Nov. 7th Skills Quizzes

The nurse is caring for an older adult client immediately after knee surgery. The client has a Foley catheter in place. The client's spouse is concerned that the client has "never had to have a catheter before." What is the best response from the nurse?

"It is common for a postoperative client to have a urinary catheter until the effects of anesthesia have worn off and the client is more mobile." Rationale:It is common for a postoperative client to have a urinary catheter until the effects of anesthesia have worn off and the client is more mobile, especially older clients. While kidney function can be affected by different reasons, it is not the primary reason to insert a urinary catheter. The client with knee surgery should not be at risk for bladder clots. While many postoperative clients may have urinary catheters, it is not a good explanation to simply state that "It is protocol."

Check the PACU medication administration record. Rationale:The priority is to check what medications and administration times are recorded for the client to evaluate when pain medication can be safely given. Checking for IV patency prior to medication administration is important, but not as important as ensuring safe medication administration. Repositioning the client may be helpful in increasing comfort, but it would decrease immediate postoperative pain.

"There are several nonpharmacologic methods to reduce pain and anxiety. Let me teach you about some of them." Rationale:Nonpharmacological measures may reduce anxiety and reduce the need for pain medication at any time during the postoperative period. Asking about fear of addiction does not address the client's question. Nonpharmacologic methods can be implemented postoperatively regardless of prior client experience.

4The nurse is teaching the client about postoperative leg exercises. The nurse would instruct the client to repeat leg exercises how many times?

3 times Rationale:Clients should perform each leg exercise three times. Leg exercises assist to prevent muscle weakness, promote venous return, and decrease complications related to venous stasis.

A postoperative client reports unrelieved pain. What intervention would be the nurse take first?

Assess the client's pain and surgical site. Rationale:When the client has unrelieved pain, the nurse should first fully assess the pain (location, description, alleviating factors, and causal factors) and surgical site, reposition the client, check the post-anesthesia care unit (PACU) record to validate any analgesic given in the past, and check postoperative prescriptions for PRN analgesic. If enough time has elapsed, a dose of pain medication would be given. If enough time has not elapsed, the nurse would contact the health care provider to address the pain. Pain can be a clue to other problems, such as hemorrhage.

The preoperative nurse is admitting a client who is scheduled for surgery later in the day. The client is wearing contact lenses, has several body piercings, has fingernails covered with nail polish, and is wearing cosmetics, false eyelashes, and a wedding band. Which should the nurse instruct the client to remove before the surgery? Select all that apply.

Body piercings, Cosmetics, Fingernail polish, Contact lenses, False eyelashes Rationale:The nurse should request that the client remove all but the wedding band. Cosmetics, jewelry, nail polish, and prostheses (such as contact lenses and false eye lashes) can interfere with assessment during surgery, so clients should be asked to remove them. Some facilities allow a wedding band to be taped to the finger.

The nurse is caring for a postoperative client. The client reports pain that is rated 9 on a 10-point scale. The client is not due for pain medication for another hour. After assessing the client and repositioning, the client reports no improvement in pain. What intervention does the nurse perform next?

Call the surgeon and report the assessment. Rationale:The client may need changes in the pain medication prescription, which would come from the surgeon. It is too soon to administer pain medication early. While relaxation techniques may be helpful, because the client rates the pain quite high, this may not be completely effective. The client should not have to wait an additional hour if there is an intervention that could occur sooner.

The nurse is assessing a postoperative client immediately upon return from the post-anesthesia care unit (PACU). The client is requesting pain medication. What is the priority action for the nurse?

Check the PACU medication administration record. Rationale:The priority is to check what medications and administration times are recorded for the client to evaluate when pain medication can be safely given. Checking for IV patency prior to medication administration is important, but not as important as ensuring safe medication administration. Repositioning the client may be helpful in increasing comfort, but it would decrease immediate postoperative pain.

The nurse is performing postoperative care for a client returning to the room following a cholecystectomy. After the first hour, how often would the nurse take the client's vital signs?

Every 30 minutes for the next 2 hours. Rationale:The nurse would obtain vital signs every 15 minutes for the first hour, followed by every 30 minutes for the next 2 hours, followed by every hour for 4 hours, and then finally every 4 hours.

