chapter 37: Perioopertive NCLEX/end of chapter questions
The nurse is concerned that an older client is developing a postoperative infection. What did the nurse assess to make this clinical determination? 1. Fever 2. Confusion 3. Tachycardia 4. Inflammation
answer: 2
The client's postoperative orders state "diet as tolerated." The client has been NPO. The nurse will advance the client's diet to clear liquids based on which assessment? Select all that apply. 1) Does not complain of nausea or vomiting. 2) Pain level is maintained at a rating of 2-3 out of 10. 3) States passing flatus. 4) Ambulates with minimal assistance. 5) Expresses feeling "hungry."
answer: 1, 3
A client in the postanesthesia care unit is to have suction applied through a nasogastric tube. When documenting, the nurse should include which information? (Select all that apply.) 1. The time suction was started 2. Characteristics of wound drainage 3. Pressure on the suction 4. Integrity of the surgical dressing 5. Color and consistency of drainage
answer: 1, 3, 5
The nurse is planning a perioperative client's needs upon discharge. What should be included when determining these needs? (Select all that apply.) 1. Client's abilities to provide self-care 2. Date of anticipated discharge 3. Physician performing the surgery 4. Financial resources 5. Need for home healthcare services
answer: 1, 4, 5
The overall goal of nursing care during the intraoperative phase is the clients?
Safety
) The nurse is caring for a client who is having surgery and is currently being transported to the operating room suite. The nurse should document that the client is in which operative phase? 1. Preoperative phase 2. Intraoperative phase 3. Postoperative phase 4. Perioperative phase
answer: 1
A client recovering from surgery asks the nurse why turning, deep-breathing, and coughing exercises need to be done. What should the nurse respond? 1. "These exercises help prevent pneumonia." 2. "The doctor ordered the exercises." 3. "All surgical clients must do these exercises." 4. "These exercises prevent thrombophlebitis."
answer: 1
During the assessment of a client recovering from surgery, the nurse notes decreased breath sounds in both lower lobes bilaterally. What should the nurse do? 1. Coach the client to deep-breathe and cough. 2. Restrict fluids. 3. Remind the client to perform leg exercises. 4. Maintain on bed rest.
answer: 1
The nurse is admitting a client to the medical-surgical unit following a cholecystectomy. Which assessment should the nurse perform first? 1. Level of consciousness 2. Dressing 3. Drains 4. Skin color
answer: 1
The nurse is caring for a client in the immediate postoperative period (PACU). Which intervention should the nurse implement to reduce the risk of thrombophlebitis? 1. Leg exercises 2. Coughing every 2 hours 3. Ambulating every 2 hours 4. Oxygen by mask
answer: 1
The nurse is caring for an 80-year-old client preparing for surgery. The nurse realizes this client is at increased risk for which reason? 1. The physiological deficits of aging increase the surgical risk for older adults. 2. The older adult has increased kidney function. 3. The older adult has an increase in sensory function. 4. The older adult will turn, cough, and deep-breathe more effectively.
answer: 1
The nurse is preparing a 23-year-old female client for surgery. The nurse should anticipate which diagnostic test to be prescribed for this client? 1. Pregnancy test 2. EEG 3. EKG 4. Pulmonary function tests
answer: 1
The nurse is preparing to conduct preoperative teaching. What should be included in this teaching? 1. Information related to what will happen to the client 2. Referral of the client to the physician for any misconceptions the client may have 3. The role of the nurse during surgery 4. How to perform activities of daily living (ADLs) following surgery
answer: 1
The nurse is completing a preoperative assessment with a client. What should this assessment include? (Select all that apply.) 1. Current health status 2. Allergies 3. Current medications 4. Mental status 5. Respiratory rate
answer: 1, 2, 3, 4
The nurse is obtaining preoperative assessment data. What should be included in this assessment? (Select all that apply.) 1. Current health status 2. Allergies 3. Current medications 4. Mental status 5. Mother's maiden name
answer: 1, 2, 3, 4
The nurse is preparing to complete a physical assessment before surgery. Which assessments should the nurse obtain? (Select all that apply.) 1. Mini mental status 2. Assessment of hearing 3. Assessment of the respiratory system 4. Gastrointestinal assessment 5. Maintain NPO status
answer: 1, 2, 3, 4
A client is scheduled for lung resection surgery. What should the nurse keep in mind when determining this client's degree of risk for this major surgical procedure? (Select all that apply.) 1. Age 2. Medications 3. General health 4. Blood pressure 5. Nutritional status
answer: 1, 2, 3, 5
The nurse has identified the goals of maintaining client safety and homeostasis during the intraoperative phase of client care. What nursing activities would support these goals? (Select all that apply.) 1. Maintain the sterile field. 2. Perform instrument counts. 3. Instruct in postoperative exercises. 4. Position the client appropriately for surgery. 5. Perform preoperative skin preparation.
