Exam 1 Practice Questions: Adult 1

The nurse evaluates that discharge teaching for a patient hospitalized with pneumonia has been effective when the patient makes which statement about measures to prevent a relapse? a. "I will seek immediate medical treatment for any upper respiratory infections." b. "I should continue to do deep breathing and coughing exercises for at least 12 weeks." c. "I will increase my food intake to 2400 calories a day to keep my immune system well." d. "I must have a follow-up chest x-ray in 6 to 8 weeks to evaluate the pneumonia's resolution."

"I must have a follow-up chest x-ray in 6 to 8 weeks to evaluate the pneumonia's resolution." (The follow-up chest x-ray examination will be done in 6 to 8 weeks to evaluate pneumonia resolution. A patient should seek medical treatment for upper respiratory infections that persist for more than 7 days. It may be important for the patient to continue with coughing and deep breathing exercises for 6 to 8 weeks, not 12 weeks, until all of the infection has cleared from the lungs. Increased fluid intake, not caloric intake, is required to liquefy secretions.)

To which patient should the nurse plan to administer round-the-clock antipyretic drugs? a. A 76-yr-old patient with bacterial meningitis and a temperature of 104.2°F b. An 82-yr-old patient after hip replacement surgery and a temperature of 100.4°F c. A 14-yr-old patient with infectious mononucleosis and a temperature of 101.6°F d. A 59-yr-old patient with an acute myocardial infarction and a temperature of 99.8°F

A 76-yr-old patient with bacterial meningitis and a temperature of 104.2°F (Moderate fevers (up to 103°F) usually produce few problems in most patients and do not require antipyretic therapy. If the patient is very young or very old, is extremely uncomfortable, or has a significant medical problem (e.g., severe cardiopulmonary disease, brain injury), the use of antipyretics should be considered. High fevers (above 104°F) should be treated with antipyretics. High fevers can damage body cells and cause delirium and seizures.)

The nurse is caring for a patient with a nursing diagnosis of hyperthermia related to pneumonia. What assessment data does the nurse obtain that correlates with this nursing diagnosis (select all that apply.)? Select all that apply. a. A temperature of 101.4°F b. Heart rate of 120 beats/min c. Respiratory rate of 20 breaths/min d. A productive cough with yellow sputum e. Reports of unable to have a bowel movement for 2 days

a, b, d (A fever is an inflammatory response related to the infectious process. A productive cough with discolored sputum (which should be clear) is an indication that the patient has pneumonia. A respiratory rate of 20 breaths/min is within normal range. Inability to have a bowel movement is not related to a diagnosis of pneumonia. A heart rate of 120 beats/min indicates that there is increased metabolism due to the fever and is related to the diagnosis of pneumonia.)

The nurse is admitting a patient with a diagnosis of pulmonary embolism. What risk factors is a priority for the nurse to assess (select all that apply.)? Select all that apply. a. Obesity b. Pneumonia c. Malignancy d. Cigarette smoking e. Prolonged air travel

a, c, d, e (An increased risk of pulmonary embolism is associated with obesity, malignancy, heavy cigarette smoking, and prolonged air travel with reduced mobility. Other risk factors include deep vein thrombosis, immobilization, and surgery within the previous 3 months, oral contraceptives and hormone therapy, heart failure, pregnancy, and clotting disorders.)

During the preoperative interview with the nurse, a patient scheduled for an elective hysterectomy to treat benign tumors of the uterus tells the nurse that she just does not know whether she can go through with the surgery because she knows she will die in surgery as her mother did. The most appropriate response by the nurse is a. "Tell me more about what happened to your mother." b. "You will receive medications to reduce your anxiety." c. "Surgical techniques have improved a lot in recent years." d. "Many people have fears and anxieties about surgery."

a. "tell me more about what happened to your mother." (The patient's statement may indicate an unusually high anxiety level or a family history of problems such as malignant hyperthermia, which will require precautions during surgery. The other statements are accurate, but the nurse's initial response should be further assessment.)

The nurse is performing a respiratory assessment. Which finding best supports the nursing diagnosis of ineffective airway clearance? a. Basilar crackles b. Oxygen saturation of 85% c. Presence of greenish sputum d. Respiratory rate of 28 breaths/min

a. Basilar crackles (The presence of adventitious breath sounds indicates that there is accumulation of secretions in the lower airways. This would be consistent with a nursing diagnosis of ineffective airway clearance because the patient is retaining secretions. The rapid respiratory rate, low oxygen saturation, and presence of greenish sputum may occur with a lower respiratory problem but do not definitely support the nursing diagnosis of ineffective airway clearance.)

When the patient is being examined for venous thromboembolism (VTE) in the calf, what diagnostic test should the nurse expect to teach the patient about first? a. Duplex ultrasound b. Contrast venography c. Magnetic resonance venography d. Computed tomography venography

a. Duplex ultrasound (The duplex ultrasound is the most widely used test to diagnose VTE. Contrast venography is rarely used now. Magnetic resonance venography is less accurate for calf veins than pelvic and proximal veins. Computed tomography venography may be used but is invasive and much more expensive than the duplex ultrasound.)

An older adult patient living alone is admitted to the hospital with a diagnosis of pneumococcal pneumonia. Which clinical manifestation, observed by the nurse, indicates that the patient is likely to be hypoxic? a. Sudden onset of confusion b. Oral temperature of 102.3oF c. Coarse crackles in lung bases d. Clutching chest on inspiration

a. Sudden onset of confusion (Confusion or stupor (related to hypoxia) may be the only clinical manifestation of pneumonia in an older adult patient. An elevated temperature, coarse crackles, and pleuritic chest pain with guarding may occur with pneumonia, but these symptoms do not indicate hypoxia.)

The intraoperative activity that is performed by the perioperative nurse and is specific to the circulating function is a. admitting, identifying, and assessing the patient. b. counting sponges, needles, and surgical instruments. c. passing instruments to the surgeon and assistants. d. preparing the instrument table and sterile equipment.

a. admitting, identifying, and assessing the patient (The circulating nurse is responsible for admitting, identifying, and assessing the physiologic and emotional status of the patient. Counting sponges, needles, and surgical instruments is included in both the circulating and scrub roles. Management of sterile instruments and handing instruments to the surgeon are included in the scrub role. Preparation of the instrument table and sterile equipment is included in both the circulating and scrub roles.)

. Data obtained during the peri-operative nurse's assessment of a patient in the preoperative holding area that would indicate a need for special protection techniques during surgery include a. a history of spinal and hip arthritis. b. verbalization of anxiety by the patient. c. a stated allergy to cats and dogs. d. having a sip of water 2 hours previously.

a. history of spinal and hip arthritis ( The patient with arthritis may require special positioning to avoid injury and postoperative discomfort. Preoperative anxiety and having a sip of water 2 to 3 hours before surgery are not unusual for the preoperative patient. An allergy to cats and dogs will not impact the care needed during the intraoperative phase.)

3. A surgical patient received a volatile liquid as an inhalation anesthetic during surgery. Postoperatively the nurse should monitor the patient for a. incisional pain. b. hypertension. c. tachypnea. d. myoclonia.

a. incisional pain (Because volatile liquid inhalation agents are rapidly metabolized, postoperative pain occurs soon after surgery. Hypertension and tachypnea are not associated with general anesthetics. Myoclonia may occur with nonbarbiturate hypnotics but not with the inhaled inhalation agents.)

During discharge teaching for an older adult patient with chronic obstructive pulmonary disease (COPD) and pneumonia, which vaccine should the nurse recommend that this patient receive? a. Pneumococcal b. Staphylococcus aureus c. Haemophilus influenzae d. Bacille-Calmette-Guérin (BCG)

a. pneumococcal (The pneumococcal vaccine is important for patients with a history of heart or lung disease, recovering from a severe illness, age 65 years or older, or living in a long-term care facility. A Staphylococcus aureus vaccine has been researched but not yet been effective. The Haemophilus influenzae vaccine would not be recommended as adults do not need it unless they are immunocompromised. The BCG vaccine is for infants in parts of the world where tuberculosis is prevalent.)

The nurse instructs a patient with a pulmonary embolism about administering enoxaparin after discharge. Which statement by the patient indicates understanding about the instructions? a. "I need to take this medicine with meals." b. "The medicine will be prescribed for 10 days." c. "I will inject this medicine into my upper arm." d. "The medicine will dissolve the clot in my lung."

b. "The medicine will be prescribed for 10 days." (Enoxaparin is a low-molecular-weight heparin that is administered for 10 to 14 days and prevents future clotting but does not dissolve existing clots. Fibrinolytic agents (e.g., tissue plasminogen activator or alteplase) dissolve an existing clot. Enoxaparin is administered subcutaneously by injection into the abdomen.)

A patient with varicose veins has been prescribed compression stockings. Which nursing instruction would be most appropriate? a. "Try to keep your stockings on 24 hours a day, as much as possible." b. "While you're still lying in bed in the morning, put on your stockings." c. "Dangle your feet at your bedside for 5 minutes before putting on your stockings." d. "Your stockings will be most effective if you can remove them for a few minutes several times a day."

b. "While you're still lying in bed in the morning, put on your stockings." (The patient with varicose veins should apply stockings in bed before rising in the morning. Stockings should not be worn continuously and should not be removed several times daily. Dangling at the bedside before application is likely to decrease their effectiveness.)

A nurse is caring for a patient with a diagnosis of deep venous thrombosis (DVT). The patient has an order to receive 30 mg enoxaparin (Lovenox). Which injection site should the nurse use to administer this medication safely? a. Buttock, upper outer quadrant b. Abdomen, anterior-lateral aspect c. Back of the arm, 2 inches away from a mole d. Anterolateral thigh, with no scar tissue nearby

b. Abdomen, anterior-lateral aspect (Enoxaparin (Lovenox) is a low-molecular-weight (LMW) heparin that is given as a deep subcutaneous injection in the right and left anterolateral abdomen. All subcutaneous injections should be given away from scars, lesions, or moles.)