The nurse is caring for a client immediately after colon surgery. The nurse checks vital signs on the client. Oxygen saturation is 89%. What action should the nurse take?

Have the client deep breathe and cough then reassess. Rationale:Low oxygen saturations with the postoperative client can be a result of shallow breathing and effects of anesthesia. The nurse should have the client deep breathe and cough to see if oxygen saturations increase before notifying the surgeon or applying oxygen. Administering pain medication may cause further respiratory depression, making saturation worse.

The nurse checks the dressing of a postoperative client. There is a moderate amount of fresh blood on the outside of the dressing. After reinforcing the dressing, the nurse checks vital signs on the client. What is the rationale for checking vital signs for this client?

If the client has an increased heartrate, the client may be experiencing decreased fluid volume. Rationale:In this case, vital signs are taken to assess fluid volume deficits that may be related to bleeding. In acute blood loss, the heartrate will increase even before blood pressure decreases. With fresh bleeding, fever is not a priority. Having the client deep breathe and cough could increase bleeding.

The nurse, assessing the dressing of a postoperative client, notes that a previously clean dressing has a scant amount of dried blood. What would be the recommended nursing intervention in this situation?

Mark the area on the dressing with time and date and monitor for changes. Rationale:A new surgical dressing may have dried blood or drainage. The nurse should monitor for changes. The nurse should not change the dressing unless it has been prescribed by the surgeon. The dressing should not need to be reinforced if there are no changes. The incision site should not be left open to air until prescribed by the surgeon.

The nurse, assessing the dressing of a postoperative client, notes that a previously clean dressing has a large amount of fresh blood. What is the recommended nursing intervention in this situation?

Notify the health care provider and reinforce the dressing with more bandages. Rationale:If a previously clean dressing has a large amount of fresh blood, the nurse would not remove the dressing; instead, the health care provider would be notified, and the dressing would be reinforced with new bandages. Removing the bandage could dislodge any clot that is forming and lead to further blood loss.

The nurse is assessing a postoperative client who is recovering from anesthesia. Which signs should the nurse interpret as indicating that peristalsis is returning in the client? Select all that apply.

Presence of bowel sounds Rationale:Anesthetic agents and narcotics depress peristalsis and normal functioning of the gastrointestinal tract. Flatus and presence of bowel sounds indicate return of peristalsis. Frequency, burning, or urgency may indicate possible urinary tract abnormality. Clients may experience chills in the postoperative period, but this is not an indication of the return of peristalsis.

The nurse is caring for a client who returned from the postanesthesia care unit 3 hours ago. The surgical dressing was dry and intact upon arrival to the postoperative unit, but now it is saturated with fresh blood. Which actions should the nurse take first?

Reinforce the dressing with more bandages until the bleeding stops. Rationale:In this situation, the nurse should not remove the dressing but should reinforce it with more bandages. Removing the bandage could dislodge any clot that is forming and lead to further blood loss. Measuring vital signs would be of lower priority than reinforcing the dressing to stop the bleeding. Drawing a circle around the drainage and noting the time is not the proper first action.

The nurse is caring for a client who just returned from the postanesthesia care unit following surgery to repair a fractured arm. Place the following interventions in order of highest priority to lowest priority.

Your Response: 1)Place the client in a position that facilitates breathing. 2)Measure pulse, blood pressure, respirations, and temperature. 3)Measure oxygen saturation. 4)Assess neurovascular status to the affected arm. 5)Assess dressing for bleeding or other drainage. 6)Assess for pain and administer prescribed analgesics, if indicated. Rationale:Priority of assessment is airway, breathing, circulation (ABC). Thus, the correct order of interventions is as follows: 1) Place the client in a position that facilitates breathing. 2) Measure pulse, blood pressure, respirations, and temperature. 3) Measure oxygen saturation. 4) Assess neurovascular status to the affected arm. 5) Assess dressing for bleeding or other drainage. 6) Assess for pain and administer prescribed analgesics, if indicated.

A nurse is creating a leg exercise regimen for client who is recovering from surgery. Which factors should the nurse consider when recommending leg exercises to this client? Select all that apply.

