows the patient to recover from anesthesia in a stimulating environment to facilitate awakening and reorientation." B) "The PACU allows the patient to recover from the effects of anesthesia, and the patient stays in PACU until he or she is oriented, has stable vital signs, and is without complications." C) "Frequently, patients are recovered in the medical-surgical unit, but hospitals are usually short of beds, and the PACU is an excellent place to triage patients." D) "The medical-surgical unit is frequently very busy and unable accept the patient from surgery, so the patients are observed and monitored in PACU until a bed is available."

Ans: B Feedback: The PACU provides care for the patient while he or she recovers from the effects of anesthesia. The patient must be oriented, have stable vital signs, and show no evidence of hemorrhage or other complications. Patients will sometimes recover in the intensive care unit, but this is considered an extension of the PACU. Option A is incorrect; the PACU does allow the patient to recover from anesthesia, but the environment is calm and quiet as patients are initially disoriented and confused as they begin to awaken and reorient. Option C is incorrect; patients are not usually recovered in the medical-surgical unit, and although hospitals are occasionally short of beds, the PACU is should not used for patient triage. Option D is incorrect; in an emergency, the medical-surgical unit may be unable to accept a patient from surgery, and so the patients are observed and monitored in PACU until a bed is available, but this is the exception to the rule

31. You are the nurse writing a plan of care for a patient who is status postsurgery for a broken femur. What is the most important goal for this patient? A) Relief of pain B) Optimal respiratory function C) Optimal cardiovascular function D) Unimpaired wound healing

Ans: B Feedback: The major goals for the patient include optimal respiratory function, relief of pain, optimal cardiovascular function, increased activity tolerance, unimpaired wound healing, maintenance of body temperature, and maintenance of nutritional balance.

20. Your patient has undergone a colon resection. While turning him, wound dehiscence with evisceration occurs. What is your first response? A) Call the physician B) Place saline-soaked sterile dressings on the wound C) Take a blood pressure and pulse D) Pull the dehiscence closed

Ans: B Feedback: The nurse should first place saline-soaked sterile dressings on the open wound to prevent tissue drying and possible infection. Then the nurse should call the physician and take the patient's vital signs. The dehiscence needs to be surgically closed, so the nurse should never try to close it.

10. You admit a patient to the postanesthesia care unit with a blood pressure of 130/90 and a pulse of 68 beats per minute. After 30 minutes, the patient's blood pressure is 120/65, and the pulse is 100. You document the patient's skin as cold, moist, and pale. What is the patient showing signs of? A) Hypothermia B) Hypovolemic shock C) Neurogenic shock D) Malignant hypothermia

Ans: B Feedback: The patient is exhibiting symptoms of hypovolemic shock; therefore, the nurse should notify the patient's physician and anticipate orders for fluid and/or blood product replacement.

19. You are the nurse caring for a patient who just had surgery. What is your highest priority? A) Assessing for hemorrhage B) Maintaining a patent airway C) Managing the patient's pain D) Assessing vital signs every 15 minute

Ans: B Feedback: The primary objective in the immediate postoperative period is to maintain ventilation and, thus, prevent hypoxemia (reduced oxygen in the blood) and hypercapnia (excess carbon dioxide in the blood). Assessing for hemorrhage and vital sign assessment are also important but constitute second and third priorities. Pain management is important but only after the patient has been stabilized.

22. Your postoperative patient suddenly presents with hypotension; rapid, thready pulse; oliguria; and cold, pale skin. You suspect hemorrhage. What would be your first nursing action? A) Notify the physician B) Determine the cause of hemorrhage C) Order blood work D) Put the patient in Trendelenberg position

Ans: B Feedback: Transfusing blood or blood products and determining the cause of hemorrhage are the initial therapeutic measures. Options A, C, and D are incorrect because they are not the initial actions the nurse would take.

17. The PACU nurse is caring for a patient who has arrived from the operating room who is still unconscious. During the initial assessment, the nurse notices that the patient's skin is blue and dusky. She looks, listens, and feels for breathing, and determines the patient is not breathing. The priority intervention is to A) check an oxygen saturation rate, continue to monitor for apnea, and perform a focused assessment. B) treat the possible airway obstruction by tilting the head back and pushing forward on the angle of the lower jaw. C) check the arterial pulses, and place the patient in the Trendelenburg position. D) call a code blue, and then get an rapid intubation kit and prepare to reintubate.