The nurse is caring for a patient with a recent history of deep vein thrombosis (DVT) who is scheduled for an emergency appendectomy. Vitamin K is ordered for immediate administration. The international normalized ratio (INR) value is 1.0. Which nursing action is most appropriate? a. Administer the medication as ordered. b. Hold the medication and record in the electronic medical record. c. Hold the medication until the lab result is repeated to verify results. d. Administer the medication and seek an increased dose from the health care provider

b. Hold the medication and record in the electronic medical record. (Vitamin K is the antidote to warfarin (Coumadin), which the patient has most likely been taking before admission for treatment of DVT. Warfarin is an anticoagulant that impairs the ability of the blood to clot. Therefore, it may be necessary to give vitamin K before surgery to reduce the risk of hemorrhage. However, the INR value is normal, and vitamin K is not required, so the medication would be held and recorded in the electronic medical record.)

After admitting a patient from home to the medical unit with a diagnosis of pneumonia, which physician orders will the nurse verify have been completed before administering a dose of cefuroxime to the patient? a. Orthostatic blood pressures b. Sputum culture and sensitivity c. Pulmonary function evaluation d. Serum laboratory studies ordered for AM

b. Sputum culture and sensitivity (The nurse should ensure that the sputum for culture and sensitivity was sent to the laboratory before administering the cefuroxime because this is community-acquired pneumonia. It is important that the organisms are correctly identified (by the culture) before the antibiotic takes effect. The test will also determine whether the proper antibiotic has been ordered (sensitivity testing). Although antibiotic administration should not be unduly delayed while waiting for the patient to expectorate sputum, orthostatic blood pressures, pulmonary function evaluation, and serum laboratory tests will not be affected by the administration of antibiotics.)

A patient has the following pre-op medication order: morphine 10 mg with atropine 0.4 mg IM. The nurse informs the patient that this injection will a. Decrease nausea and vomiting during and after surgery b. Decrease oral and respiratory secretions, thereby drying the mouth. c. Decrease anxiety and produce amnesia of the pre-op period. d. Induce sleep, so that patient will not be aware during transport to the operating room.

b. decrease oral and respiratory secretions, thereby drying the mouth (Atropine, an anticholinergic medication, is frequently used preoperatively to decrease oral and respiratory secretions during surgery, and the addition of morphine will help to relieve discomfort during the preoperative procedures. Antiemetics decrease nausea and vomiting during and after surgery, and scopolamine and some benzodiazepines induce amnesia. An actual sleep state is rarely induced by preoperative medications unless an anesthetic agent is administered before the patient is transported to the operating room.)

The nurse is caring for a group of patients. Which patient is at risk of aspiration? a. A 58-yr-old patient with absent bowel sounds 12 hours after abdominal surgery b. A 67-yr-old patient who had a cerebrovascular accident with expressive dysphasia c. A 26-yr-old patient with continuous enteral tube feedings through a nasogastric tube d. A 92-yr-old patient with viral pneumonia and coarse crackles throughout the lung fields

c. A 26-yr-old patient with continuous enteral tube feedings through a nasogastric tube (Conditions that increase the risk of aspiration include decreased level of consciousness, difficulty swallowing (dysphagia), and nasogastric intubation with or without tube feeding. With loss of consciousness, the gag and cough reflexes are depressed, and aspiration is more likely to occur. Dysphasia is difficulty with speech. Absent bowel sounds and coarse crackles do not increase the risk for aspiration)

The nurse is performing a respiratory assessment for a patient admitted with pneumonia. Which clinical manifestation should the nurse expect to find? a. Hyperresonance on percussion b. Vesicular breath sounds in all lobes c. Increased vocal fremitus on palpation d. Fine crackles in all lobes on auscultation

c. Increased vocal fremitus on palpation (A typical physical examination finding for a patient with pneumonia is increased vocal fremitus on palpation. Other signs of pulmonary consolidation include bronchial breath sounds, egophony, and crackles in the affected area. With pleural effusion, there may be dullness to percussion over the affected area.)

The nurse is caring for a patient with pneumonia unresponsive to two different antibiotics. Which action is most important for the nurse to complete before administering a newly prescribed antibiotic? a. Teach the patient to cough and deep breathe. b. Take the temperature, pulse, and respiratory rate. c. Obtain a sputum specimen for culture and Gram stain. d. Check the patient's oxygen saturation by pulse oximetry.

c. Obtain a sputum specimen for culture and Gram stain. (A sputum specimen for culture and Gram stain to identify the organism should be obtained before beginning antibiotic therapy. However, antibiotic administration should not be delayed if a specimen cannot be readily obtained because delays in antibiotic therapy can increase morbidity and mortality risks.)

1.The nurse from the general surgical unit is asked to bring the patient's hearing aid to the surgical suite. The nurse will take the hearing aid to the a. clean core. b. scrub sink areas. c. nursing station or information desk. d. corridors of the operating room area.

c. nursing station or information desk (C. The nurse from the general unit would not be wearing surgical scrub attire or a head covering and would be restricted to the nursing station or information desk, which are unrestricted areas. The clean core, scrub sink area, and corridors are semi-restricted areas and require that staff members wear surgical scrub attire and head coverings.)

What nurse is nonsterile in the operating room?

circulating nurse and peri-op nurse

A 39-yr-old woman with a history of smoking and oral contraceptive use is admitted with a venous thromboembolism (VTE) and prescribed unfractionated heparin. What laboratory test should the nurse review to evaluate the expected effect of the heparin? a. Platelet count b. Activated clotting time (ACT) c. International normalized ratio (INR) d. Activated partial thromboplastin time (APTT)

d. Activated partial thromboplastin time (APTT) (Unfractionated heparin can be given by continuous IV for VTE treatment. When given IV, heparin requires frequent laboratory monitoring of clotting status as measured by activated partial thromboplastin time (aPTT). Platelet counts can decrease as an adverse reaction to heparin.)

The nurse is caring for a patient with ineffective airway clearance. What is the priority nursing action to assist this patient expectorate thick lung secretions? a. Humidify the oxygen as able. b. Administer cough suppressant q4hr. c. Teach patient to splint the affected area. d. Increase fluid intake to 3 L/day if tolerated.

d. Increase fluid intake to 3 L/day if tolerated. (Although several interventions may help the patient expectorate mucus, the highest priority should be on increasing fluid intake, which will liquefy the secretions so that the patient can expectorate them more easily. Humidifying the oxygen is also helpful but is not the primary intervention. Teaching the patient to splint the affected area may also be helpful in decreasing discomfort but does not assist in expectoration of thick secretions.)

An older adult patient is admitted with acute respiratory distress related to cor pulmonale. Which nursing action is most appropriate during admission of this patient? a. Perform a comprehensive health history with the patient to review prior respiratory problems. b. Complete a full physical examination to determine the effect of the respiratory distress on other body functions. c. Delay any physical assessment of the patient and review with the family the patient's history of respiratory problems. d. Perform a physical assessment of the respiratory system and ask specific questions related to this episode of respiratory distress.

d. Perform a physical assessment of the respiratory system and ask specific questions related to this episode of respiratory distress. (Because the patient is having respiratory difficulty, the nurse should ask specific questions about this episode and perform a physical assessment of this system. Further history taking and physical examination of other body systems can proceed when the patient's acute respiratory distress is being managed.)

The nurse is caring for an older adult patient who underwent a left total knee arthroplasty. On the third postoperative day, the patient reports shortness of breath, slight chest pain, and that "something is wrong." Temperature is 98.4°F, blood pressure is 130/88 mm Hg, respirations are 36 breaths/min, and oxygen saturation is 91% on room air. What is the priority nursing action? a. Notify the health care provider. b. Administer a nitroglycerin tablet sublingually. c. Conduct a thorough assessment of the chest pain. d. Sit the patient up in bed as tolerated and apply oxygen.

d. Sit the patient up in bed as tolerated and apply oxygen. (The patient's clinical picture is most likely pulmonary embolus, and the first action the nurse takes should be to assist with the patient's respirations. For this reason, the nurse should sit the patient up as tolerated and apply oxygen before notifying the physician. The nitroglycerin tablet would not be helpful, and the oxygenation status is a bigger problem than the slight chest pain at this time.)

The nurse notes that a preoperative patient is drowsy but oriented in the receiving area. To identify the patient, the nurse should a. ask family members to verify the patient's identity, the surgeon, and the planned operative procedure and location. b. check the patient's hospital ID number with the ID band and patient chart. c. ask the surgeon to identify the patient and the planned surgical procedure. d. have the patient state name, doctor's name, and the operative procedure planned in addition to checking the hospital number, ID band, and chart.

d. have the patient state name, doctor's name, and the operative procedure planned in addition to checking the hospital number, ID band, and chart. (For an alert patient, correct procedure includes having the patient give this information as well as checking the ID band, chart, and hospital number. Family members are not responsible for giving accurate information about the patient. The nurse will check the patient's identification and chart, and the surgeon may also be asked to identify the patient, but these are not considered sufficient to identify a patient accurately.)

Which nurse is responsible for preparing the room with the patient and advocating for them throughout the experience?

peri-op nurse

What nurse is sterile in the operating room?

scrub nurse

The nurse administered midazolam to a patient during a colonoscopy. What nursing action is appropriate if the patient's respiratory rate changes from 14 breaths/min to 3 breaths/min? a. Administer flumazenil b. Give a dose of naloxone. c. Initiate oxygen at 4 L/min per nasal cannula. d. Reposition the patient with the head of bed up.

Administer flumazenil (Midazolam is a benzodiazepine administered during monitored anesthesia care to patients having procedures such as a colonoscopy. The nurse should monitor the level of consciousness and assess for respiratory depression, hypotension, and tachycardia. To reverse severe benzodiazepine-induced respiratory depression, the nurse would administer flumazenil. Naloxone would reverse opioid-induced respiratory depression. Oxygen should be initiated based on pulse oximetry but at a higher concentration than what is provided with a nasal cannula at 4 L/min. The patient with severe respiratory depression should receive 100% oxygen with a non-rebreather mask. Repositioning the patient will not reverse the effects of sedation and may interfere with the procedure in progress.)