Your Response: Health care provider preference Client's physical condition Facility protocol Client's individual needs Rationale:Leg exercises increase venous return through flexion and contraction of the quadriceps and gastrocnemius muscles. It is important to individualize leg exercises to client needs, physical condition, health care provider preference, and facility protocol. Current popularity of the exercise and the cardiovascular intensity of the exercise are not factors to consider.

Which postoperative complications can be reduced by appropriate client teaching about deep-breathing exercises? Select all that apply.

Your Response: Bronchitis, Pneumonia, Severe hypoxemia, Atelectasis Rationale:Deep-breathing exercises can decrease respiratory complications. Deep vein thrombophlebitis and wound infection are unrelated to deep-breathing exercises.

A nurse is instructing a client in how to perform leg exercises following surgery. The client asks the nurse, "Why do I have to do these exercises?" Which is the health reason the nurse should mention?

Your Response: To increase venous return of blood to the heart Rationale:During surgery, venous blood return from the legs slows. In addition, some client positions used during surgery decrease venous return. Thrombophlebitis, deep vein thrombosis, and the risk for emboli are potential complications from circulatory stasis in the legs. Leg exercises increase venous return through flexion and contraction of the quadriceps and gastrocnemius muscles. Although leg exercises may also strengthen the leg muscles, improve the efficiency of the heart, and increase flexibility, the health reason to perform them following surgery is to increase venous return of blood to the heart.

The preoperative nurse is teaching a client about deep-breathing exercises. The client asks, "Why do I need to learn about this?" Which response by the nurse is correct?

Your Response:"After surgery, deep-breathing exercises help to remove anesthetic gasses and mucus and improve oxygen supply to body tissues." Rationale:Deep-breathing exercises are intended to help prevent postoperative complications, such as low oxygen levels, accumulation of secretions, and atelectasis.

The nurse is caring for a postoperative client after abdominal surgery. The client states, "I don't want to change positions in bed because I am afraid." How should the nurse respond?

Your Response:"Changing position decreases your risk of pulmonary and skin complications." Rationale:The nurse should help the client change positions every 2 hours to decrease risk of pulmonary and skin complications. Therefore, the nurse should not wait for a long period of time without helping the client change positions. Telling the client that he or she has nothing to be afraid of invalidates the client's feelings. Although the postoperative prescription may include changing the client's position every w hours, this response does not explain why it is important.

A client who is scheduled to undergo coronary bypass surgery in a week asks the nurse whether he should discontinue taking his cholesterol medicine ahead of the surgery. Which should be the nurse's response?

Your Response:"I will need to check with your health care provider about that." Rationale:The client may be permitted to take certain medications before surgery. The health care provider, not the nurse, should provide guidance about which medications should be taken and which ones should be held.

The nurse is performing a preoperative assessment with a client on the morning of surgery. The client states, "I know I wasn't supposed to eat or drink anything after midnight, but I just had to have a little orange juice and dry toast this morning. I hope it won't be a problem." Which response is most appropriate?

Your Response:"I will need to notify your surgeon. This may affect your ability to have surgery today." Rationale:Food and fluid are restricted before surgery to ensure that the stomach contains a minimal amount of gastric secretions. Recent research has challenged this practice, so the surgeon and anesthesia provider will make the final determination about the safety of proceeding with surgery.

The nurse is preparing a client on the day of surgery. The client states consumption of a "very small amount of oatmeal this morning." What is the proper response from the nurse?

Your Response:"I will need to report that information to your surgeon." Rationale:The nurse needs to inform the surgeon that the client has not been NPO to see if surgery can proceed. It would be up to the surgeon as to whether surgery can proceed. Surgery may need to be cancelled or delayed. Because surgery increases risks of nausea, vomiting and aspiration, the surgeon should be notified of the issue to ensure client safety and comfort. Stomach contents should not affect pain after surgery.

The preoperative nurse is talking with a client who is scheduled to go to the operating room within the next 10 minutes. The client states, "I don't know if I am really ready to have this surgery." Which response by the nurse is most appropriate?

Your Response:"If you are unsure, I'll contact your surgeon and you can discuss your options." Rationale:Clients should not undergo surgery until they are sure of their decision. Operating room schedules should not take priority over client questions. The client should have the opportunity to discuss the surgery and ask further questions before the procedure is canceled.

