PERIOPERATIVE NURSING

A nurse is to position a client in the postanesthesia care unit. Which factor is most important for the nurse to consider? a. allow for skeletal deformities b. prevent pressure on bony prominences c. provide for adequate thoracic expansion d. avoid stretching of neuromuscular tissue

c

An obese client has abdominal surgery for removal of the gallbladder. Which should the nurse be most concerned about if exhibited by the client? a. constipation b. urinary retention c. shallow breathing d. inability to provide self-care

c

A client's perineal area must be examined by the primary health-care provider prior to surgery. In which position should the nurse place the client for this physical assessment? a. sims b. supine c. lithotomy d. trendelenburg

c

Shade the location

right shoulder area

The primary health-care provider prescribes morphine sulfate 12 mg subcutaneneously STAT for a postop client. The morphine sulfate vial that there are 10mg per mL. Indicate on the syringe the line to which it should be filled

1.2mL

Which of the following independent and dependent nursing interventions help prevent thrombophelbitis during the postop period? Select all that apply a. applying lower-extremity sequential compression devices when in bed b. wearing antiembolism stockings when out of bed c. walking in the hall several times a day d. using an incentive spirometer e. coughing and deep breathing f. keeping the legs uncrossed

a,b,c,f

A nurse is caring for a client recovering from abdominal surgery. Which nursing action is effective in the facilitating ventilation? Select all that apply a. encouraging fluid intake b. preventing abdominal distention c. positioning in the side-lying position d. implementing passive ROM e. ensuring that an incentive spirometer is used every hour when awake

a,b,e

A nurse is teaching a postoperative client the nutrients that are best for supporting collagen production that promotes wound healing. Which food selected by the client indicates that the teaching was effective? Select all that apply a. yellow bell peppers b. whole-grain bread c. cantaloupe d. oranges e. kiwi

a,c,d,e

Which is the next most important assessment made by the nurse after ensuring a postoperative client has a patent airway? a. condition of drains b. level of consciousness c. stability of the vital signs d. location of the surgical dressing

c

A nurse in the postanesthesia care unit at 3pm receives report from the nurse who is completing the day shift. The following information about a 65 man who was admitted to the unit at 1:30pm after repair of a double inguinal hernia is reported. Which information does not meet the standard criteria for discharge from the unit? a. stability of vital signs b. LOC c. absence of bowel sounds d. presence of a urinary catheter

a

A nurse is assessing a client who had spinal anesthesia. For which common response should the nurse assess the client? a. headache b. neuropathy c. lower back discomfort d. increased blood pressure

a

A nurse is assessing a postoperative client. Which client response identified by the nurse indicates altered renal perfusion? a. oliguria b. cachexia c. yellow sclera d. suprapubic distention

a

A nurse is caring for 2 clients. One of the clients has a Jackson-Pratt drain and the other client has a Hemovac drain. Which does the nurse understand is the difference between these two drains? a. the size of the collection container b. how the pressure within the collection container is reestablished c. the type of pressure that promotes drainage to the collection container d. where the collection container should be placed in relation to the insertion site

a

A nurse is caring for a postoperative client. The client asks the nurse why Vitamin C was prescribed. Which information should the nurse include in a response to this question? Select all that apply a. facilitates healing b. improves digestive processes c. increases transport of oxygen to cells d. encourages growth of red blood cells e. minimizes formation of deep vein thrombosis

a

A postoperative client experiences tachycardia, sudden chest pain, and low blood pressure. Which complication associated with the postoperative period should the nurse conclude that the client most likely experienced? a. pulmonary embolus b. hemorrhage c. heart attack d. pneumonia

a

On the second postoperative day after an above-the-knee amputation, the client's elastic dressing accidentally comes off. Which should the nurse do first? a. wrap the residual limb with an elastic compression bandage b. apply a saline dressing to the residual limb c. notify the primary health-care provider d. place two pillows under the limb

a

When should the nurse initiate planned interventions regarding a client's perioperative management? a. when the consent form is signed b. when the decision for surgery is made c. when the client is admitted for surgery d. when the client is transferred to the operating room

a

Which client having emergency surgery should the nurse anticipate to be at the highest risk for postoperative mortality? a. individual who has alcoholism b. person who has epilepsy c. middle-age adult d. infant

a

Which client responses best support the decision to discharge the client from the postanesthesia care unit? a. SaO2 of 95%, vital signs stable for 30 minutes, active gag reflex b. tolerable pain, ability to move extremities, dry intact dressing c. urinary output of 30 mL/hr, awake, turning from side to side d. afebrile, adventitious breath sounds, ability to cough