A patient had surgery at an ambulatory surgery center. Which criteria support that this patient is ready for discharge (select all that apply.)? Select all that apply. a. Vital signs baseline or stable b. Minimal nausea and vomiting c. Wants to go to the bathroom at home d. Responsible adult taking patient home e. Comfortable after IV opioid 15 minutes ago

a, b, d (Ambulatory surgery discharge criteria includes meeting phase I PACU discharge criteria that includes vital signs baseline or stable and minimal nausea and vomiting. Phase II criteria include a responsible adult driving patient, no IV opioid drugs for the past 30 minutes, able to void, able to ambulate if not contraindicated, and received written discharge instruction with patient understanding confirmed.)

The PACU nurse has received a patient, and all the following assessments are included in the initial assessment. In which order should the nurse perform the following actions for the patient with no complications? A. surgical site B. neuro C. circulation D. Output E. airway F. GI G. breathing

E, G, C, B, D, A, F (The airway, breathing, and circulation are evaluated first with vital signs, ECG, and other noninvasive methods. In a patient not experiencing surgical complications, initial neurologic assessment will next focus on level of consciousness, orientation, sensory (touch, temp, pain) and motor status, and reactivity of pupils. Then output of urine and blood or wound drainage lost during surgery will be assessed for balance with the IV and irrigation input. The surgical site will next be assessed. The gastrointestinal system's bowel tones will be assessed last if there is no nausea and vomiting.)

a surgical nurse enters a surgical suite to ensure surgical asepsis is maintained. which of the following requires intervention by the nurse? a. the scrub technologist is wearing a watch under his scrubs b. the circulating nurse opens dressing packages before applying sterile gloves c. the surgeon has her hands folded 2 inches above her waist d. the holding area nurse is performing client educaiton

a. the scrub technologist is wearing a watch under his scrubs (finger and wrist jewelry are likely contaminated with microorganisms and bacteria)

A nurse is assessing a client who is 2 hours postop following an appendectomy. Which of the following findings should the nurse report to the provider? a. urine output of 20 mL/hr b. temperature of 97.9 c. a 2 cm x 2 cm area of bloody drainage on the dressing d. WBC 9,000 mm

a. urine output of 20 mL/hr (The nurse should notify the provider if the client's urine output is less than 30 mL/hr. Decreased output can indicate hypovolemia and decreased perfusion of the kidneys.)

A nurse is caring for a client who is preoperative and is asking multiple questions about the risks of the procedure. Which of the following actions should the nurse take? a. explain the risks and benefits of the surgery to the client b. Ask the surgeon to speak to the client for verification c. reassure the client that the procedure is necessary for recovery d. notify the circulating nurse that the client has questions about the procedure

b. ask the surgeon to speak to the client for clarification (It is the responsibility of the surgeon to explain the risks and benefits of the surgery.)

An older adult patient is being prepared for surgery. What assessment data needs to be included for this patient (select all that apply.)? Select all that apply. a. Fluid balance history b. Attitude about surgery c. Foods the patient dislikes d. Current mobility problems e. Current cognitive function f. Patient's opinion about the surgeon

a, d, e, (Preoperative fluid balance history is especially critical for older adults because they have reduced adaptive capacity that puts them at greater risk for over- and underhydration. Mobility problems must be assessed to assist with intraoperative and postoperative positioning and ambulation. Preoperative assessment of the older person's baseline cognition function is especially crucial for intraoperative and postoperative evaluation because they are more prone to adverse outcomes during and after surgery from the stressors of the surgery, dehydration, hypothermia, and anesthesia. Attitude about surgery and opinion or faith in the surgeon are important for all patients. Foods the patient dislikes are not important unless the patient is allergic to them, but this is no more important for older patients than it is for all patients.)

A circulating nurse is monitoring the temperature in a surgical suite. The nurse should identify that cool temperatures reduce a client's risk for which of the following potential complications of surgery? a. malignant hyperthermia b. blood clots c. infection d. hypoxia

c. infection (The nurse should identify that a cool room temperature with humidity between 30% and 60%, along with a proper air exchange and filtering system, reduces the risk of infection for clients during surgery.)

A nurse is caring for an unconscious patient who has just been admitted to the postanesthesia care unit after abdominal hysterectomy. How should the nurse position the patient? a. Left lateral position with head supported on a pillow b. Prone position with a pillow supporting the abdomen c. Supine position with head of bed elevated 30 degrees d. Semi-Fowler's position with the head turned to the right

a. Left lateral position with head supported on a pillow (An unconscious patient should be placed in the lateral "recovery" position to keep the airway open and reduce the risk of aspiration. When conscious, the patient is usually returned to a supine position with the head of the bed elevated to maximize expansion of the thorax by decreasing the pressure of the abdominal contents on the diaphragm.)

A patient with a recent diagnosis of prostate cancer is scheduled for a radical prostatectomy. Before signing the consent, the patient tells the nurse, "I am not sure if this surgery is safe." Which response by the nurse is the most appropriate? a. "Tell me what you know about your surgery and the risks involved." b. "Any surgery has risks, but we will be here to take good care of you." c. "You seem anxious. After you sign the consent, I can give you a sedative." d. "You do not need to be concerned. Your surgeon has not had any complaints."

a. "Tell me what you know about your surgery and the risks involved." (The health care provider performing the surgery is responsible for obtaining the patient's consent. The nurse may witness the patient's signature on the consent form. As a patient advocate, the nurse should verify that the patient understands the surgery and the risks involved. If the nurse determines that the patient is unclear about operative plans, the nurse should contact the health care provider about the patient's need for more information. The other options provide false reassurance or do not respond to the patient's concern.)

The circulating nurse is caring for a patient during a colon resection. What observation made by the nurse is immediately recognized as a violation of aseptic technique? a. A glove contacts the leg of the table that supports the sterile field. b. The cuff of the scrub nurse's sterile gown contacts the sterile field. c. The sterile field was established at 0650, and the current time is 0900. d. Bacteria are present in the nares and upper respiratory passages of the nurse.

a. A glove contacts the leg of the table that supports the sterile field. (Tables are sterile only at tabletop level. Areas below this are considered contaminated. The sterile gown below the point 2 inches above the elbow is considered sterile. The passage of time in and of itself does not necessarily render a field contaminated. Bacteria are inevitable in the respiratory passages of team members, but they present a threat to sterility only if they are not confined by attire.)

In planning postoperative interventions to promote repositioning, ambulation, coughing, and deep breathing, which action should the nurse recognize will best enable the patient to achieve the desired outcomes? a. Administering adequate analgesics to promote relief or control of pain b. Asking the patient to demonstrate the postoperative exercises every 1 hour c. Giving the patient positive feedback when the activities are performed correctly d. Warning the patient about possible complications if the activities are not perform

a. Administering adequate analgesics to promote relief or control of pain (Even when a patient understands the importance of postoperative activities and demonstrates them correctly, it is unlikely that the best outcome will occur unless the patient has sufficient pain relief to cooperate with the activities.)

A postoperative patient has a bronchial obstruction resulting from retained secretions and an oxygen saturation of 87%. What condition does the nurse suspect is occurring? a. Atelectasis b. Bronchospasm c. Hypoventilation d. Pulmonary embolism

a. Atelectasis (The most common cause of postoperative hypoxemia is atelectasis, which may be the result of bronchial obstruction caused by retained secretions or decreased respiratory excursion. Bronchospasm involves the closure of small airways by increased muscle tone, whereas hypoventilation is marked by an inadequate respiratory rate or depth. Pulmonary emboli do not involve blockage by retained secretions.)

The nurse is providing discharge teaching to a patient who has had a laparoscopic cholecystectomy at an ambulatory surgery center. Which statement, if made by the patient, indicates an understanding of the discharge instructions? a. "I will have someone stay with me for 24 hours in case I feel dizzy." b. "I should wait for the pain to be severe before taking the medication." c. "Because I did not have general anesthesia, I will be able to drive home." d. "It is expected after this surgery to have a temperature up to 102.4º F."

a. I will have someone stay with me for 24 hours in case I feel dizzy." (The nurse must assess understanding of discharge instructions and the ability of the patient and caregiver to provide for home care needs. A responsible adult caregiver must accompany the patient. The patient may not drive after receiving anesthetics or sedatives. The patient should understand how to manage pain, and pain medication should be taken before the pain becomes severe. The patient should understand symptoms to be reported, such as a fever.)

The patient is having a mole removed that has changed appearance. What does the nurse teach the patient about the rationale for this surgical procedure? a. It is to prevent malignancy. b. It is to alleviate symptoms. c. It is to cure the malignancy. d. It is to provide cosmetic improvement.

a. It is to prevent malignancy. (Removing a mole that is changing is to prevent as well as diagnose malignancy. There are no symptoms to alleviate mentioned or cosmetic problems for this patient.)

The perioperative nurse would recognize the need to monitor the patient for hallucinations and agitation when which anesthetic agent is administered? a. Ketamine b. Halothane c. Thiopental d. Nitrous oxide

a. Ketamine (A disadvantage of ketamine is the associated risk of agitation, hallucinations, and nightmares. Ketamine is considered dissociative anesthesia. These unwanted effects are not associated with the use of thiopental, halothane, or nitrous oxide.)

A nurse is caring for a client who is 12 hour postop from a gastrectomy and has an NG tube set to continuous low suction. Which of the following findings requires intervention by the nurse? a. gastric distention b. absent bowel sounds c. urine output of 150 mL over the last 4 hours d. yellow drainage in the NG tube

a. gastric distention (Gastric distention is an indication that the NG tube is not patent. The nurse should check the tubing for kinks, blockages, and loose connections. The nurse should also reposition the client to facilitate drainage. The nurse should avoid removing or irrigating the tube unless directed to do so by the surgeon.)

A surgical patient's premedication regimen includes midazolam. What are the most likely desired effects of this medication that the nurse should recognize? a. Monitored anesthesia care and amnesia b. Potentiates volatile agents to speed induction c. Analgesia and prevention of intraoperative vomiting d. Relaxation of skeletal muscles and facilitation of endotracheal intubation

a. Monitored anesthesia care and amnesia (Midazolam is a benzodiazepine that is widely used for its ability to induce amnesia and provide moderate sedation (conscious sedation). Nitrous oxide is a gaseous agent that potentiates volatile agents to speed induction and reduce total dosage and side effects. Antiemetics prevent intraoperative vomiting. Neuromuscular blocking agents facilitate endotracheal intubation.)

