Perioperative and pneumonia NCLEX questions
After teaching a patient scheduled for ambulatory surgery using moderate sedation, the nurse determines that the patient has understood the teaching based on which of the following statements? "I'm so glad that I will be unconscious during the surgery." "I won't feel it, but I'll have a tube to help me breathe." "Only the surgical area will be numb." "I'll be sleepy but able to respond to your questions."
"I'll be sleepy but able to respond to your questions."
The nurse has provided preoperative instructions to a client scheduled for surgery at an ambulatory care center. Which statement, made by the client, would indicate that further instruction is needed? "If I do not follow the instructions, my surgery could be cancelled." "The nurse will explain the details of the surgery before I sign a consent." "My medical records will be sent to the ambulatory care center prior to my surgery." "The physician will update my family after the procedure and provide specific discharge instructions."
"The nurse will explain the details of the surgery before I sign a consent."
The nurse is preparing to discharge a client from the PACU using a PACU room scoring guide. With what score can the client be transferred out of the recovery room? 4 5 6 7
7 explanation: score of 7-10 is reasonable for discharge
On auscultation, which finding suggests a right pneumothorax? Bilateral inspiratory and expiratory crackles Absence of breath sounds in the right thorax Inspiratory wheezes in the right thorax Bilateral pleural friction rub
Absence of breath sounds in the right thorax
The policies and procedures on a preoperative unit are being amended to bring them closer into alignment with the focus of the Surgical Care Improvement Project (SCIP). What intervention most directly addresses the priorities of the SCIP? Actions aimed at increasing participation of families in planning care Actions aimed at preventing surgical site infections Actions aimed at increasing interdisciplinary collaboration Actions aimed at promoting the use of complementary and alternative medicine (CAM)
Actions aimed at preventing surgical site infections explanation: SCIP focuses on preventing complications such as SSI and VTE
The intraoperative nurse advocates for each client who receives care in the surgical setting. How can the nurse best exemplify the principles of client advocacy? By encouraging the client to perform deep breathing preoperatively By limiting the client's contact with family members preoperatively By maintaining the privacy of each client By eliciting informed consent from clients
By maintaining the privacy of each client
What are the circulating nurse's responsibilities, in contrast to the scrub nurse's responsibilities? Assisting the surgeon Coordinating the surgical team Setting up the sterile tables Passing instruments
Coordinating the surgical team
A nurse is assessing a client who comes to the clinic for care. Which findings in this client suggest bacterial pneumonia? Nonproductive cough and normal temperature Sore throat and abdominal pain Hemoptysis and dysuria Dyspnea and wheezing
Dyspnea and wheezing
What action by the nurse best encompasses the preoperative phase? Educating clients on signs and symptoms of infection Documenting the application of sequential compression devices (SCDs) Monitoring vital signs every 15 minutes Shaving the client using a straight razor
Educating clients on signs and symptoms of infection
The nurse admits a client to the postanesthesia care unit with a blood pressure of 132/90 mm Hg and a pulse of 68 beats per minute. After 30 minutes, the client's blood pressure is 94/47 mm Hg, and the pulse is 110. The nurse documents that the client's skin is cold, moist, and pale. This client is showing signs of what potential issue? Hypothermia Hypovolemic shock Neurogenic shock Malignant hyperthermia
Hypovolemic shock
A nurse is caring for a client with chest trauma. Which nursing diagnosis takes the highest priority? Impaired gas exchange Anxiety Decreased cardiac output Ineffective tissue perfusion (cardiopulmonary)
Impaired gas exchange reasoning: ABCs (breathing before circulation)
A critical-care nurse is caring for a client diagnosed with pneumonia as a surgical complication. The nurse's assessment reveals that the client has an increased work of breathing due to copious tracheobronchial secretions. What should the nurse encourage the client to do? Increase oral fluids unless contraindicated. Call the nurse for oral suctioning, as needed. Lie in a low Fowler or supine position. Increase activity.
Increase oral fluids unless contraindicated.
Verification that all required documentation is completed is an important function of the intraoperative nurse. The intraoperative nurse should confirm that the client's accompanying documentation includes which of the following? Discharge planning Informed consent Analgesia prescription Educational resources
Informed consent
An older adult recovering from anesthesia for a surgical procedure develops delirium. Which action(s) will the nurse take to help this client? Select all that apply. Decrease physical activity. Limit unfamiliar noises. Engage in conversation. Keep lights on in the room Ensure adequate pain control
Limit unfamiliar noises. Engage in conversation. Keep lights on in the room Ensure adequate pain control
The client asks the nurse about ways to control pain other than taking pain medication. Which strategy should the nurse include when responding to the client? Select all that apply. Listening to music An On-Q pump Watching television An epidural infusion Changing position
Listening to music, watching television, changing position
The nurse is assessing a client's potential for pulmonary emboli. What finding indicates possible deep vein thrombosis? Pain in the feet Coolness to lower extremities Decreased urinary output Localized calf tenderness
Localized calf tenderness
A student nurse is scheduled to observe a surgical procedure. The nurse provides the student nurse with education on the dress policy and provides all attire needed to enter a restricted surgical zone. Which observation by the nurse requires immediate intervention? Hair is pulled back and covered by a cap. Scrub top and drawstring are tucked into pants. Shoe covers are used. Mask is placed over nose and extends to bottom lip.
Mask is placed over nose and extends to bottom lip.