Ans: B Feedback: When a nurse finds a patient who is not breathing, the priority intervention is to open the airway and treat the possible hypopharyngeal obstruction. To treat the possible airway obstruction, the nurse tilts the head back and then pushes forward on the angle of the lower jaw or performs the jaw thrust method to open the airway. Option A is incorrect; this is an emergency and requires the basic life support intervention of airway, breathing, and circulation assessment. Option C is incorrect; arterial pulses should be checked only after airway and breathing have been established. Option D is incorrect; calling a code blue is appropriate in this case, and the patient may need to be reintubated, but the nurse should never leave the patient without an airway to get a rapid intubation kit and prepare for reintubation.

39. The home health nurse is caring for a postoperative patient who was discharged home on day 2 after surgery. The nurse is making her initial visit on the patient's post-op day 3. The nurse will assess for wound infection. Generally speaking, what is the latest post-op day that a wound infection may become evident? A) Day 6 B) Day 5 C) Day 4 D) Day 3

Ans: B Feedback: Wound infection may not be evident until at least postoperative day 5. This makes the other options incorrect.

37. The nurse is caring for a postoperative patient who needs daily dressing changes. The patient is 3 days post-op and should be going home the next day. Up until now, the patient has refused to learn how to change her dressing. What would indicate to the nurse the patient's readiness to learn how to change her dressing? (Mark all that apply.) A) The patient wants you to teach a family member to do dressing changes. B) The patient expresses interest in the dressing change. C) The patient looks at the incision. D) The patient expresses dislike of the surgical wound. E) The patient assists in opening the packages of dressing material for the nurse.

Ans: B, C, E Feedback: While changing the dressing, the nurse has an opportunity to teach the patient how to care for the incision and change the dressings at home. The nurse observes for indicators of the patient's readiness to learn, such as looking at the incision, expressing interest, or assisting in the dressing change. Options A and D do not indicate willingness to learn how to change the dressing.

24. What are the determining factors for a patient to be discharged from the PACU? (Mark all that apply.) A) Temperature within normal limits B) Stable blood pressure C) Ability to respond to voice commands D) Adequate oxygen saturation E) Adequate respiratory function

Ans: B, D, E Feedback: A patient remains in the PACU until fully recovered from the anesthetic agent. Indicators of recovery include stable blood pressure, adequate respiratory function, and adequate oxygen saturation level compared with baseline. Patients can be released from PACU with a temperature outside normal limits because of anesthesia. Patients can often respond to voice commands before they meet the requirements for release from the PACU.

19. A patient is scheduled for surgery the next day. What is the best approach to this surgery? A) A surgical approach B) A medical approach C) An interdisciplinary approach D) A nursing approach

Ans: C Feedback: An interdisciplinary approach involving the surgeon, anesthesiologist or anesthetist, and nurse is best. Options A, B, and D are incorrect as they do not indicate the best approach.

16. You are caring for a male patient who has had spinal anesthesia. The patient is under a physician's order to lie flat postoperatively. When the patient asks to go to the bathroom, you encourage him to comply with the physician's order. What is the rationale for complying with this order? A) Hypotension B) Respiratory depression C) A headache D) Pain at the lumbar injection site

Ans: C Feedback: Lying flat reduces the risk of headache after spinal anesthesia. Hypotension and respiratory depression may be adverse effects of spinal anesthesia associated with the spread of the anesthetic, but lying flat doesn't help reduce these effects. Pain at the lumbar injection site typically isn't a problem.

28. As a circulating nurse, you are the advocate of each of your patients. What does patient advocacy in the operating room entail? A) Use of safety straps B) Maintaining adequate pain medication C) Maintaining patient's privacy D) Decreasing risk of infection

Ans: C Feedback: Patient advocacy in the OR entails maintaining the patient's physical and emotional comfort, privacy, rights, and dignity. The use of safety straps, maintaining adequate pain medication, and decreasing the risk of infection are not part of the advocacy role.