The nurse demonstrates that the client understands preoperative teaching by documenting which client statement?

Your Response:"Leg exercises will help decrease risk of a blood clot." Rationale:Documenting that the client is prepared for surgery is non-specific and does not adequately address the scope of the preoperative teaching. Early mobility helps improve circulation and decreases likelihood of respiratory complications. Leg exercises increase circulation and decrease risk of thrombosis. Proper incentive spirometry use consists of deep inhalations to expand alveoli, not forceful exhalations.

The nurse assists a client to turn in the bed. The client has just returned from abdominal surgery. How does the nurse instruct the client?

Your Response:"Use a pillow to splint the incision." Rationale:The client needs to use a pillow to splint the incision during movement to reduce pain. The client needs to change position every 2 hours or less; "frequently" could be misinterpreted by the client. It is easier to turn laterally when the head of the bed is flat. Independence is encouraged, so if the client feels capable, he or she may move in the bed on his or her own.

The nurse is preparing a client on the day of surgery. The client is scheduled to have a total replacement of the right knee. What question would be the priority for the nurse ask the client?

Your Response:"What procedure and location is your surgery today?" Rationale:The priority would be to ensure that the client can verbalize the type of surgery and correct location site to decrease risk of wrong procedure. The other questions are important for history-taking and postsurgery planning but are not the priority for client safety.

A nurse is explaining to a client about coughing following surgery. Which teaching statements follows the recommended guidelines?

Your Response:"When coughing, apply firm pressure on the incision with a bath blanket to minimize discomfort." Rationale:The client is encouraged to cough after surgery to remove secretions from the lungs. Placing a bath blanket or pillow over the incision when coughing decreases client discomfort.

The nurse is teaching a preoperative client how to perform deep-breathing exercises after back surgery. What is the best method to ensure that the client understands the procedure?

Your Response:Ask the client for a return demonstration. Rationale:The best way to ensure that client teaching has been effective for the psychomotor domain (the integration of mental and muscular activity) is to ask the client for a return demonstration. This ensures that the client is able to perform the exercises properly. Practice promotes effectiveness and compliance. The other methods could also be used, but a return demonstration is the most effective and efficient method.

The nurse is reviewing the preoperative prescription for a client on the day of surgery. The nurse notes a prescription for an antibiotic to be given prior to surgery. What is the priority for the nurse?

Your Response:Assess the client's medication allergies. Rationale:While the nurse should assess the IV site prior to medication administration, the priority would be checking medication allergies for client safety. Vital signs would not be indicated prior to antibiotic administration. The client's home medication list is important, but medication allergies would be the priority.

The acute care nurse is preparing a client for surgery. Which action is essential to complete before transferring the client to surgery?

Your Response:Assure that diagnostic testing has been completed and results are available. Rationale:All prescribed diagnostic tests should be performed, and results made available before the client goes to surgery. Unless otherwise indicated, no special positioning is required preoperatively. Graduated compression stockings, if prescribed, should remain in place. The surgeon, not the nurse, is responsible for marking the skin.

The nurse is caring for a postoperative client after abdominal surgery. The nurse is assisting the client to turn from the back onto the right side. On which techniques should the nurse instruct the client?

Your Response:Bend the left knee and use the left hand to grasp the bed rail while pulling body over to the right side. Rationale:The nurse should instruct the client to bend the left knee and reach across with the left hand to grasp the right-side rail of the bed when turning toward the right side or bend the right knee and use the right hand to grasp the left side rail if turning to the left. This allows the client to assist with body mechanics and less pulling. The other options do not allow for optimal, fluid body mechanics to assist both the client and the nurse in client turning.

What is the first responsibility of the nurse when preparing a client for surgery?

Your Response:Ensure that the informed consent has been signed, witnessed, and dated. Rationale:The nurse should begin by ensuring that consent is given to verify that the client has been informed of the procedure and its risks. The surgeon is responsible for explaining the details of the surgical procedure and the risks and complications of surgery to the client and family. The nurse is responsible for clarifying what the surgeon has explained and contacting the surgeon if the client does not understand or has further questions. The nurse does not assess for previous anesthesia complications.

The nurse helps turn a postsurgical client in bed. What is the most important intervention prior to leaving the client's room?