a

Which factor places a client at the highest risk for postoperative nausea and vomiting after receiving general anesthesia? a. obesity b. inactivity c. hypervolemia d. unconsciousness

a

Which is the most common dietary prescription the nurse can anticipate after a client who had abdominal surgery exhibits a return of intestinal peristalsis? a. clear liquids b. full liquids c. low fiber d. regular

a

A client had a tonsillectomy and is on a soft diet. Which of the following should the nurse encourage this client to have during the first 24 hours after surgery? Select all that apply a. warm pudding b. milk shakes c. apple juice d. ice pops e. gelatin

c,d,e

A nurse is caring for a postop client who had abdominal surgery. The client states "the incision just felt like it gave way." the nurse identifies that the client had a dehiscence with slight evisceration. Which of the following should the nurse implement. Select all that apply a. instruct the client to avoid coughing or bearing down b. notify the primary health-care provider immediately c. position the client in the low-Fowler position d. cover the incision with a sterile dressing e. prepare the client for surgery

a,b,c,d,e

A nurse is caring for a client with the following type of portable wound drainage device. Which should the nurse do when caring for a client with this type of drainage system? Select all that apply a. empty the container and then compress the collection container, close the port, and release hand compression b. wear sterile gloves when emptying the collection container c. keep the collection container below the insertion site d. shorten the length of the tubing by one inch daily e. attach tubing to clothing

a,c,e

A client has a right abdominal incision. Which should the nurse teach the client to do when getting out of bed? Select all that apply a. exit from the left side of the bed b. ask the nurse to apply an abdominal binder c. hold a pillow against the abdomen with both hands d. use the left arm to push up to a sitting position on the side of the bed e. sit on the side of the bed for a few minutes before moving to standing

a,d,e

A client has abdominal surgery. Which should the nurse do to best assess for a sign of postoperative ileus in this client after surgery? a. identify the time of the first bowel movement b. monitor the tolerance of a clear liquid diet c. palpate for abdominal distention d. auscultate for bowel sounds

d

A client arrives in the postanesthesia care unit. Which is the most important information that the nurse needs to know? a. anxiety level before surgery b. type and extent of the surgery c. type of intravenous fluids administered d. special requests that were expressed by the client

b

A nurse compares the advantages and disadvantages of a central venous catheter inserted into a peripheral vein and a central venous catheter inserted into a subclavian vein. Which of the following does the nurse conclude is the reason why a peripheral catheter is more desirable? a. because it will not be in the superior vena cava b. because it will not cause a tension pneumothorax c. because it will not prevent the development of an infection

b

A nurse is evaluating the effectiveness of nursing interventions for meeting the nutrient needs of clients during the first 2 days after abdominal surgery. Which outcome is most important? a. nausea and vomiting have not occurred b. fluid and electrolytes are balanced c. wound healing is progressing d. oral intake is reestablished

b

A nurse is performing preoperative teaching a week before surgery. The client is taking 650mg of aspirin twice a day for arthritis. Which instruction should the nurse expect the surgeon to have the nurse include in the preoperative teaching? a. continue to take the aspirin indefinitely b. stop taking aspirin 5 days before surgery c. withhold the dose of aspirin on the morning of surgery d. reduce the dose of aspirin to 81mg a day until after surgery

b

A nurse is to apply a transparent wound barrier over a client's incision. Which nursing action is appropriate? a. stretch the transparent dressing snugly over the entire wound b. clean the skin with normal saline before applying the dressing c. cover the transparent wound barrier with a gauze dressing and secure with paper tape d. ensure the reinforcing tape extends several inches beyond the edges of the transparent wound barrier

b

A postoperative client is transferred back to the surgical unit with an abdominal dressing and a Penrose drain. Which is the most important nursing action associated with caring for the client with a Penrose drain? a. removing the excess external portion until drainage stops b. changing the soiled dressing carefully c. maintaining the negative pressure d. pinning the drain to the dressing

b

How many days after surgery should the nurse anticipate that a postoperative client will begin to exhibit signs and symptoms of a wound infection if it should occur? a. fifth day b. third day c. ninth day d. seventh day

b

There are discharge criteria for clients in the postanesthesia care unit (PACU) regardless of the type of anesthesia used and additional criteria for specific types of anesthesia. Which is the criterion specific for the client who has received spinal anesthesia? a. oxygen saturation reaches the presurgical baseline b. motor and sensory function returns c. nausea and vomiting are minimal d. headache is reported as tolerable

b

A client received conscious sedation during a colonoscopy. Which should the nurse expect regarding the client's experience with this procedure? a. client will be unresponsive and pain free b. client will be at risk for malignant hyperthermia c. client will be sleepy but able to follow verbal commands d. client will be positioned in the supine position to prevent headache