37. As an intraoperative nurse, you know that maintaining an aseptic environment in the operating room is essential. When moving around surgical areas, what distance must be kept from the sterile field? A) 2 feet B) 18 inches C) 1 foot D) 6 inches

Ans: C Feedback: Sterile areas must be kept in view during movement around the area. At least a 1-foot distance from the sterile field must be maintained to prevent inadvertent contamination. This makes options A, B, and D incorrect.

41. Your patient is a 25-year-old obstetric patient. You know that she is at increased risk for what? A) Infection B) Hypothermia C) Anesthesia awareness D) Moderate sedation

Ans: C Feedback: The Joint Commission has issued an alert regarding the phenomenon of patients being partially awake while under general anesthesia (referred to as anesthesia awareness). Patients at greatest risk of anesthesia awareness are cardiac, obstetric, and major trauma patients.

13. You are the circulating nurse caring for a 78-year-old patient who is scheduled for a total hip replacement. Which of the factors should you consider during the preparation of the patient in the operating room? A) The patient should be placed in Trendelenburg position. B) The patient must be firmly restrained at all times. C) Pressure points should be assessed and well padded. D) The preoperative shave should be done by the circulating nurse.

Ans: C Feedback: The vascular supply should not be obstructed by an awkward position or undue pressure on a body part. During surgical procedures, the patient is at risk for impairment of skin integrity due to a stationary position and immobility. An elderly patient is at an increased risk of injury and impaired skin integrity. Options A, B, and D are incorrect. A Trendelenburg position is not indicated for this patient. Once anesthetized for a total hip replacement, the patient cannot move. A preoperative shave is not performed; excess hair is removed by means of a clipper.

18. You are the nurse performing wound care on a 68-year-old male patient. Which of the following practices violates surgical asepsis? A) Holding sterile objects above the waist B) Considering a 1 inch (2.5 cm) edge around the sterile field as being contaminated C) Pouring solution onto a sterile field cloth D) Opening the outermost flap of a sterile package away from the body

Ans: C Feedback: Whenever a sterile barrier is breached, the area must be considered contaminated. Pouring solution onto a sterile field cloth violates surgical asepsis because moisture penetrating the cloth can carry microorganisms to the sterile field via capillary action. The other options are practices that help ensure surgical asepsis.

12. You are the nurse caring for a patient after abdominal surgery in the postanesthesia care unit. The patient's blood pressure has increased and the patient is restless. The patient's oxygen saturation is 97%. You know that the change in your patient is most likely caused by what? A) The patient's temperature is low. B) The patient is in shock. C) The patient is in pain. D) The patient is nauseated.

Ans: C Feedback: An increase in blood pressure and restlessness are symptoms of pain. The patient's oxygen saturation is 97%, so hypothermia and shock are not likely causes of the patient's restlessness.

36. As an intraoperative nurse, you know that the patient's emotional state can influence the outcome of his or her surgical procedure. How would you best reinforce the patient's ability to influence their outcome? A) Teach the patient guided imagery B) Assess the patient's coping strategies C) Incorporate cultural, ethnic, and religious considerations as appropriate D) Give him or her anti-anxiety medication

Ans: C Feedback: Because the patient's emotional state remains a concern, the care initiated by preoperative nurses is continued by the intraoperative nursing staff that provides the patient with information and reassurance. The nurse supports coping strategies and reinforces the patient's ability to influence outcomes by encouraging active participation in the plan of care incorporating cultural, ethnic, and religious considerations as appropriate. Options A, B, and D are incorrect. They are not the best options in the intraoperative period.

32. You are caring for a 71-year-old patient who is 4 days postoperative for bilateral inguinal hernias. The patient has a history of congestive heart failure and peptic ulcer disease. The patient is refusing to ambulate and will not drink fluids except for hot tea with her meals. The nurse's aide reports to you that this patient's vital signs are slightly elevated and she has a nonproductive cough. When you assess the patient, you find there are crackles at the base of the lungs. What would you suspect is wrong with your patient? A) Flash pulmonary edema B) Pneumonia C) Hypostatic pulmonary congestion D) Right-sided heart failure

Ans: C Feedback: Hypostatic pulmonary congestion, caused by a weakened cardiovascular system that permits stagnation of secretions at lung bases, may develop; this condition occurs most frequently in elderly patients who are not mobilized effectively. The symptoms are often vague, with perhaps a slight elevation of temperature, pulse, and respiratory rate, as well as a cough. Physical examination reveals dullness and crackles at the base of the lungs. If the condition progresses, then the outcome may be fatal. Options A, B, and D are incorrect.