Your Response:Ensure the call light is within the client's reach. Rationale:Dimming the lights may be a client request but making sure that the call light is within reach is the most important safety priority. A pillow for client support may be used, but it does not ensure client safety. While documentation of the time and client's position is necessary, it can be completed outside of the client's room. Ensuring that the call light is within the client's reach is a priority safety invention.

The nurse is teaching a client how to turn in bed postoperatively. How often is turning recommended?

Your Response:Every two hours. Rationale:Turning client in bed is recommended every two hours. Turning and repositioning the client is important to prevent postoperative complications and minimize pain.

When initiating deep-breathing exercises for a postoperative client, what would be the nurse's instructions for the first breath?

Your Response:Exhale first and breathe in through the nose. Rationale:For the first breath, the nurse would instruct the client to exhale first, breathe in through the nose, and hold the breath for five seconds. The client would then breathe out through the mouth with pursed lips. Deep inhalation promotes lung expansion.

The nurse is teaching deep-breathing exercises to a client who is undergoing thoracic surgery. In what position would the nurse place the client for these exercises?

Your Response:Fowler's Rationale:The nurse would put the client in the Fowler's (sitting) position to promote chest expansion and lessen exercise of the abdominal muscles.

The nurse is preparing a client on the day of surgery. Which process is priority for preparing the client physically for the surgery?

Your Response:Have the client remove contact lenses, nail polish, and cosmetics. Rationale:The nurse would instruct the client to remove all clothing including undergarments and put on a hospital gown. The client would also remove any cosmetics, jewelry (including body piercings), contact lenses, and nail polish. The nurse would instruct the client to remove any dentures or mouth pieces prior to surgery.

The nurse is teaching a preoperative client how to perform deep-breathing exercises. What is the next step the client would take after exhaling first and breathing in through the nose?

Your Response:Hold the breath for five seconds and exhale through pursed lips. Rationale:For the second breath in deep-breathing exercises, the nurse would instruct the client to hold the breath for five seconds and exhale through pursed lips as if whistling.

The preoperative nurse has prepared a client for surgery and has been notified that the operating room staff is ready for the client. The client states, "My bladder feels full. I need to go to the bathroom!" Which action by the nurse is appropriate?

Your Response:Inform the operating room staff and assist the client to the bathroom. Rationale:Clients should empty the bowel and bladder before surgery. A urinary catheter is not indicated. The remaining statements are untrue.

The nurse is teaching a preoperative client how to cough following a surgical procedure. Which statement accurately describes a step in this procedure?

Your Response:Inhale and exhale three times, inhale and hold the breath for three seconds, and lightly cough three times. Rationale:The correct procedure for coughing after surgery is to inhale and exhale three times, inhale and hold the breath for three seconds, lightly cough three times, take another deep breath, and strongly cough again two times. Coughing helps to remove retained mucous from the respiratory tract.

The nurse is caring for a postoperative client after abdominal surgery. Why is it important to splint the client's incision during coughing exercises?

Your Response:It will support the incision and decrease pain. Rationale:Bleeding can occur even with incisional splinting, and incisional assessment should be made before and after the exercises. Splinting does support the incision and decrease pain. While the coughing exercises will help decrease risk of postoperative pneumonia, the splinting of the incision is not a factor in that risk. Splinting of the incision should not change the client's risk of incisional infection.

The preoperative nurse is reviewing the chart of a client whose surgery is scheduled to begin in the next 15 minutes and notices that the consent form is not signed. The nurse contacts the surgeon who states, "We have already reviewed this procedure extensively, so ask the client to sign the consent form and I will verify it in the operating room." Which action by the nurse is appropriate?

Your Response:Keep the client in the preoperative area and inform the surgeon that it is the health care provider's responsibility to obtain consent for surgery. Rationale:If a consent form is not signed, the nurse should notify the surgeon. It is the health care provider's responsibility to obtain consent for surgery and anesthesia. Preoperative medications cannot be given until the consent form is signed. The client should not proceed to surgery without a signed consent form (unless it is an emergency).

The nurse is teaching a client about splinting and coughing postoperatively. What position would the nurse teach the client to assume for coughing?