Five minutes after receiving a preoperative sedative medication by IV injection, a patient asks to get up to go to the bathroom to urinate. What is the most appropriate action for the nurse to take? a. Offer the patient to use a urinal or bedpan after explaining the need to maintain safety. b. Assist the patient to the bathroom and stay next to the door to assist patient back to bed when done. c. Allow the patient to go to the bathroom since the onset of the medication will be more than 5 minutes. d. Ask the patient to hold the urine for a short period since a urinary catheter will be placed in the operating room.

a. Offer the patient to use a urinal or bedpan after explaining the need to maintain safety. (The prime issue after administration of either sedative or opioid analgesic medications is safety. Because the medications affect the central nervous system, the patient is at risk for falls and should not be allowed out of bed, even with assistance. The other options would not be safe for the patient.)

The nurse observes a patient experiencing chills related to an infection. What is the priority action by the nurse? a. Provide a light blanket. b. Encourage a hot shower. c. Monitor temperature every hour. d. Turn up the thermostat in the patient's room.

a. Provide a light blanket. (Chills often occur in cycles and last for 10 to 30 minutes at a time. They usually signal the onset of a rise in temperature. For this reason, the nurse should provide a light blanket for comfort but avoid overheating the patient.)

A nurse is receiving evening shift report on four clients who returned from the PACU that morning. The nurse should assess which of the following clients first? a. a client who is postop following a thoracotomy and has a chest tube with 150 mL of bright-red blood in the collection chamber from the past 1 hour b. a client who is postop following a small bowel resection and has a temporary colostomy along with absent bowel sounds in all four quadrants c. a client who is postop following a tonsillectomy and has had one episode of coffee-ground emesis d. a client who is postop following a total knee arthroplasty and is reporting a knee pain level of 7 on a scale from 0-10

a. a client who is postop following a thoracotomy and has a chest tube with 150 mL of bright-red blood in the collection chamber from the past 1 hour

A nurse is monitoring a client who received succinylcholine during a surgical procedure. Which of the following actions should the nurse take if the client develops manifestations of malignant hyperthermia? a. administer dantrolene b. institute seizure precautions c. remove ET tube d. give IV atropine

a. administer dantrolene (The nurse should administer dantrolene by IV bolus at 2 to 5 mg/kg to reverse the manifestations for a client who has malignant hyperthermia. Seizures are not a manifestation of malignant hyperthermia. A client who has malignant hyperthermia should have the endotracheal tube maintained for airway management during the crisis. A client who has malignant hyperthermia should manifest tachycardia. Therefore, administering atropine is not recommended because tachycardia is an adverse effect of atropine.)

An alert patient does not want to have a tracheostomy inserted because of extended endotracheal intubation, although family members state that they want it done. What is the best action for the nurse to take? a. Advocate for the patient's rights. b. Try to change the patient's mind. c. Call surgery to cancel the procedure. d. Tell the family they cannot interfere.

a. advocate for the patient's rights (The nurse must act as the patient's advocate and assist the patient with fulfilling his wishes. However, as the patient's advocate, the nurse must be sure he knows the risks and benefits of refusing a tracheostomy. Trying to change the patient's mind is unethical because it is contrary to acting as an advocate. As long as the patient is lucid, he retains the right of self-determination. Canceling the procedure is not indicated until discussion with the patient and surgeon has occurred. Telling the family they cannot interfere can aggravate or escalate the situation.)

A nurse is reviewing the medication administration record for a client who is scheduled for surgery the next day. The nurse should identify that which of the following medications places the client at risk for complications during surgery and should be reported to the provider? a. clopidogrel b. atorvastatin c. ranitidine d. alendronate

a. clopidogrel (The nurse should identify that clopidogrel is an oral antiplatelet medication used to prevent coronary artery stenosis and other vascular incidents. Therefore, the mediation should be discontinued 5 days prior to surgery because it acts similarly to aspirin and can cause the client to experience increased bleeding during and after surgery. )

A nurse is reviewing the medical record of a client who is to undergo general anesthesia for surgery. The nurse should report which of the following things to the provider? a. serum potassium 2.8 mEq/L b. serum sodium level 140 mEq/L c. INR 1.5 d. BUN 12 mg/dL

a. serum potassium 2.8 mEq/L (potassium should be 3.5-5; sodium should be 136-145; INR should be 0.7-1.8, and BUN should be 10-20)

A nurse is teaching a patient how to promote healing following abdominal surgery. What should be included in the teaching (select all that apply.)? Select all that apply. a. Take the antibiotic until the wound feels better. b. Take the analgesic every day to promote adequate rest for healing. c. Be sure to wash hands after changing the dressing to avoid infection. d. Take in more fluid, protein, and vitamins C, B, and A to facilitate healing. e. Notify the health care provider of redness, swelling, and increased drainage.

b, c (Fluid is needed to replace fluid from insensible loss and from exudates as well as the increased metabolic rate. Protein corrects the negative nitrogen balance that results from the increased metabolic rate and that needed for synthesis of immune factors and healing. Vitamin C helps synthesize capillaries and collagen. Vitamin B complex facilitates metabolism. Vitamin A aids in epithelialization. The health care provider should be notified if there are signs of infection. If prophylactic antibiotics are prescribed, they must be taken until they are completely gone. Initially analgesics are taken throughout the day (e.g., every 3 to 4 hours) as needed. Infection must be avoided with aseptic procedures, including washing the hands before changing the dressing.)

Which intraoperative nursing responsibilities should be performed by the scrub nurse (select all that apply.)? Select all that apply. a. Documenting intraoperative care b. Keeping track of irrigation solutions for monitoring of blood loss c. Passing instruments and supplies to the surgeon by anticipating his or her needs d. Coordinating the flow and activities of members of the surgical team in the surgical suite e. Performing the count of sponges, needles, and instruments used during the surgical procedure

b, c, e (Both the scrub nurse and circulating nurse participate in the counting of surgical sponges, needles, and instruments. Passing instruments to the surgeon and other sterile activities are the exclusive responsibility of the scrub nurse. The circulating nurse takes primary responsibility for the coordination of the surgical suite and documentation.)

The nurse is preparing a patient for a surgical procedure. Before admitting the patient into the perioperative suite, what documents must the nurse make sure are in the chart of the patient (select all that apply.)? Select all that apply. a. Electrocardiogram b. Signed consent form c. Functional status evaluation d. Renal and liver function tests e. A history and physical examination report

b, e (The National Patient Safety Goals (NPSG) require documentation of a history and physical, signed consent form, and nursing and preanesthesia assessment in the chart of a patient going for surgery. The physical examination explains in detail the overall status of the patient before surgery for the surgeon and other members of the surgical team.)

A nurse is providing discharge instructions for a client who is postoperative following abdominal surgery. Which of the following client statements indicates an understanding of the teaching? a. "I will have an increase in yellow-colored drainage from my incision for 2 weeks" b. "I will eat foods that are high in protein and vitamin C during my recovery" c. "I should avoid taking OTC pain medication if my pain is not severe d. "I will remain on bed rest until my follow-up appointment with my doctor

b. "I will eat foods that are high in protein and vitamin C during my recovery (which promotes wound healing)

A patient asks a student nurse if his family member may accompany him to the surgical area. What is the best response by the nurse? a. "Your family member may not enter the surgical area" b. "Your family can be with you in the preoperative holding area. c. "Your family can't be with you until the postanesthesia care unit. d. "Your family is only allowed in the conference room for preoperative teaching."

b. "Your family can be with you in the preoperative holding area. (The perioperative nurse should explain to the student nurse that the family can be in the preoperative holding area before the patient goes to surgery, but this includes talking to the nurse at the nursing station. They are also taken to the conference room for preoperative and postoperative meetings with staff, including teaching.)

A nurse is providing preop teaching for a client who is about to have a below-the-knee amputation. Which of the following instructions should the nurse include? a. "You should avoid lying on your abdomen after surgery." b. "Your surgeon might prescribe an antibiotic before surgery." c. "It is important for you to sit in a chair at the bedside for several hours every day to reduce the risk of pneumonia." d. "To promote wound healing, it is important for you to reduce your intake of carbohydrates once you return home."

b. "Your surgeon might prescribe an antibiotic before surgery." (A client who has a surgical amputation of an extremity is at risk for infection. Therefore, the provider often prescribes a broad-spectrum, prophylactic antibiotic to reduce the risk of infection.)

A nurse is providing teaching for a client who is in the immediate postoperative period and has a PCA pump. Which of the following statement should the nurse include in the teaching? a. "you will receive a dose of medication every time you push the button." b. "do not allow your family to push the PCA button if you're sleeping." c. "You cannot receive too much medication by pushing the button." d. "do not push the PCA button until your pain reaches a severe level."

b. "do not allow your family to push the PCA button if you are sleeping." (The nurse should instruct the client that she should be awake when receiving a dose of the medication and that she is the only authorized user of the PCA pump. Therefore, allowing a family member to push the button is unauthorized and a safety risk for the client. Clients have different tolerance levels for opioid analgesics. Therefore, the nurse should instruct the client to report nausea, dizziness, and other adverse effects indicating excessive sedation. Opioid analgesia places the client at risk for respiratory depression. Therefore, the nurse should monitor the client closely for indications of sedation and respiratory depression.)

The nurse is providing preoperative teaching to a group of patients. To which patient should the nurse plan to teach coughing and deep breathing exercises? a. A 20-yr-old man who is scheduled for a tonsillectomy b. A 40-yr-old woman who is scheduled for an open cholecystectomy c. A 30-yr-old woman who is scheduled for a transsphenoidal hypophysectomy d. A 50-yr-old man who is scheduled for an evacuation of a subdural hematoma

b. A 40-yr-old woman who is scheduled for an open cholecystectomy (Patients with abdominal surgeries should be taught how to cough and deep breathe to prevent pulmonary complications such as atelectasis and pneumonia. Coughing and deep breathing is contraindicated in cranial surgeries (e.g., subdural hematoma evacuation or transsphenoidal hypophysectomy) and tonsillectomies.)