c

A nurse assesses the client on admission to the postanesthesia care unit and collects the following data: receiving 40% oxygen via a simple face mask, SaO2 92%, opens eyes and responds....which is consistent with his previous blood pressure. Calculate the client's Aldrete score a. 10 b. 9 c. 8 d. 7

c

A nurse is caring for a client who had an abdominal hysterectomy. Which intervention best prevents postoperative thrombophelbitis? a. utilization of compression stockings at night b. deep breathing and coughing exercises daily c. leg exercises 10 times per hour when awake d. elevation of the legs on 2 pillows

c

A nurse is caring for a postoperative client. Which action is effective in preventing postoperative urinary tract infections? a. eating foods with roughage b. taking sitz baths twice a day c. drinking an adequate amount of fluid d. increasing the intake of citrus fruit juices

c

A nurse is considering the commonalities and differences of equipment used for gastric decompression. Which is the major advantage to using a double-lumen tube? a. minimizes the risk of a bowel obstruction b. ensures drainage of the intestines c. prevents gastric mucosal damage d. promotes gastric rest

c

Four days after abdominal surgery, while being transferred from a bed to a chair, a client says to a nurse, "my incision feels funny all of a sudden." Which should the nurse do first? a. take the vital signs b. apply an abdominal binder immediately c. place the client in the low-Fowler position d. encourage slow deep breathing by the client

c

A client has negative pressure wound therapy (VAC) after the amputation of a toe. The tubing is connected to intermittent negative pressure. What should the nurse do when the film over the wound collapses when negative pressure is exerted? a. notify the primary health-care provider b. decrease the extent of negative pressure c. apply a new transparent film over the wound d. continue to observe the functioning of the device

d

A client is admitted to the postanesthesia care unit. Which nursing action is most important during the client's stay in this unit? a. monitoring urinary output b. assessing level of consciousness c. ensuring patency of drainage tubes d. suctioning mucus from respiratory passages

d

A client spikes a fever during the first postoperative day after major abdominal surgery. The nurse suspects that the fever indicates an infection. Which site does the nurse conclude most likely is the source of the infection? a. intestines b. bladder c. wound d. lungs

d

A hospitalized client who has been receiving medications via a variety of routes for several days is scheduled for surgery at 10 am. Which should the nurse plan to do on the day of surgery? a. use an alternative route for the oral medications b. withhold all the previously prescribed medications c. withhold the oral medications and administer the other drugs d. obtain directions from the primary health-care provider regarding the medications

d

A nurse is caring for a client who had abdominal surgery. Which type of incisional drainage should the nurse expect 4 hours after surgery? a. serous wound drainage b. purulent wound drainage c. sanguineous wound drainage d. serosanguineous wound drainage

d

A nurse is caring for a client with a nasogastric tube attached to suction. What is the most important nursing action in relation to the nasogastric tube? a. using sterile technique when irrigating the tube b. recording intake and output every 2 hours c. providing oral hygiene every 4 hours d. setting suction at the prescribed level

d

A nurse is caring for several clients who received general anesthesia. A client with which concurrent health problem poses the highest risk for the development of a postoperative complication? a. gastroesophageal reflux disease b. reduced reflexes c. hypothyroidism d. emphysema

d

One hour after the reduction of a compound fracture of the ulna and radius and application of a cast, the nurse observes a centimeter circle of drainage on the client's cast. Which should the nurse do first? a. inform the surgeon immediately b. reinforce the cast with a gauze dressing c. monitor the area frequently for expansion d. circle the spot with a pen and date, time, and initial the area

d

A primary health-care provider prescribes antiembolism stockings for a client. Place the following steps in the order in which they should be implemented when applying these stockings. a. assess the client's contraindications to the use of stockings b. apply the stockings before getting the client out of bed in the morning c. ensure that the stockings are 1-2 inches below the popliteal fold in the back of the knee d. explain that the stockings are prescribed and what is to be done and why e. measure the smallest circumference of the ankle, the largest of the calf, and the length of the heel to 1-2 in below the popliteal fold in the back of the knee f. turn the stocking inside out so that the foot portion is inside the stocking leg

d,a,e,b,f,c

A nurse must initiate placement of a continuous passive motion machine after the client had a total knee replacement. Place the following steps in the order in which they should be implemented. a. position the extremity on the platform so the knee is centered over the break in the platform b. set the degree of flexion, speed, and time on and off the machine as prescribed c. ensure that the extremity is aligned with the client's hips and torso d. assess the client's skin and provide skin care after the procedure e. position sheepskin on the platform, especially at the gluteal fold f. position the controller within easy reach of the client

e,a,c,b,f,d