An OR nurse will be participating in the intraoperative phase of a client's kidney transplant. What action will the nurse prioritize in this aspect of nursing care? Monitoring the client's physiologic status Providing emotional support to family Maintaining the client's cognitive status Maintaining a clean environment
Monitoring the client's physiologic status
Following admission of the postoperative client to the clinical unit, which of the following assessment data requires the most immediate attention? Blood pressure of 94/62 mm Hg Respiratory rate of 12 breaths per minute Oxygen saturation of 82% Urine output of 60 ml/hr
Oxygen saturation of 82%
The postanesthesia care unit nurse is caring for a client who had a hernia repair. The client's blood pressure is now 164/92 mm Hg; the client has no history of hypertension prior to surgery and preoperative blood pressure was 112/68 mm Hg. The nurse should assess for which potential causes of hypertension following surgery? Dysrhythmias, blood loss, and hyperthermia Electrolyte imbalances and neurologic changes A parasympathetic reaction and low blood volumes Pain, hypoxia, and bladder distention
Pain, hypoxia, and bladder distention
The client is undergoing a surgical procedure that is expected to last several hours. Which nursing diagnosis is most related to the duration of the procedure? Risk for perioperative positioning injury related to positioning in the OR Risk of latex allergy response related to possible exposure in the OR environment Disturbed sensory perception related to the effects of general anesthesia Anxiety related to ineffective coping with surgical concerns
Risk for perioperative positioning injury related to positioning in the OR
The surgical client has been intubated and general anesthesia has been administered. The client exhibits cyanosis, shallow respirations, and a weak, thready pulse. The nurse recognizes that the client is in which stage of general anesthesia? Stage I Stage II Stage III Stage IV
Stage IV explanation: Stage IV: medullary depression is characterized by shallow respirations, a weak, thready pulse, dilated pupils that do not react to light, and cyanosis.
The circulating nurse in an outpatient surgery center is assessing a client who is scheduled to receive moderate sedation. Which principle should guide the care of a client receiving this form of anesthesia? The client must never be left unattended by the nurse. The client should begin a course of antiemetics the day before surgery. The client should be informed that the client will remember most of the procedure. The client must be able to maintain the client's own airway.
The client must never be left unattended by the nurse.
The nurse is teaching the client about patient-controlled analgesia. Which of the following would be appropriate for the nurse to include in the teaching plan? The client can self-administer oral pain medication as needed with patient-controlled analgesia. Family members can be involved in the administration of pain medications with patient-controlled analgesia. Therapeutic drug levels can be maintained more evenly with patient-controlled analgesia. There are no advantages of patient-controlled analgesia over a PRN dosing schedule.
Therapeutic drug levels can be maintained more evenly with patient-controlled analgesia.
The nurse is providing preoperative teaching to a client scheduled for surgery. The nurse is instructing the client on the use of deep breathing, coughing, and the use of incentive spirometry when the client states, "I don't know why you're focusing on my breathing. My surgery is on my hip, not my chest." What rationale for these instructions should the nurse provide? To prevent chronic obstructive pulmonary disease (COPD) To promote optimal lung expansion To enhance peripheral circulation To prevent pneumothorax
To promote optimal lung expansion
A client vomits postoperatively. What is the most important nursing intervention? Measure the amount of vomitus to estimate fluid loss, in order to accurately monitor fluid balance. Offer tepid water and juices to replace lost fluids and electrolytes. Support the wound area so that unnecessary strain will not disrupt the integrity of the incision. Turn the client's head completely to one side to prevent aspiration of vomitus into the lungs.
Turn the client's head completely to one side to prevent aspiration of vomitus into the lungs.
The nurse is caring for a client 6 hours post surgery. The nurse observes that the client voids urine frequently and in small amounts. The nurse knows that this most probably indicates what? Requirement of intermittent catheterization Calculus formation Urine retention Urinary infection
Urine retention
What assessment method would the nurse use to determine the areas of the lungs that need draining? Inspection Chest X-ray Arterial blood gas (ABG) levels Auscultation
auscultation
A nurse evaluates the potential effects of a client's medication therapies before surgery. Which drug classification may cause respiratory depression from an associated electrolyte imbalance during anesthesia? corticosteroids diuretics insulin anticoagulants
diuretics
A PACU nurse is caring for an older adult who presents with clinical manifestations of delirium. What short-term outcome would be most important for this client? experiences pain within tolerable limits. exhibits wound healing without complications. resumes usual urinary elimination pattern. maintains adequate fluid status.
experiences pain within tolerable limits.
The nurse understands that the purpose of the "time out" is to: verify all necessary supplies are available. identify the client's allergies. clarify the roles of the OR personnel. maintain the safety of the client.
maintain the safety of the client
The nurse is physically preparing a client for surgery. What immediate pre-operative concerns would the nurse address before the client is taken to the operating room? Select all that apply. medication elimination care of glasses activity support system
medication, elimination, care of glasses
A client is to receive general anesthesia with sevoflurane. What does the nurse anticipate would be given with the inhaled anesthesia? oxygen alfentanil rocuronium lidocaine
oxygen
A physician stated to the nurse that the client has fluid in the pleural space and will need a thoracentesis. The nurse expects the physician to document this fluid as pleural effusion. pneumothorax. hemothorax. consolidation.
pleural effusion.
A client is scheduled for a prostatectomy, and the anesthesiologist plans to use a spinal (subarachnoid) block during surgery. In the operating room, the nurse positions the client according to the anesthesiologist's instructions. Why does the client require special positioning for this type of anesthesia? To prevent confusion To prevent seizures To prevent cerebrospinal fluid (CSF) leakage To prevent cardiac arrhythmias
to prevent CSF leakage
A nurse is assessing a postoperative client with hyperglycemic blood glucose levels. Which post-surgical risk factor would decrease if the surgical client maintained strict blood glycemic control? nutrient deficiencies respiratory complications wound healing liver dysfunction
wound healing