28. You have just received a postoperative patient from the PACU to the medical-surgical unit. Your patient is an 84-year-old female who had surgery for a left hip replacement. What is a primary concern for this patient in the first few hours on the unit? A) Ability to ambulate B) Clean dressings on the surgical site C) Neurologic status D) Ability to communicate

Ans: C Feedback: In the initial hours after admission to the clinical unit, adequate ventilation, hemodynamic stability, incisional pain, surgical site integrity, nausea and vomiting, neurologic status, and spontaneous voiding are primary concerns. A total hip patient does not ambulate during the first few hours on the unit. Dressings are assessed but may have some drainage on them. Ability to communicate is near baseline when the patient is discharged from the PACU.

4. Your patient is a 78-year-old male who has had outpatient surgery. You are getting him up for his first walk postoperatively. To decrease the potential for orthostatic hypotension, what should you plan to have the patient do? A) Sit in a chair for 10 minutes prior to ambulating B) Drink plenty of fluids to increase circulating blood volume C) Stand upright for 2 to 3 minutes prior to ambulating D) Sit upright on the side of the bed for 15 minutes prior to ambulating

Ans: C Feedback: Older adults are at an increased risk for orthostatic hypotension secondary to age-related changes in vascular tone. The patient should sit up and then stand for 2 to 3 minutes before ambulating to alleviate orthostatic hypotension. Therefore options A, B, and D are incorrect.

9. You are caring for a 79-year-old man who has returned to the medical-surgical unit following abdominal surgery. Your patient is unable to ambulate and is now refusing to wear an external pneumatic compression stocking. You explain that refusing to wear external pneumatic compression stockings places him at significant risk for what? A) Sepsis B) Infection C) Pulmonary embolism D) Hematoma

Ans: C Feedback: Patients who have surgery that limit mobility are at an increased risk for pulmonary embolism secondary to deep vein thrombosis. The use of an external pneumatic compression stocking significantly reduces the risk by increasing venous return to the heart and limiting blood stasis. Options A and B are incorrect; the risk of infection or sepsis would not be affected by an external pneumatic compression stocking. Option D is incorrect; a hematoma or bruise would not be affected by the external pneumatic compression stocking unless the stockings were placed directly over the hematoma.

14. You are the nurse caring for 82-year-old women in the PACU. The woman begins to awaken and responds to her name but is confused, restless, and agitated. What are you aware of? A) Postoperative confusion is an indication of an oxygen problem or possibly a stroke during surgery. B) Confusion, restlessness, and agitation are normal postoperative findings and will diminish in time. C) Postoperative confusion is common in the elderly, but it could also indicate a significant blood loss. D) Confusion, restlessness, and agitation indicate inadequate pain management, and analgesics will help.

Ans: C Feedback: Postoperative confusion is common in the elderly, but it could also indicate blood loss and the potential for hypovolemic shock and is a critical symptom for the nurse to identify. Option A is a good answer; postoperative confusion is an indication of an oxygen problem or possibly a stroke during surgery, but blood loss is more likely. Option B is incorrect; restlessness and agitation are never normal postoperative findings. Option D is incorrect; confusion, restlessness, and agitation may indicate inadequate pain management, but pain could be assessed by report of pain, splinting of the affected area, and vital signs.

6. You are caring for a postoperative patient on the medical-surgical unit. During each patient assessment, you evaluate your patient for infection. Which sign or symptom would be most indicative of infection? A) Presence of an indwelling urinary catheter B) Rectal temperature of 100ºF (37.8ºC) C) Red, warm, tender incision D) White blood cell (WBC) count of 8,000/mL

Ans: C Feedback: Redness, warmth, and tenderness in the incision area should lead the nurse to suspect a postoperative infection. The presence of any invasive device predisposes a patient to infection but by itself doesn't indicate infection. A rectal temperature of 100ºF would be a normal expectation in a postoperative patient because of the inflammatory process. A normal white blood cell count ranges from 4,000 to 10,000/mL.