Which preoperative patient has the greatest risk of bleeding as a result of prescribed medication? a. A woman who takes metoprolol for the treatment of hypertension b. A man who is taking clopidogrel after the placement of a coronary artery stent c. A man whose type 1 diabetes is controlled with insulin injections four times daily d. A man who recently started taking finasteride for the treatment of benign prostatic hyperplasia

b. A man who is taking clopidogrel after the placement of a coronary artery stent (Any drug that inhibits platelet aggregation, such as clopidogrel, represents a bleeding risk. Insulin, metoprolol, and finasteride are less likely to contribute to a risk for bleeding.)

The nurse is working on a surgical floor and is preparing to receive a postoperative patient from the postanesthesia care unit (PACU). What should the nurse's initial action be upon the patient's arrival? a. Assess the patient's pain. b. Assess the patient's vital signs. c. Check the rate of the IV infusion. d. Check the physician's postoperative orders.

b. Assess the patient's vital signs. (The highest priority action by the nurse is to assess the physiologic stability of the patient. This is accomplished in part by taking the patient's vital signs. The other actions can then take place in rapid sequence.)

A postoperative patient is now able to eat and is requesting a snack. What snack should the nurse recommend for the patient that will facilitate wound healing? a. Apple b. Custard c. Popsicle d. Potato chips

b. Custard (Custard would be the best snack because it is made from milk, egg, sugar, and vanilla. Wound healing is facilitated by protein, carbohydrates, and B vitamins. Custard also contains calcium and a small amount of vitamin A and zinc. The other snacks do not offer this abundance of healing nutrients. Orange juice with the custard would be good to provide the vitamin C and fluid that are also needed for healing.)

Lorazepam (Ativan) 1 mg IV is ordered for a patient before surgery. What is the most appropriate action for the nurse to take before the administration of this medication? a. Ask the patient about an allergy to iodine or shellfish. b. Encourage or assist the patient to the bathroom to void. c. Explain that the medication is used to prevent postoperative nausea. d. Check the laboratory results for the most recent serum potassium level.

b. Encourage or assist the patient to the bathroom to void. (The nurse should instruct the patient to void before administering preoperative medications that may interfere with balance and increase the fall risk when ambulating to the bathroom. Lorazepam is a benzodiazepine that may be used for sedation and amnesia before surgery. Lorazepam does not affect serum potassium, is not contraindicated in patients with allergies to iodine or shellfish, and is not indicated to prevent or treat nausea)

A patient having abdominal surgery had an estimated blood loss of 400 mL and received 300 mL of 0.9% normal saline. Postoperatively, the patient's blood pressure is 70/48 mm Hg. What treatment does the nurse anticipate administering? a. Blood administration b. IV fluid administration c. An ECG to check circulatory status d. Return to surgery to check for internal bleeding

b. IV fluid administration (The nurse should anticipate restoring circulating volume with IV infusion. Although blood could be used to restore circulating volume, there are no manifestations in this patient indicating a need for blood administration. An ECG may be done if there is no response to the fluid administration, there is a past history of cardiac disease, or cardiac problems were noted during surgery. Returning to surgery to check for internal bleeding would only be done if patient's level of consciousness changes or the abdomen becomes firm and distended.)

The nurse is admitting a patient to the same-day surgery unit and the patient informs the nurse they took kava last evening to sleep. Which nursing action would be most appropriate? a. Tell the patient that using kava to help sleep is often helpful. b. Inform the anesthesiologist of the patient's recent use of kava. c. Tell the patient that the kava should continue to help him relax before surgery. d. Inform the patient about the dangers of taking herbal medicines without consulting his

b. Inform the anesthesiologist of the patient's recent use of kava. (Kava may prolong the effects of certain anesthetics. Thus, the anesthesiologist needs to be informed of recent ingestion of this herbal supplement. Patients should not take anything before surgery without the health care provider's knowledge.)

The nurse is circulating for a surgical procedure. What clinical manifestation would indicate to the nurse that the patient may be experiencing malignant hyperthermia? a. Hypocapnia b. Muscle rigidity c. Decreased body temperature d. Confusion upon arousal from anesthesia

b. Muscle rigidity (Malignant hyperthermia is a metabolic disease characterized by hyperthermia with rigidity of skeletal muscles from altered control of intracellular calcium occurring as a result of exposure to certain anesthetic agents in susceptible patients. Hypoxemia, hypercapnia, and ventricular dysrhythmias may also be seen with this disorder.)

A patient informs the nurse prior to the surgical procedure that she is so nervous about the procedure and had to take a Xanax last night, but it did not relieve the anxiety. What is the priority action by the nurse? a. Review the surgery with the patient. b. Notify the anesthesia care provider (ACP). c. Administer another dose of alprazolam (Xanax). d. Tell the patient that everything will be okay with the surgery.

b. Notify the ACP (In determining the psychologic status of the patient, the nurse notes the patient's anxiety. The nurse should notify the ACP after assessing the cause of the anxiety or fear the patient is experiencing. The patient may only need to talk about the surgery related to the situation, concerns with the unknown or body image, or past experiences to relieve the anxiety, but the nurse cannot assume that lack of knowledge is the cause of the anxiety. Medication administration will be prescribed by the ACP if needed, but medications can also be administered during surgery. Reassuring the patient is not taking the patient's needs into account.)

A patient had abdominal surgery last week and returns to the clinic for follow-up. The nurse assesses thick, white, malodorous drainage. How should the nurse document this drainage? a. Serous b. Purulent c. Fibrinous d. Catarrhal

b. Purulent (Purulent drainage consists of white blood cells, microorganisms, and other debris that signal an infection. Serous drainage is a thin, watery, clear or yellowish drainage frequently seen with broken blisters. Fibrinous drainage occurs with fibrinogen leakage and is thick and sticky. Catarrhal drainage occurs when there are cells that produce mucus associated with the inflammatory response.)

A nurse is creating a plan of care for a client who is preop for a total hip arthroplasty, practices Judaism, and adheres to a kosher diet. Which of the following interventions is the nurse's priority? a. listen and allow the client to express feelings about the surgery b. determine if the client's faith conflicts with the treatment plan c. ensure the client's meal plan serves only kosher food following surgery d. teach the client how to perform various relaxation exercises

b. determine if the client's faith conflicts with the treatment plan (The nurse's priority intervention when using the nursing process is assessment. By determining if the client's faith, religious practices, or views conflict with the current treatment plan or surgical procedure, the nurse can take the necessary steps to inform the provider and prevent an issue during or after the surgical procedure.)

A nurse is assessing a client who is 2 days postop following a total prostatectomy. The nurse notes that the client's right calf is red, edematous, and warm to the touch. Which of the following actions should the nurse take? a. apply an ice pack to the client's right calf b. elevate the client's right extremity c. administer testosterone to the client d. gently massage the client's right calf

b. elevate the client's right extremity (These findings suggest the client has deep-vein thrombosis. The nurse should keep the client's right extremity elevated to promote venous return.)

A nurse is caring for a client who is 2 days postop following a cholecystectomy. The client has been vomiting for the past 24 hours and reports a pain level of 8/10. The nurse notes a hard, distended abdomen and absent bowel sounds. After conferring with the provider, which of the following actions should the nurse take first? a. draw the client's blood for electrolytes b. insert an NG tube c. administer pain medication d. initiate intake and output

b. insert an NG tube (The greatest risk to the client is fluid and electrolyte imbalance as a result of accumulated fluid and gas in the gastrointestinal tract. The first action the nurse should take is to insert an NG tube to begin decompression of the bowel.)

A patient is ordered to receive acetaminophen 650 mg per rectum every 6 hours as needed for fever greater than 102°F. Which parameter would the nurse monitor, other than temperature, if the patient requires this medication? a. Pain level b. Intake and output c. Oxygen saturation d. Level of consciousness

b. intake and output (Because fever can lead to excessive perspiration and evaporation of body fluid via the skin, the nurse should monitor the patient's overall intake and output to be sure that the patient remains in proper fluid balance. Pain, oxygen saturation, and level of consciousness will also be monitored as with all patients, but intake and output are the priority for this patient.)

The nurse is positioning a patient after a surgical procedure. What is the best position unless contraindicated, for this patient to be placed in to prevent respiratory complications? a. Supine b. Lateral c. Semi-Fowler's d. High-Fowler's

b. lateral (Unless contraindicated by the surgical procedure, an unconscious patient is positioned in a lateral "recovery" position. This recovery position keeps the airway open and reduces the risk of aspiration if the patient vomits. Once conscious, the patient is usually returned to a supine position with the head of the bed elevated)

A nurse is assessing a client who is preoperative. The nurse should identify that which of the following factors reported by the client increases the risk for a postoperative wound infection? a. frequent use of echinacea b. long-term use of corticosteroids c. history of osteoporosis d. diet high in vitamin C

b. long term use of corticosteroids

A nurse is caring for a client who has a surgical wound with a Penrose drain in place. Which of the following interventions should the nurse plan to perform? a. cut a slit in a 4-inch gauze pad to place around the drain b. use sterile technique when performing dressing changes c. establish a clamping schedule prior to removal d. apply negative pressure when emptying the drain

b. use the sterile technique when performing dressing changes (The nurse should change the Penrose drain dressing using the surgical aseptic technique. A drain sponge should be used around a Penrose drain. A gauze pad should never be cut and used around a drain due to the risk of dressing fibers becoming embedded in the wound. Establish a clamping schedule prior to removal. Clamping a Penrose drain can lead to infection. A Penrose drain is an open system and drains by gravity.)

A nurse is providing discharge teaching for a client who is postoperative following a rhinoplasty using general anesthesia. Which of the following instruction should the nurse include. a. "Lie on your side when resting for the first week after surgery." b. "Limit intake to clear liquids for the first 24 hours after surgery." c. "Use cool compresses on your eyes, nose, and face." d. "Close your mouth when you are about to sneeze."

c. "Use cool compresses on your eyes, nose, and face." (Cool compresses on his face can reduce swelling and ecchymosis)

A nurse in the PACU is assessing a client who is postop. Which of the following findings should the nurse report to the provider? a. blood pressure 10% lower than the baseline b. pain level of 4 on a 0-10 scale c. presence of inspiratory stridor d. small amount of sanguinous drainage on dressing

c. presence of inspiratory stridor (The nurse should report inspiratory stridor to the provider because it is a manifestation of tracheal edema and requires intervention.)