answer: 1, 2, 4, 5
The nurse is preparing to instruct a client on leg exercises to be used when recovering from abdominal surgery. What should the nurse determine before beginning this teaching? (Select all that apply.) 1. Type of surgery 2. Time of surgery 3. Postoperative diet 4. Preoperative orders 5. Name of the surgeon
answer: 1, 2, 4, 5
The nurse is assessing an abdominal wound in the postoperative period. Which sign should indicate to the nurse that an infection is present? 1. Absence of bleeding 2. Edges warm to the touch 3. Edges well approximated 4. Sutures in place
answer: 2
The nurse is planning care for a client during the postoperative period. What should the nurse identify as the goal of care for this client? 1. Provide necessary preoperative teaching. 2. Assist the client to achieve the most optimal health status possible. 3. Ensure client safety. 4. Maintain an aseptic environment.
answer: 2
The nurse is preparing a 6-year-old child for a tonsillectomy. Which strategy should the nurse use for teaching this client? 1. Pamphlets 2. Play 3. Books 4. Videotapes
answer: 2
The nurse is preparing a care plan for a client about to undergo surgery. Which nursing diagnosis would take priority during the intraoperative phase of surgery? 1. Ineffective Protection 2. Risk for Aspiration 3. Impaired Skin Integrity 4. Risk for Falls
answer: 2
The nurse is preparing to apply antiembolic stockings to a postoperative client. What should be done first, before applying the stockings? 1. Measure the calf. 2. Assess for circulatory problems. 3. Assess the client's blood pressure. 4. Clean the stockings.
answer: 2
The surgical team conducts a final verification of the correct client, procedure, and site. In which way should the nurse document this validation? 1. SBAR 2. Time-out 3. SOAPIE note 4. Hand-off communication
answer: 2
A client is anxious about receiving general anesthesia for a surgical procedure. What should the nurse explain are the advantages of having this type of anesthesia? (Select all that apply.) 1. The client remains conscious. 2. Respiratory rate can be regulated easily. 3. It is used for minor surgical procedures. 4. The anesthesia can be adjusted to the length of the operation. 5. It focuses on a single nerve or nerve group.
answer: 2, 4
A client is having a surgical procedure. At which time does the postoperative phase begin? 1. When healing is complete 2. When the decision to have surgery is made 3. With admission to the postanesthesia care unit 4. When the client is transferred to the operating table
answer: 3
A client is scheduled for a cholecystectomy. Which should the nurse identify as the purpose of this surgical procedure? 1. Diagnostic 2. Palliative 3. Ablative 4. Constructive
answer: 3
The nurse has just inserted a nasogastric tube for gastric suction. What is the most reliable test for confirming tube placement? 1. Place the stethoscope over the stomach and listen for a swishing sound while inserting water into the tube. 2. Place the stethoscope over the stomach and listen for a swishing sound while inserting air into the tube. 3. Aspirate stomach contents and check the acidity using a pH test strip. 4. Connect the tube to suction and observe the contents.
answer: 3
The nurse is caring for a client in the recovery area. In which position should the nurse place the unconscious client during the immediate postanesthesia phase? 1. Supine 2. Prone 3. Side-lying 4. Supine with a pillow under the head
answer: 3
The nurse is caring for a client on the postoperative unit. Which nursing diagnosis is the priority for this client? 1. Self-Care Deficit 2. Disturbed Body Image 3. Ineffective Airway Clearance 4. Risk for Falls
answer: 3
The nurse is evaluating the effectiveness of preoperative instruction regarding leg exercises with a client recovering from surgery. Which observation indicates that the instructions were effective? 1. The lower extremity is swollen and hot to touch. 2. The vein feels hard. 3. There is no cramping or pain with ambulation. 4. There is pain in the calf with dorsiflexion.