23. You are the intraoperative nurse transferring a patient from the OR to the PACU after replacement of the right knee. The patient is a 73-year-old female. You know that special attention must be paid to what? A) Cardiovascular status B) Positioning C) Keeping the patient warm D) Keeping the patient hydrated

Ans: C Feedback: Special attention is given to keeping the patient warm because elderly patients are more susceptible to hypothermia. Cardiovascular status, positioning, and hydration are all important for the nurse to pay attention to but are secondary concerns in elderly patients.

13. You are the nurse in the emergency department (ED). You are caring for a man who has returned to the ED after receiving ten stitches for a knife wound while cleaning fish. The wound is now infected, the stitches were removed, and the wound is cleaned and packed with gauze. The ED doctor plans to have the man return tomorrow to remove the packing and resuture the wound. You are aware that the wound will now heal by what? A) Late intention B) Second intention C) Third intention D) First intention

Ans: C Feedback: Third-intention healing or secondary suture is used for deep wounds that either had not been sutured early or that had the suture break down and are resutured later, which is what happened in this case. Secondary suture brings the two opposing granulation surfaces back together; however, this usually results in a deeper and wider scar. These wounds are also packed postoperatively with moist gauze and covered with a dry sterile dressing. Option A is incorrect; late intention is a term that sounds good but is used simply to distract the unsure test-taker. Option B is incorrect; second intention is when the wound is left open and the wound is filled will granular tissue. Option D is incorrect; first intention wounds are wounds made aseptically with a minimum of tissue destruction.

36. In portable wound suction, the use of gentle, constant suction enhances drainage of these fluids and collapses the skin flaps against the underlying tissue, thus removing "dead space." Which of the following is a portable suction device? A) Penrose B) Chest tube C) Jackson-Pratt D) Hemodynavac

Ans: C Feedback: Types of wound drains include the Penrose, Hemovac, and Jackson-Pratt drains. A Penrose drain and a chest tube are not portable suction devices. There is no such thing as a Hemodynavac

22. You are a circulating nurse in the day surgery center. You know that each patient has the potential for complications intraoperatively. What are these complications? (Mark all that apply.) A) Malignant hypothermia B) Pain C) Hypothermia D) Anaphylaxis E) Nausea

Ans: C, D, E Feedback: Potential intraoperative complications include nausea and vomiting, anaphylaxis, hypoxia, hypothermia, and malignant hyperthermia. Options A and B are not potential complications.

3. A 21-year-old patient is positioned on the OR bed prior to knee surgery. The anesthesiologist administers the anesthetic. What is the next step in the care of this patient? A) Grounding B) Hanging IV fluids C) Giving blood D) Intubating

Ans: D Feedback: When the patient arrives in the OR, the anesthesiologist or anesthetist reassesses the patient's physical condition immediately prior to initiating anesthesia. The anesthetic is administered, and the patient's airway is maintained through an intranasal intubation, oral intubation, or a laryngeal mask airway. This makes options A, B, and C incorrect.

20. What is the basis of the collaboration of the surgical team that results in the best outcome for the patient? A) Historical precedence B) Patient request C) Physician need D) Evidence-based practice

Ans: D Feedback: Collaboration of the surgical team using evidence-based practice tailored to specific case results in optimal patient care and improved outcomes. The distracters are not the basis for the collaboration of the surgical team.

29. The nurse is caring for a patient who is scheduled to have a needle biopsy of the pleura. The patient tells the anesthesiologist he wants a local conduction block. Which local conduction block can be used to block the nerves leading to the chest? A) Transsacral block B) Brachial plexus block C) Peudental block D) Paravertebral block

Ans: D Feedback: Examples of common local conduction blocks include paravertebral anesthesia, which produces anesthesia of the nerves supplying the chest, abdominal wall, and extremities; brachial plexus block, which produces anesthesia of the arm; and transsacral (caudal) block, which produces anesthesia of the perineum and, occasionally, the lower abdomen. A peudental block was used in obstetrics before the almost-routine use of epidural anesthesia.