Your Response:Sitting up and leaning forward. Rationale:The nurse would teach the client to sit up and lean forward for coughing exercises. This position facilitates removal of retained mucus from the respiratory tract when coughing.

The nurse is assisting a postoperative client to perform leg exercises. Which is the first step in this exercise?

Your Response:Straighten the knee, raise the foot, and extend the lower leg for a few seconds. Rationale:The order in which leg exercises are performed is: (1) straighten the knee, raise the foot, and extend the lower leg for a few seconds; (2) point the toes of both legs toward the foot of bed and then relax them; (3) flex or pull the toes toward the chin; and (4) extend the legs and make circles with both ankles.

The nurse is providing preoperative care for a client on the day of surgery. What is the most important goal of preoperative nursing?

Your Response:Teach the activities that the client will perform postoperatively. Rationale:The nurse should ensure that the client can explain and demonstrate the breathing, coughing, leg exercises, and turning in bed that help minimize complications from surgery. This client teaching is the priority activity, as it pertains to client safety. The client should already be aware of their specific surgical procedure and potential complications from prior conversations with their surgeon. While it is important to ensure the client is comfortable, it is not the priority.

The nurse is caring for a client who had abdominal surgery yesterday and is reluctant to cough and perform deep breathing. Which strategy will most likely increase the client's willingness to cough and perform deep breathing?

Your Response:Teach the client how to splint the abdomen while coughing. Rationale:Splinting the abdomen decreases discomfort while coughing. Telling the client about complications will be less effective that teaching splinting techniques. Respiratory treatments are not indicated for cough production. Side-lying position is less effective than upright positioning to clear secretions and expand the lungs.

The nurse is teaching a preoperative client how to perform deep-breathing exercises. How many times and how often would the client be instructed to perform these exercises following surgery?

Your Response:Three times every one to two hours. Rationale:The client would perform deep-breathing exercises three times every one to two hours for the first 24 hours after surgery to promote lung expansion and volume.

After positioning the client to teach deep-breathing exercises, the nurse asks the client to place the hands on the rib cage. What is the rationale for this action?

Your Response:To feel the chest rise. Rationale:During deep-breathing exercises, the nurse asks the client to put the hands on the rib cage to feel the chest rise and the lungs expand as the diaphragm descends. Splinting, during coughing, protects the surgical incision.

A nurse is teaching a client how to perform leg exercises. Which postoperative complications may be prevented with leg exercises?

Your Response:Venous stasis. Rationale:Leg exercises assist to prevent muscle weakness, promote venous return, and decrease complications related to venous stasis. Stroke and hemorrhage may be prevented by frequent dressing assessments. Varicose veins are not caused by surgery.

What is the most important reason to include the client's family members and/or other caregivers during preoperative teaching?

Your Response:to provide support and reinforcement of activities in the postoperative period Rationale:A supportive family member or caregiver can help reinforce activities and motivate client compliance. While the family member or caregiver may help with the client's medical history, this would not affect the postoperative period. Even if the family member or caregiver is present during preoperative teaching, it is not possible to eliminate all postoperative risks. The client will likely require postoperative analgesia, which would not be affected by the family member or caregiver's presence during preoperative teaching.

What is the rationale for assessing a postoperative client in different positions?

to assess for any blood pooling Rationale:The postoperative client should be assessed for blood pooling, which could indicate excessive hemorrhage. While movement may help mobilize respiratory secretions, this would be better accomplished through cough, deep breathing, and incentive spirometry. The client would not need to be repositioned only for pain assessment. Skin breakdown would be something that needs monitoring over time.

The nurse checks the dressing of an immediately postoperative client for color, odor, presence of drains, and amount of drainage. What is the rationale for this assessment?

to monitor for bleeding and signs of infection Rationale:Monitoring for color, odor, presence of drains, and amount of drainage are important to assess for signs of bleeding and infection. Pain control is a separate issue. There would be no need to monitor for signs of early healing. Client position is a comfort issue but monitoring the dressing should have no bearing on client position.

How should the nurse assess the postoperative surgical dressing?

turn the client Rationale:The assessment of the dressing includes turning the client for checking of pooling of blood or drainage. While the other items are important postoperative interventions, they are not specifically related to dressing assessment.