A nurse is assessing the client's recovery from spinal anesthesia. Which of the following sensations should the nurse expect to return to the client first? a. pain b. cold c. touch d. warmth

c. touch (first touch, then pain, then warmth, then cold)

The perioperative nurse is reviewing the chart of a patient who is being admitted into the operating room for a laminectomy. What information obtained from the chart review should the nurse discuss with the anesthesiologist? a. The patient's grandmother developed hypothermia during a craniotomy. b. The patient's mother developed contact dermatitis related to a latex allergy. c. The patient's brother developed nausea after surgery with general anesthesia. d. The patient's father developed an elevated temperature during a recent surgery.

c. After a surgical scrub, the surgical technologist puts on a sterile gown and one pair of sterile gloves. (After a surgical hand scrub is completed, the surgical technologist should put on a sterile surgical gown and two pairs of gloves to prevent the transmission of microorganisms. Surgical hand antisepsis is completed by scrubbing fingers and hands first followed by progression to forearms and elbows. The hands should be held away from surgical attire and higher than the elbows at all times to prevent contamination. After performing a surgical hand scrub and applying a sterile gown and two pairs of sterile gloves, the person may manipulate and organize all sterile items for use during the procedure.)

The unlicensed assistive personnel (UAP) is assisting the patient with Crohn's disease with perineal care. The UAP tells the nurse that the patient had feces coming from the vagina. What is the priority action by the nurse? a. Notify the health care provider. b. Document the fistula formation. c. Assess the patient and vaginal drainage. d. Have the UAP apply a dressing to the vagina.

c. Assess the patient and vaginal drainage. (With Crohn's disease, a fistula may have formed between the bowel and the vagina. The nurse should first assess the patient and drainage from the vagina. Then the nurse should notify the health care provider, document the occurrence and care provided, describe interventions prescribed, and document the care and patient response.)

When assessing a patient's surgical dressing on the first postoperative day, the nurse notes new, bright-red drainage about 5 cm in diameter. What is the priority action by the nurse? a. Recheck in 1 hour for increased drainage. b. Notify the surgeon of a potential hemorrhage. c. Assess the patient's blood pressure and heart rate. d. Remove the dressing and assess the surgical incision.

c. Assess the patient's blood pressure and heart rate. (The first action by the nurse is to gather additional assessment data to form a more complete clinical picture. The nurse can then report all of the findings. Continued reassessment will be done. Agency policy determines whether the nurse may change the dressing for the first time or simply reinforce it.)

In caring for the postoperative patient on the clinical unit after transfer from the PACU, which care can the nurse delegate to the unlicensed assistive personnel (UAP)? a. Monitor the patient's pain. b. Do the admission vital signs. c. Assist the patient to take deep breaths and cough. d. Change the dressing when there is excess drainage.

c. Assist the patient to take deep breaths and cough. (The UAP can encourage and assist the patient to do deep breathing and coughing exercises and report complaints of pain to the nurse caring for the patient. The RN should do the admission vital signs for the patient transferring to the clinical unit from the PACU. The LPN or RN will monitor and treat the patient's pain and change the dressings.)

When reviewing the preoperative forms, the nurse notices that the informed consent form is not present or signed. What is the best action for the nurse to take? a. Have the patient sign the consent form. b. Have the family sign the form for the patient. c. Call the surgeon to obtain consent for surgery. d. Teach the patient about the surgery and get verbal permission.

c. Call the surgeon to obtain consent for surgery. (The informed consent for the surgery must be obtained by the physician. The nurse can witness the signature on the consent form and verify that the patient (or caregiver if patient is a minor, unconscious, or mentally incompetent to sign) understands the informed consent. Verbal consents are not enough. The state's nurse practice act and agency policies must be followed.)

The nurse is doing a preoperative assessment on a male patient who has type 2 diabetes mellitus; weighs 146 kg; and is 5 feet 8, inches tall. Which patient assessment is a priority related to anesthesia? a. Has hemoglobin A1C of 8.5% b. Has several seasonal allergies c. Has a body mass index of 48.8 kg/m2 d. Has a history of postoperative vomiting

c. Has a body mass index of 48.8 kg/m2 (The patient's body mass index is the priority because it indicates the patient is severely obese. The patient's size may impair the anesthesiologist's ability to ventilate and medicate the patient properly, as well as the surgery room staff's ability to position the patient safely. The other factors are not the priority.)

A nurse is assigned to provide preoperative teaching to a patient scheduled for coronary artery bypass surgery who only speaks Spanish. What is the best method for the nurse to teach the patient how to use an incentive spirometer? a. Give the patient a pamphlet written in Spanish with directions on the use of the incentive spirometer. b. Ask another Spanish-speaking patient in the preoperative area to translate as the nurse describes the procedure. c. Have the hospital interpreter available while the nurse demonstrates the procedure and the patient returns the demonstration. d. Notify the postoperative unit to have a Spanish-speaking nurse provide teaching on the incentive spirometer after surgery.

c. Have the hospital interpreter available while the nurse demonstrates the procedure and the patient returns the demonstration. (If the patient does not speak English, it is essential that the services of a competent interpreter be obtained. Hospitals are required to provide interpreters for common languages other than English. Demonstration and return demonstration is the most effective teaching method for use of equipment such as the incentive spirometer and should be done in the preoperative period if possible)

An older adult patient has been admitted before having surgery for a bilateral mastectomy and breast reconstruction. What should the nurse include in the patient's preoperative teaching (select all that apply.)? Select all that apply. a. Information about various options for reconstructive surgery b. Information about the risks and benefits of her particular surgery c. Information about risk factors for breast cancer and the role of screening d. Information about where in the hospital she will be taken postoperatively e. Information about performing postoperative deep-breathing and coughing exercises

d, e (During preoperative teaching, it is important to introduce the role of deep-breathing and coughing exercises and to inform the patient about the different locations involved in her hospital stay. The specific risks and benefits of her surgery and reconstruction options should be addressed by her surgeon. Teaching about breast cancer screening would be inappropriate, and likely insensitive, at this point in her disease trajectory.)

The nurse is caring for a Native American patient 2 days after a thoracotomy for tumor resection. What would be the most appropriate action if the patient does not report any pain? a. Contact the health care provider. b. Identify possible reasons for denial of pain. c. Administer the prescribed pain medication. d. Assess the renal and liver function test results.

c. Identify possible reasons for denial of pain. (Encourage older adults to report pain, especially those who are reluctant to discuss pain or deny pain when it is likely present, such as after surgery. Older patients may be hesitant to request pain medication, believe pain is an inevitable consequence of surgery, and may not understand how to use patient-controlled machines. Some cultures discourage the expression of pain. The nurse should encourage the use of analgesics, explaining to the patient that untreated pain has a negative effect on recovery. Assessment of pain and administration of medications are within the scope of practice of a nurse. An older patient may have decreased renal and liver function that may lead to drug toxicity. However, this would not be a reason for denial of pain. Administration of pain medication must be based on the patient assessment.)

A patient is admitted to the postanesthesia care unit (PACU) after abdominal surgery. Which assessment, if made by the nurse, is the best indicator of respiratory depression? a. Increased respiratory rate b. Decreased oxygen saturation c. Increased carbon dioxide pressure d. Frequent premature ventricular contractions (PVCs)

c. Increased carbon dioxide pressure (Transcutaneous carbon dioxide pressure (PtcCO2) monitoring is a sensitive indicator of respiratory depression. Increased CO2 pressures would indicate respiratory depression. Clinical manifestations of inadequate oxygenation include increased respiratory rate, dysrhythmias (e.g., premature ventricular contractions), and decreased oxygen saturation.)

A patient arrives in the emergency department reporting fever for 24 hours and lower right quadrant abdominal pain. After laboratory studies are performed, what does the nurse determine indicates the patient has a bacterial infection? a. Increased platelet count b. Increased blood urea nitrogen c. Increased number of band neutrophils d. Increased number of segmented myelocytes

c. Increased number of band neutrophils (The finding of an increased number of band neutrophils in circulation is called a shift to the left, which is commonly found in patients with acute bacterial infections. Platelets increase with tissue damage through the inflammatory process and for healing but are not the best indicator of infection. Blood urea nitrogen is unrelated to infection unless it is in the kidney. Myelocytes increase with infection and mature to form band neutrophils, but they are not segmented. The mature neutrophils are segmented.)

The nurse is caring for a preoperative patient who has an order for vitamin K by subcutaneous injection. The nurse should verify that which laboratory study is abnormal before administering the dose? a. Hematocrit (Hct) b. Hemoglobin (Hgb) c. Prothrombin time (PT) d. Partial thromboplastin time (PTT)

c. Prothrombin time (PT) (Vitamin K counteracts hypoprothrombinemia and/or reverses the effects of warfarin (Coumadin) and thus decreases the risk of bleeding. High values for either the PT or the international normalized ratio demonstrate the need for this medication.)

A patient with pneumonia has a fever of 103°F. What nursing actions will assist in managing the patient's febrile state? a. Administer aspirin on a scheduled basis around the clock. b. Provide acetaminophen every 4 hours to maintain consistent blood levels. c. Administer acetaminophen when the patient's oral temperature exceeds 103.5°F. d. Provide drug interventions if complementary and alternative therapies have failed.

c. Provide acetaminophen every 4 hours to maintain consistent blood levels. (Antipyretics should be given around the clock to prevent acute swings in temperature. ASA would not be the drug of choice because of its antiplatelet action and accompanying risk of bleeding. When treating fever, drug interventions are not normally withheld in lieu of complementary therapies.)

The nurse is performing a preoperative assessment for a patient scheduled for a surgical procedure. What is the rationale for the nurse's careful documentation of the patient's current medication list? a. Some medications may alter the patient's perceptions about surgery. b. Many anesthetics alter renal and hepatic function, causing toxicity of other drugs. c. Some medications may interact with anesthetics, altering the potency and effect of the drugs. d. Routine medications are withheld the day of surgery, requiring dosage and schedule adjustments after surgery.

c. Some medications may interact with anesthetics, altering the potency and effect of the drugs. (Drug interactions may occur between prescribed medications and anesthetic agents used during surgery. For this reason, it is important to take a careful medication history and check that it has been communicated to the anesthesia care provider. Routine medications may or may not be prescribed for use the day of surgery.)