11. A nurse is caring for a patient following surgery under a spinal anesthetic. What interventions can the nurse implement to prevent a spinal headache? A) Have the patient sit in a chair B) Ambulate the patient C) Limit fluids D) Keep the patient lying flat

Ans: D Feedback: Measures that increase cerebrospinal pressure are helpful in relieving headache. These include maintaining a quiet environment, keeping the patient lying flat, and keeping the patient well hydrated. Options A and B are incorrect; having the patient sit or stand up decreases cerebrospinal pressure and would not relieve a spinal headache. Limiting fluids, option C, is incorrect because it also decreases cerebrospinal pressure and would not relieve a spinal headache.

17. You are packing a patient's abdominal wound with sterile, half-inch Iodoform gauze. You drop some of the gauze onto the patient's abdomen 2 inches (5 cm) away from the wound. What should you do? A) Apply povidone-iodine (Betadine) to that section of the gauze and continue packing the wound. B) Pick up the gauze and continue packing the wound after irrigating the abdominal wound with Betadine solution. C) Continue packing the wound and inform the physician that an antibiotic is needed. D) Discard the gauze packing and repack the wound with new Iodoform gauze.

Ans: D Feedback: Sterile surfaces or articles may touch other sterile surfaces or articles and remain sterile; contact with unsterile objects at any point renders a sterile area contaminated. The sterile gauze became contaminated when it was dropped on the patient's abdomen. It should be discarded and new Iodoform gauze should be used to pack the wound. Betadine should not be used in the wound unless ordered.

33. As a perioperative nurse, you know that the 2009 National Patient Safety Goals all pertain to the perioperative areas. Which of the 2009 National Patient Safety Goals has the most direct relevance to the operating room? A) Improve safety of using medications B) Reduce the risk of patient harm resulting from falls C) Reduce the risk of health care-associated infections D) Reduce the risk of surgical fires

Ans: D Feedback: The National Patient Safety Goals all pertain to the perioperative areas, but the one with the most direct relevance to the OR is the reduction of the risk of surgical fires.

25. The circulating nurse meets the patient in a warm and friendly manner. The nurse discusses what the patient can expect in surgery. What basic communication skills does the nurse use? A) Talk slowly and softly B) Use medically acceptable terms C) Give pre-operative medications first D) Touch

Ans: D Feedback: When discussing what the patient can expect in surgery, the nurse uses basic communication skills, such as touch and eye contact, to reduce anxiety. Option A is incorrect; you should talk normally to the patient. Option B is incorrect; speak in language the patient can understand. Option C is incorrect; giving medication is not a communication skill.

29. The nurse's aide notifies you that your patient has decreased oxygen saturation levels. You assess the patient and find that he is tachypnic, has crackles on auscultation, and his sputum is frothy and pink. What do you suspect is wrong with this patient? A) Flash pulmonary embolism B) Atelectasis C) Laryngospasm D) Flash pulmonary edema

Ans: D Feedback: Flash pulmonary edema occurs when protein and fluid accumulate in the alveoli unrelated to elevated pulmonary artery occlusive pressure. Signs and symptoms include agitation; tachypnea; tachycardia; decreased pulse oximetry readings; frothy, pink sputum; and crackles on auscultation. Laryngospasm does not cause crackles or frothy, pink sputum. The patient with atelectasis has decreased breath sounds over the affected area; the scenario does not indicate this. Option A does not exist.

11. You are a nurse in the PACU caring for a 56-year-old male patient who had a hernia repair. The patient's blood pressure is now 164/92, he has no history of hypertension prior to surgery, and his preoperative blood pressure was 112/68. You know that hypertension following surgery is often related to what? A) Dysrhythmias, blood loss, and hyperthermia B) Electrolyte imbalances and neurologic changes C) A parasympathetic reaction and low blood volumes D) Pain, hypoxia, or bladder distention, which all cause sympathetic stimulation

Ans: D Feedback: Hypertension is common in the immediate postoperative period secondary to sympathetic nervous system stimulation from pain, hypoxia, or bladder distention. Options A and B are incorrect; dysrhythmias, blood loss, hyperthermia, electrolytes imbalances, and neurologic changes are not common postoperative reasons for hypertension. Option D is incorrect; a parasympathetic reaction and low blood volumes would cause hypotension.