answer: 3
The nurse is preparing the skin of a client for surgery. For which reason should this preparation be done? 1. Sterilize the skin 2. Assess the surgical site before surgery 3. Reduce the risk of postoperative wound infection 4. Clean any moles the client may have
answer: 3
) The nurse is preparing a client for an upper GI endoscopy. For which type of anesthesia should the nurse prepare the client to receive? 1. Local anesthesia 2. Spinal anesthesia 3. Epidural anesthesia 4. Conscious sedation
answer: 4
A client recovering from surgery has antiembolic stockings applied. Which should the nurse document about this procedure? 1. Type of surgery 2. Name of the surgeon 3. Orientation of the client 4. Time when the stockings were applied
answer: 4
Assistive personnel (AP) responds when a client recovering from surgery calls for help. Which should the AP do when the client has accidentally removed the nasogastric tube? 1. Reinsert the tube 2. Suction the client's mouth 3. Empty the suction cannister 4. Notify the nurse immediately
answer: 4
The nurse determines that interventions to prevent postoperative constipation have been effective in a client recovering from surgery. What did the nurse assess to make this clinical decision? 1. Abdominal distention present. 2. Gas pains present. 3. Client vomiting. 4. Bowel movement occurred 24 hours after resuming a normal diet.
answer: 4
The nurse wants to ensure that a client recovering from surgery does not develop thrombophlebitis. Which action should the nurse take to reduce the client's risk of this postoperative complication? 1. Administer an anticoagulant. 2. Assist the client to cough every 2 hours. 3. Monitor intake and output every 2 hours. 4. Provide for early ambulation.
answer: 4
The nurse is caring for a postoperative client with an abdominal wound and a drain. What can the nurse assign to assistive personnel (AP)? (Select all that apply.) 1. Clean the wound. 2. Assess the skin around the wound. 3. Determine the effectiveness of pain medication. 4. Report if the dressing is soiled. 5. Report if the dressing is loose.
answer: 4, 5
The nurse assesses a postoperative client who has a rapid, weak pulse; urine output < 30 ml/hr and decreased blood pressure. the clients skin is cool and clammy. What complication should the nurse suspect? a. Thrombophlebitis b. Hypovolemic shock c. Pneumonia d. Wound dehiscence
answer: B
which test is the best resource for determining the preoperative status of a client's liver function? A. serum electrolytes b. BUN, creatinine c. ALT, AST d. serum albumin
answer: C
A client who is having a Mastectomy expresses sadness about losing her breast. based on this information, the nurse would identify that the client is at risk for what nursing diagnosis? a. altered body image b. grieving c. fear d. impaired coping
answer: b
A client being admitted for right total knee replacement tells the nurse that he is afraid because a friend of his needed eye surgery and they operated on the wrong eye. which statements could the nurse make to address the clients fears? select all that apply A. "don't worry, nothing like this has ever happened at this hospital" B. "you will be asked to write "yes" with a marker on your right knee to indicate it is the correct knee" C. "before the surgery begins the surgical team takes a time out to conduct a final verification of the correct client, procedure and site" D. "An "X" will be marked on your left knee to indicate that this is not the correct knee" E. " your surgeon will verify the correct knee by writing his initials on the right knee"
answer: b, c, e
The client is most likely to require the greatest amount of analgesics for pain during which period? a. immediately after surgery b. 4 hours after surgery c. 12-36 hours after surgery d. 48-60 hours after surgery
answer: c
Which statement by the client indicates that the preoperative teaching regarding gallbladder surgery has been effective? a. " I cannot eat or drink anything after midnight" b. "I'm not going to cough after surgery because it might open my incision" c. "I might have a stroke if I stop taking my anticoagulant" d. "The nurse showed me how to contract and relax my calf muscles"
answer: d
A postop client who had abdominal surgery is holding a pillow against his abdomen during deep-breathing and coughing exercises. what term does the nurse use to describe the technique?
answer: splinting
Which of the following actions can the nurse assign to assistive personnel? select all that apply 1. teaching preoperative info 2. managing GI suction 3. Reinforcing preoperative teaching 4. Reapplying antiembolic stockings 5. Emptying GI suction drainage
answers: 3, 4, 5