The nurse in an ambulatory surgery center has administered the following preoperative medications to a patient scheduled for general surgery: diazepam, cefazolin, and famotidine. What mode of transportation to the operating room (OR) would be the most appropriate for the nurse to arrange for this patient? a. Seated in a wheelchair accompanied by a responsible family member b. Ambulatory and accompanied by a hospital escort and a family member c. Stretcher with side rails up and accompanied by OR transportation personnel d. Ambulatory accompanied by an OR staff member or transportation personnel

c. Stretcher with side rails up and accompanied by OR transportation personnel (The patient has received a sedative (diazepam) and should be transported either by stretcher (with side rails raised) or wheelchair and accompanied by either OR staff, OR transport personnel, or the nurse.)

The nurse is providing care to a patient with an open abdominal wound after surgery. What teaching should the nurse provide to the patient regarding the healing process? a. The wound will be stapled together until it heals. b. The healing will contract the area to close the wound. c. The wound will be left open and heal from the edges inward. d. The wound will be sutured after the current infection is controlled.

c. The wound will be left open and heal from the edges inward. (With secondary healing, the wound is left open and heals from the edges inward and from the bottom up. With primary intention, the wound edges are stapled or sutured, and healing occurs until the contraction of the healing area closes the defect and brings the skin edges closer together to form a mature scar. With tertiary healing, the contaminated wound is left open and closed after the infection is controlled.)

When assessing a patient who is receiving cefazolin for the treatment of a bacterial infection, which data suggest that treatment has been effective? a. White blood cell (WBC) count of 8000/ìL; temperature of 101?5? F b. White blood cell (WBC) count of 4000/ìL; temperature of 100?5? F c. White blood cell (WBC) count of 8500/ìL; temperature of 98.4?5? F d. White blood cell (WBC) count of 16,500/ìL; temperature of 98.8?5? F

c. White blood cell (WBC) count of 8500/ìL; temperature of 98.4?5? F (This response is correct because both the WBC count and the temperature are within the normal range. A normal WBC is 4000 to 11,000/ìL. An elevated WBC count and elevated temperature are indicators of infection.)

While performing preoperative teaching, the patient asks when he is no longer able to eat or drink. Based on the most recent practice guidelines established by the American Society of Anesthesiologists, what is the best response by the nurse? a. "Stay NPO after midnight." b. "Maintain NPO status until after breakfast." c. "You may drink clear liquids up to 2 hours before surgery." d. "You may drink clear liquids up until she is moved to the OR."

c. You may drink clear liquids up to 2 hours before surgery." (Practice guidelines for preoperative fasting state the minimum fasting period for clear liquids is 2 hours. Evidence-based practice no longer supports the long-standing practice of requiring patients to be NPO after midnight.)

A nurse is caring for a client who is postop following abdominal surgery. Which of the following nursing interventions should the nurse perform to prevent respiratory complications? a. instruct the client to exhale into the incentive spirometer every 1-2 hours b. minimize the amount of pain medication the client receives to prevent sedation c. advise the client to splint the surgical incision when coughing and deep breathing d. reposition the client every 8 hours for the first 48 hours

c. advise the client to splint the surgical incision when coughing and deep breathing (Splinting the incision supports the surgical site and decreases pain during coughing and deep breathing.)

A nurse is planning care for a client who is postoperative and has a closed-wound drainage system in place. which of the following interventions should the nurse plan include? a. check the patency of the drain every 12 hours b. clamp the drain while the client is ambulating c. cleanse the drain plug with alcohol after emptying d. secure the drain to the client's bed sheet

c. cleanse the drain plug with alcohol after emptying (after emptying the drain, the nurse should use one hand to compress the top and bottom of the device together and the other to cleanse the plug before placing it. Nurse should check amount, color, and type of drainage at least every 8 hours)

A patient requests that the nurse give his hearing aid to a family member so it will not be lost in surgery. What is the appropriate action by the nurse? a. Give the hearing aid to the wife as he wishes. b. Tape the hearing aid to his ear to prevent loss. c. Encourage the patient to wear it for the surgery. d. Tell the surgery nurse that he has his hearing aid out.

c. encourage the patient to wear it for the surgery. (Although jewelry is removed before surgery, hearing aids should be left in place to allow the patient to better follow instructions given in the surgical suite and the postanesthesia care unit (PACU), as well as the dismissal instructions that will be given before he returns home for recovery.)

A nurse is caring for a client who is receiving moderate (conscious) sedation with midazolam. The client's respiratory rate decreases from 16/min to 6/min, and the oxygen saturation decreases from 92% to 85%. Which of the following medications should the nurse administer? a. atropine b. acetylcysteine c. flumazenil d. protamine sulfate

c. flumazenil (The client's respiratory rate and oxygen saturation level indicate increased sedation caused from a benzodiazepine. The nurse should administer flumazenil, a benzodiazepine agonist, to reverse the sedative effects of the medication. Atropine is used for overdose of cholinesterase inhibitors. Acetylcysteine is used for acetaminophen overdose, and protamine sulfate is used to treat heparin overdose.)

The patient donated a kidney, and early ambulation is included in the plan of care, but the patient refuses to get up and walk. What rationale should the nurse explain to the patient for early ambulation? a. "Early walking keeps your legs limber and strong." b. "Early ambulation will help you be ready to go home." c. "Early ambulation will help you get rid of your syncope and pain." d. "Early walking is the best way to prevent postoperative complications."

d. "Early walking is the best way to prevent postoperative complications." (The best rationale is that early ambulation will prevent postoperative complications that can then be discussed. Ambulating increases muscle tone, stimulates circulation that prevents venous stasis and venous thromboembolism, speeds wound healing, and increases vital capacity and maintains normal respiratory function. These things help the patient be ready for discharge, but early ambulation does not eliminate syncope and pain. Pain management should always occur before walking.)

A nurse is providing teaching for a client who is scheduled to undergo moderate sedation for a bronchoscopy. The nurse should verify that the client understands the procedure when the client states the following? a. "I will need a bowel prep the day before the procedure" b. "I will drink plenty of fluids he morning of the procedure c. "I can eat as soon as the procedure is over." d. "I can expect to feel sleepy for several hours after the procedure."

d. "I can expect to feel sleepy for several hours after the procedure."

A nurse is providing preop teaching to a client who is scheduled to have a mastectomy with reconstructive surgery. Which of the following statements by the client indicates an understanding of the teaching? a. "I should wait to take my pain medication until after I have completed my range-of-motion exercises." b. "I should wait a week after surgery to start my hand-strengthening exercises." c. "I will be able to lift up an object that weighs 10 pounds 2 weeks after surgery d. "I Will be able to shower after the doctor removes the drain."

d. "I will be able to shower after the doctor removes the drain." (A client who had a mastectomy with reconstructive surgery can shower after the provider removes the drain.)

While the perioperative nurse is transporting a patient to the operating room for general surgery, the patient states, "I am a Jehovah's Witness, and I am worried about blood transfusions." What would be the best response by the nurse to this patient's statement? a. "I will make sure that you do not receive a blood transfusion during this surgery." b. "Would you like to sign the consent form just in case you need blood during surgery?" c. "Do you have someone I can contact in an emergency if you need a blood transfusion?" d. "Tell me what you would like done if it is determined that you need blood replacement during surgery."

d. "Tell me what you would like done if it is determined that you need blood replacement during surgery." (The perioperative nurse should identify what the patient's concern is related to a blood transfusion. In addition, the nurse should clarify whether the patient wants a blood transfusion. The Jehovah's Witness community member may refuse blood transfusions, but each patient should be consulted to determine an individualized plan related to receiving or refusing blood transfusions.)

Which patient would be at highest risk for hypothermia after surgery? a. A 42-yr-old patient who had a laparoscopic appendectomy b. A 38-yr-old patient who had a lumpectomy for breast cancer c. A 20-yr-old patient with an open reduction of a fractured radius d. A 75-yr-old patient with repair of a femoral neck fracture after a fall

d. A 75-yr-old patient with repair of a femoral neck fracture after a fall (Patients at highest risk for hypothermia are those who are older, debilitated, or intoxicated. Also, long surgical procedures and prolonged anesthetic administration increase the patient's risk for hypothermia.)

An older adult patient who had surgery is displaying manifestations of delirium. What priority action would benefit this patient? a. Check the chart for intraoperative complications. b. Check which medications were used for anesthesia. c. Check the effectiveness of the analgesics received. d. Check the preoperative assessment for previous delirium or dementia.

d. Check the preoperative assessment for previous delirium or dementia. (If the patient's ABCs are okay, it is important to first know if the patient was mentally alert without cognitive impairments before surgery. Then intraoperative complications, anesthesia medications and pain will be assessed as these can all contribute to delirium.)

A patient having an open reduction internal fixation (ORIF) of a left lower leg fracture will receive regional anesthesia during the procedure. As the patient is prepared in the operating room, what should the nurse implement to maintain patient safety during surgery that is directly related to the type of anesthesia being used? a. Apply grounding pad to unaffected leg. b. Assess peripheral pulses and skin color. c. Verify the last oral intake before surgery. d. Ensure a smooth surface under the patient.

d. Ensure a smooth surface under the patient. (Regional anesthesia decreases sensation to the anesthetized area without impairing level of consciousness, which means the affected leg will be without sensation while the anesthetic is effective. A double tourniquet on the affected leg is used to restrict blood flow. This increases the patient's risk of impaired skin integrity because the patient does not have sensation and cannot identify discomfort or foreign objects and will not be moving during surgery. The nurse's role includes positioning the patient for correct alignment, exposure of the surgical site, and preventing injury. The other options will be occurring but are not directly related to the regional anesthesia.)

A patient is postoperative after a breast reduction and arrives for a follow-up appointment at the clinic. The nurse assesses excess soft pink tissue from the surgical incision site. What complication of wound healing does the nurse recognize this to be? a. Adhesion b. Contractions c. Keloid formation d. Excess granulation tissue

d. Excess granulation tissue (Excess granulation tissue, the excess soft pink tissue on the wound, is what this complication of wound healing is called. Adhesions are bands of scar tissue that form between or around organs. Wound contraction, which is a normal part of healing, is a complication when it results in deformity by shortening the tissue and impairing function. Keloid formation is a great protrusion of scar tissue that extends beyond the wound edges and may be uncomfortable.)