18. You are doing teaching with a patient who has a leg ulcer. You are teaching about tissue repair and wound healing. Which of the following statements by the patient indicates that teaching has been effective? A) "I'll limit my intake of protein." B) "I'll make sure that the bandage is wrapped tightly." C) "My foot should feel cold." D) "I'll eat plenty of fruits and vegetables."

Ans: D Feedback: Optimal nutritional status is important for wound healing, return of normal bowel function, and fluid and electrolyte balance. The nurse and patient can consult with the dietitian to plan appealing, high-protein meals that provide sufficient fiber, calories, and vitamins. Nutritional supplements, such as Ensure or Sustacal, may be recommended. Multivitamins, iron, and vitamin C supplements may be prescribed to aid in tissue healing, formation of new red blood cells, and overall nutritional status. To avoid impeding circulation to the area, the bandage should be secure but not tight. If the patient's foot feels cold, circulation is impaired, which inhibits wound healing.

1. You are the recovery room nurse who is admitting a patient from the OR. What is the first assessment you would make on a newly admitted patient? A) Heart rate B) Nail perfusion C) Core temperature D) Patency of the airway

Ans: D Feedback: The primary objective in the immediate postoperative period is to maintain ventilation and, thus, prevent hypoxemia (reduced oxygen in the blood) and hypercapnia (excess carbon dioxide in the blood). Both can occur if the airway is obstructed and ventilation is reduced (hypoventilation). This assessment is followed by cardiovascular status and the condition of the surgical site. Nail perfusion is part of the cardiovascular status. The core temperature would be assessed after the airway, cardiovascular status, and wound.

38. The nursing instructor is talking with a group of medical-surgical students about deep vein thrombosis (DVT). A student asks what factors contribute to the formation of a DVT. What would be the instructor's best response? A) "There is a genetic link in the formation of deep vein thrombi." B) "Hypervolemia is a contributory factor to deep vein thrombi." C) "There are no factors that contribute to the formation of deep vein thrombi; they just occur." D) "Dehydration is a contributory factor to the formation of deep vein thrombi."

Ans: D Feedback: The stress response that is initiated by surgery inhibits the fibrinolytic system, resulting in blood hypercoagulability. Dehydration, low cardiac output, blood pooling in the extremities, and bed rest add to the risk of thrombosis formation.

33. The nurse is admitting a patient to the medical-surgical unit from the PACU. A concern for this patient is pneumonia. What would the nurse do to help the patient clear secretions and help prevent pneumonia? A) Encourage the patient to eat a balanced diet that is high in protein B) Encourage the patient to visit with his family in the waiting room C) Encourage the patient to take his medications as ordered D) Encourage the patient to use the incentive spirometer every 2 hours

Ans: D Feedback: To clear secretions and prevent pneumonia, the nurse encourages the patient to turn frequently, take deep breaths, cough, and use the incentive spirometer at least every 2 hours. These pulmonary exercises should begin as soon as the patient arrives on the clinical unit and continue until the patient is discharged. A balanced, high protein diet; visiting family in the waiting room; or taking medications as ordered would not help to clear secretions or prevent pneumonia

25. You are the nurse in a same-day surgery center. What can you do to ensure patient safety and recovery? A) Record vital signs and intake and output B) Document all your assessment findings C) Report to the home health nurse all of the pertinent details D) Provide expert teaching

Ans: D Feedback: To ensure patient safety and recovery, expert patient teaching and discharge planning are necessary when a patient undergoes same-day or ambulatory surgery. Options A, B, and C are incorrect because they would not ensure patient safety and recovery.

2. Your patient is in the recovery room following chest surgery. The patient complains of severe nausea. What would you do next? A) Administer an analgesic B) Apply a cool cloth to the patient's forehead C) Offer the patient a small amount of ice chips D) Turn the patient completely to one side

Ans: D Feedback: Turning the patient completely to one side allows collected fluid to escape from the side of the mouth if the patient vomits. After turning the patient to the side, the nurse can offer a cool cloth to the patient's forehead. Ice chips can increase feelings of nausea. An analgesic is not administered for nausea and vomiting.