Nursing 230: Chapter 37 Preoperative

The nurse is admitting a client to the medical-surgical unit following a cholecystectomy. Which assessment should the nurse perform first? 1. Level of consciousness 2. Dressing 3. Drains 4. Skin color

1

The nurse is caring for a client in the immediate postoperative period (PACU). Which intervention should the nurse implement to reduce the risk of thrombophlebitis? 1. Leg exercises 2. Coughing every 2 hours 3. Ambulating every 2 hours 4. Oxygen by mask

1

The nurse is caring for a client who is having surgery and is currently being transported to the operating room suite. The nurse should document that the client is in which operative phase? 1. Preoperative phase 2. Intraoperative phase 3. Postoperative phase 4. Perioperative phase

1

The nurse is caring for an 80-year-old client preparing for surgery. The nurse realizes this client is at increased risk for which reason? 1. The physiological deficits of aging increase the surgical risk for older adults. 2. The older adult has increased kidney function. 3. The older adult has an increase in sensory function. 4. The older adult will turn, cough, and deep-breathe more effectively.

1

The nurse is preparing a 23-year-old female client for surgery. The nurse should anticipate which diagnostic test to be prescribed for this client? 1. Pregnancy test 2. EEG 3. EKG 4. Pulmonary function tests

1

The nurse is preparing to conduct preoperative teaching. What should be included in this teaching? 1. Information related to what will happen to the client 2. Referral of the client to the physician for any misconceptions the client may have 3. The role of the nurse during surgery 4. How to perform activities of daily living (ADLs) following surgery

1

The nurse has removed the sutures from a clients surgical wound. What should the nurse document about this procedure? Standard Text: Select all that apply. 1. Number of sutures removed 2. Appearance of the incision 3. Client teaching 4. Client tolerance of the procedure 5. Name of the surgeon.

1, 2, 3, 4

The nurse is completing a preoperative assessment with a client. What should this assessment include? Standard Text: Select all that apply. 1. Current health status 2. Allergies 3. Current medications 4. Mental status 5. Respiratory rate

1, 2, 3, 4

The nurse is obtaining preoperative assessment data. What should be included in this assessment? Standard Text: Select all that apply. 1. Current health status 2. Allergies 3. Current medications 4. Mental status 5. Mothers maiden name

1, 2, 3, 4

The nurse is preparing to complete a physical assessment before surgery. Which assessments should the nurse obtain? Standard Text: Select all that apply. 1. Mini mental status 2. Assessment of hearing 3. Assessment of the respiratory system 4. Gastrointestinal assessment 5. Maintain NPO status

1, 2, 3, 4

A client is scheduled for lung resection surgery. What should the nurse keep in mind when determining this clients degree of risk for this major surgical procedure? Standard Text: Select all that apply. 1. Age 2. Medications 3. General health 4. Blood pressure 5. Nutritional status

1, 2, 3, 5

The nurse has identified the goals of maintaining client safety and homeostasis during the intraoperative phase of client care. What nursing activities would support these goals? Standard Text: Select all that apply. 1. Maintain the sterile field. 2. Perform instrument counts. 3. Instruct in postoperative exercises. 4. Position the client appropriately for surgery. 5. Perform preoperative skin preparation.

1, 2, 4, 5

The nurse is preparing a 6-year-old child for a tonsillectomy. Which strategy should the nurse use for teaching this client? 1. Pamphlets 2. Play 3. Books 4. Videotapes

2

A client recovering from surgery asks the nurse why turning, deep breathing, and coughing exercises need to be done. What should the nurse respond? 1. These exercises help prevent pneumonia. 2. The doctor ordered the exercises. 3. All surgical clients must do these exercises. 4. These exercises prevent thrombophlebitis.

1

During the assessment of a client recovering from surgery, the nurse notes decreased breath sounds in both lower lobes bilaterally. What should the nurse do? 1. Coach the client to deep-breathe and cough. 2. Restrict fluids. 3. Remind the client to perform leg exercises. 4. Maintain on bed rest.

1

The nurse is preparing to instruct a client on leg exercises to be used when recovering from abdominal surgery. What should the nurse determine before beginning this teaching? Standard Text: Select all that apply. 1. Type of surgery 2. Time of surgery 3. Postoperative diet 4. Preoperative orders 5. Name of the surgeon

1, 2, 4, 5

A client in the postanesthesia care unit is to have suction applied through a nasogastric tube. When documenting, the nurse should include which information? Standard Text: Select all that apply. 1. The time suction was started 2. Characteristics of wound drainage 3. Pressure on the suction 4. Integrity of the surgical dressing 5. Color and consistency of drainage

1, 3, 5

The nurse is planning a perioperative clients needs upon discharge. What should be included when determining these needs? Standard Text: Select all that apply. 1. Clients abilities to provide self-care 2. Date of anticipated discharge 3. Physician performing the surgery 4. Financial resources 5. Need for home health care services

1, 4, 5

The nurse is preparing a care plan for a client about to undergo surgery. Which nursing diagnosis would take priority during the intraoperative phase of surgery? 1. Ineffective Protection 2. Risk for Aspiration 3. Impaired Skin Integrity 4. Risk for Falls

2

The nurse is preparing to apply antiembolic stockings to a postoperative client. What should be done first, before applying the stockings? 1. Measure the calf. 2. Assess for circulatory problems. 3. Assess the clients blood pressure. 4. Clean the stockings.