The nurse is caring for a patient who is immunocompromised while receiving chemotherapy for advanced breast cancer. What signs and symptoms will the nurse teach the patient to report that may indicate an infection? a. Fever and chills b. Increased blood pressure c. Increased respiratory rate d. General malaise and fatigue

d. General malaise and fatigue (An immunosuppressed individual may have the classic symptoms of inflammation or infection masked by the inability to launch a normal immune response. Therefore, in this person, early symptoms may be malaise, fatigue, or "just not feeling well.")

The surgical team in the operating room performs a surgical time-out just before starting hip replacement surgery. Which action would be part of the surgical time-out? a. Assess the patient's vital signs and oxygen saturation level. b. Check the chart for a signed consent form for the procedure. c. Determine if the patient has any questions about the procedure. d. Have the patient verify the procedure and the location of the surgery.

d. Have the patient verify the procedure and the location of the surgery. (During a surgical time-out, the surgery team will stop all activities right before the procedure to verify the patient identification, surgical procedure, and surgical site. Proper identification will be accomplished by asking the patient to state name, birth date, and operative procedure and location. In addition, the surgical team will compare the hospital ID number with the patient's own ID band and chart.)

A patient is having elective cosmetic surgery performed on the face and will be staying in the facility for 24 hours after surgery. What is the nurse's postoperative priority for this patient? a. Manage patient pain. b. Control the bleeding. c. Maintain fluid balance. d. Manage oxygenation status.

d. Manage oxygenation status. (The nurse's priority is to manage the patient's oxygenation status by maintaining an airway and ventilation. With surgery on the face, there may be swelling that could compromise her ability to breathe. Pain, bleeding, and fluid imbalance from the surgery may increase her risk for upper airway edema causing airway obstruction and respiratory suppression, which also indicate managing oxygenation status as the priority.)

The patient is going to have a colonoscopy. Which type of anesthesia should the nurse expect to be used? a. Local anesthesia b. Moderate sedation c. General anesthesia d. Monitored anesthesia care (MAC)

d. Monitored anesthesia care (MAC) (The nurse should expect MAC to be used for the patient having a colonoscopy because it can match the sedation level to the patient needs and procedural requirements. Local anesthesia would not be used because the area affected by a colonoscopy is larger than loss of sensation could be provided for with topical, intracutaneous, or subcutaneous application. Moderate sedation is used for procedures performed outside the operating room, and the patient remains responsive. General anesthesia is not needed for a colonoscopy, and it requires advanced airway management.)

An older adult patient is undergoing coronary artery bypass graft (CABG) surgery and has just experienced intraoperative vomiting. The nurse should consequently anticipate the use of which drug? a. Fentanyl b. Midazolam c. Meperidine d. Ondansetron

d. Ondansetron (Ondansetron is an antiemetic, midazolam is a benzodiazepine, and fentanyl and meperidine are opioid analgesics.)

In which surgical area will the patient's surgical skin scrub prep be performed for surgery, and what clothing is appropriate for the nurse performing the scrub to wear? a. Surgical suite wearing a lab coat b. Preoperative holding area wearing street clothes c. Postanesthesia care unit (PACU) wearing scrubs d. Operating room wearing surgical attire and masks

d. Operating room wearing surgical attire and masks (Surgical attire includes pants and shirts (or scrubs), a cap or hood, masks, and protective eyewear. All surgical attire is worn when the patient's skin is being prepped in the operating room to avoid contamination of the site. The surgical suite includes all unrestricted, semirestricted, and restricted areas of the controlled surgical environment. The staff usually wears a lab coat over their scrubs when they leave the surgical area. The staff will not wear street clothes in the preoperative holding area, although the family may. The holding area and PACU will not include prepping the patient for surgery.)

A patient is being prepared for a surgical procedure. What is the priority intervention by the nurse prior to the start of the procedure according to the National Patient Safety Goal (NPSG)? a. Prevention of infection b. Improved staff communication c. Identify patients at risk for suicide. d. Patient, surgical procedure, and site are checked.

d. Patient, surgical procedure, and site are checked. (During the surgical time-out, the Universal Protocol is used to verify the patient's identity, surgical procedure, and site to prevent mistakes in surgery. Prevention of infection is to be done at all times. Improved staff communication relates to getting important test results to the right staff on time. Identifying patient's safety risks for suicide is not usually vital before surgery and does not occur during the time-out.)

At 0600, the anesthesiologist prescribes preoperative medications for a patient who is scheduled for surgery at 0730: cefazolin IV to be infused 30 minutes before surgery; midazolam before surgery, and scopolamine patch behind the ear. Which medication should the nurse administer first? a. Cefazolin b. Fentanyl c. Midazolam d. Scopolamine

d. Scopolamine (The scopolamine patch will be administered first to allow enough time for the serum level to become therapeutic. The cefazolin will be given at 0700 to allow infusion 30 minutes before surgery. Fentanyl is an opioid and was not ordered preoperatively. Midazolam, a short-acting benzodiazepine, is used as a sedative.)

An older adult patient is having surgery. What risk areas will the nurse need to be especially aware of for this patient during surgery? a. Sterility b. Paralysis c. Urine output d. Skin integrity

d. Skin integrity (Skin of older adults has lost elasticity and is at increased risk for injury from tape, electrodes, warming or cooling blankets, and dressings. Pooling cleansing solution may create skin burns or abrasions. The nurse is responsible for monitoring patient safety and adjusting patient position as necessary to prevent pressure or misalignment. Sterility and urine output would be monitored for all patients. Paralysis would not be unusual during some types of surgery but would have an impact on any patient's skin integrity.)

An older adult female patient has come to the ambulatory surgery center for surgery. When reviewing the assessment record, what test should the nurse seek an order for before this patient has surgery? a. Blood glucose b. Pregnancy test c. Serum albumin d. Serum potassium

d. The nurse should seek a serum potassium level (because the patient takes hydrochlorothiazide. An ECG would also be appropriate to seek with the history of hypertension and cigarette smoking. There are not indications for the need of a blood glucose, pregnancy, or serum albumin test.)

The perioperative nurse is supervising the surgical technologist before the arrival of the patient in the operating room for an exploratory laparotomy. Which action, if taken by the surgical technologist, would require the nurse to intervene? a. The surgical technologist holds hands away from the body and above the elbows at all times. b. The surgical technologist scrubs the fingers and hands first followed by the forearms and elbows. c. After a surgical scrub, the surgical technologist puts on a sterile gown and one pair of sterile gloves. d. When wearing a sterile gown and gloves, the surgical technologist is able to organize the equipment on the sterile field.

d. The patient's father developed an elevated temperature during a recent surgery. (Malignant hyperthermia (MH) is an autosomal dominant disorder characterized by hyperthermia with rigidity of skeletal muscles that can result in death. It may occur if an affected individual is exposed to certain general anesthetic agents. To prevent MH, it is important for the nurse to obtain a careful family history. The patient known or suspected to be at risk for MH can be anesthetized with minimal risks if appropriate precautions are taken.)

The patient reports tenderness when she touches her leg over a vein. The nurse assesses warmth and a palpable cord in the area. The nurse knows the patient needs treatment to prevent which sequela? a. Pulmonary embolism b. Pulmonary hypertension c. Post-thrombotic syndrome d. Venous thromboembolism

d. Venous thromboembolism (The clinical manifestations are characteristic of a superficial vein thrombosis. If untreated, the clot may extend to deeper veins, and venous thromboembolism may occur. Pulmonary embolism, pulmonary hypertension, and postthrombotic syndrome are the sequelae of venous thromboembolism.)

A nurse is caring for a client who has bradycardia following a surgical procedure using spinal anesthesia. The nurse should plan to administer which of the following medications to the client? a. amiodarone b. propranolol c. methyldopa d. epinephrine

d. epinerphrine (epinephrine is a vasopressor which would increase the client's heart rate and prevent cardiac arrest

A client had an open transverse colectomy 5 days ago. The nurse enters the client's room and recognizes that the wound has eviscerated. After covering the wound with a sterile, saline-soaked dressing, which of the following actions should the nurse take? a. go to the nurses' station to seek assistance b. reinsert the organs into the abdominal cavity c. place the client in a reverse trendelenburg position d. obtain vital signs to assess for shock

d. obtain vital signs to assess for shock (The nurse should place the client in a supine position with hips and knees bent and the head of the bed elevated 15° to 20°. The nurse should make no attempt to reinsert the eviscerated contents. The nurse should stay with a client who has experienced a wound evisceration. The nurse should press the call light to seek assistance)

A nurse is providing preop teaching to a client who is scheduled for a gastrectomy in 1 week. The client is anxious about the upcoming surgery. Which of the following actions should the nurse take? a. sympathize with the client's feelings b. reassure the client that the surgery will go fine c. change the topic of discussion d. provide concise, factual information

d. provide concise, factual information (Providing concise, factual information allows for open communication and gives the nurse the opportunity to dispel the client's fears.)

A client is transferred from the surgical suite to the PACU following oral surgery. While monitoring the client's vital signs, the nurse finds that the client's tongue has become swollen and is obstructing the airway. Which of the following actions should the nurse take first? a. contact the anesthesiologist b. assist with ET intubation c. increase the client's flow of oxygen d. use the head-tilt, chin-lift method to open the airway

d. use the head-tilt, chin-lift method to open the airway (The first action the nurse should take when using the airway, breathing, circulation approach to client care is to establish a patent airway by tilting the client's head back and pushing the lower jaw forward.)

A nurse is reviewing the medical record of a client who is scheduled for an elective surgery. Which of the following medications should the nurse expect the provider to discontinue prior to surgery to minimize the risk of complications? a. cefazolin b. digoxin c. ondansetron d. warfarin

d. warfarin ( the nurse should anticipate that they will discontinue warfarin because it increases the risk of bleeding during and following surgery. digoxin does not increase client's risk for surgical complications)