2

A client is anxious about receiving general anesthesia for a surgical procedure. What should the nurse explain are the advantages of having this type of anesthesia? Standard Text: Select all that apply. 1. The client remains conscious. 2. Respiratory rate can be regulated easily. 3. It is used for minor surgical procedures. 4. The anesthesia can be adjusted to the length of the operation. 5. It focuses on a single nerve or nerve group.

2, 4

The nurse is assessing an abdominal wound in the postoperative period. Which sign should indicate to the nurse that an infection is present? 1. Absence of bleeding 2. Edges warm to the touch 3. Edges well approximated 4. Sutures in place

2

The nurse is planning care for a client during the postoperative period. What should the nurse identify as the goal of care for this client? 1. Provide necessary preoperative teaching. 2. Assist the client to achieve the most optimal health status possible. 3. Ensure client safety. 4. Maintain an aseptic environment.

2

The nurse is planning to remove the sutures from a clients surgical wound. What should the nurse do before removing the sutures? Standard Text: Select all that apply. 1. Apply clean gloves. 2. Verify the order for suture removal. 3. Ambulate the client to the bathroom. 4. Read the order to determine whether a dressing is to be applied after removal. 5. Remove the dressing and clean the incision.

2, 4, 5

A client is scheduled for a cholecystectomy. The nurse realizes that the purpose for this surgery is 1. diagnostic. 2. palliative. 3. ablative. 4. constructive.

3

The nurse has just inserted a nasogastric tube for gastric suction. What is the most reliable test for confirming tube placement? 1. Place the stethoscope over the stomach and listen for a swishing sound while inserting water into the tube. 2. Place the stethoscope over the stomach and listen for a swishing sound while inserting air into the tube. 3. Aspirate stomach contents and check the acidity using a pH test strip. 4. Connect the tube to suction and observe the contents.

3

The nurse is caring for a client in the recovery area. In which position should the nurse place the unconscious client during the immediate postanesthesia phase? 1. Supine 2. Prone 3. Side-lying 4. Supine with a pillow under the head

3

The nurse is caring for a client on the postoperative unit. Which nursing diagnosis is the priority for this client? 1. Self-Care Deficit 2. Disturbed Body Image 3. Ineffective Airway Clearance 4. Risk for Falls

3

The nurse is evaluating the effectiveness of preoperative instruction regarding leg exercises with a client recovering from surgery. Which observation indicates that the instructions were effective? 1. The lower extremity is swollen and hot to touch. 2. The vein feels hard. 3. There is no cramping or pain with ambulation. 4. There is pain in the calf with dorsiflexion.

3

The nurse is preparing the skin of a client for surgery. The nurse knows the purpose of the surgical skin preparation is to 1. sterilize the skin. 2. assess the surgical site before surgery. 3. reduce the risk of postoperative wound infection. 4. clean any moles the client may have.

3

The nurse wants to ensure that a client recovering from surgery does not develop thrombophlebitis. Which action should the nurse take to reduce the clients risk of this postoperative complication? 1. Administer an anticoagulant. 2. Assist the client to cough every 2 hours. 3. Monitor intake and output every 2 hours. 4. Provide for early ambulation.

4

The nurse determines that interventions to prevent postoperative constipation have been effective in a client recovering from surgery. What did the nurse assess to make this clinical decision? 1. Abdominal distention present. 2. Gas pains present. 3. Client vomiting. 4. Bowel movement occurred 24 hours after resuming a normal diet.

4

The nurse is preparing a client for an upper GI endoscopy. For which type of anesthesia should the nurse prepare the client to receive? 1. Local anesthesia 2. Spinal anesthesia 3. Epidural anesthesia 4. Conscious sedation

4

The nurse is caring for a postoperative client with an abdominal wound and a drain. What can the nurse delegate to unlicensed assistive personnel? Standard Text: Select all that apply. 1. Clean the wound. 2. Assess the skin around the wound. 3. Determine the effectiveness of pain medication. 4. Report if the dressing is soiled. 5. Report if the dressing is loose.

4, 5