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Which of the following statements, if made by an adolescent preparing for abdominal surgery, would indicate to the nurse that the client requires additional instruction? a) "When I can eat again, the best meal would be steak and orange juice." |
"I can have a hamburger and French fries as soon as I wake up." Explanation: Oral fluid and food may be withheld until intestinal motility resumes 819 |
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A patient had an open cholecystectomy (gall bladder removal) 36 hours earlier, and the nurse’s assessment this morning confirms that the patient has not yet had a bowel movement since prior to surgery. How should the nurse best respond to this assessment finding? a) Administer a cleansing enema. |
Monitor the patient closely and promote fluid intake. Explanation: Bowel function does not typically return immediately after surgery, but it can be promoted by encouraging fluid and fiber intake as appropriate to the patient and his or her surgery. A medical assessment is likely unnecessary at this early postoperative stage and an enema would likely be premature. The nurse may not independently increase the patient’s IV infusion, and doing so would not necessarily promote a bowel movement. 845 |
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A female client age 54 years has been scheduled for a bunionectomy (removal of bone tissue from the base of the great toe) which will be conducted on an ambulatory basis. Which of the following characteristics applies to this type of surgery? a) The client must be previously healthy with low surgical risks. |
The client will be admitted the day of surgery and return home the same day. Explanation: Outpatient surgeries, also known as ambulatory surgeries, are conducted with admission and discharge on the same day. Such surgeries have become increasingly common in recent years, and some surgeries of increasing complexity and risk are conducted on an outpatient basis. General anesthesia is possible, and common. This approach is more common for elective surgeries than urgent surgeries. 823 |
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Which of the following clients most likely requires special pre-operative assessment and treatment as a result of his or her existing medication regimen? a) A man who regularly treats his rheumatoid arthritis with over-the-counter nonsteriodal anti-inflammatory drugs (NSAIDs) |
A woman who takes daily anticoagulants to treat atrial fibrillation Explanation: Anticoagulants present a risk of hemorrhage. This risk supersedes that posed by thyroid supplements, ACE inhibitors, or most NSAIDs. 826 |
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A nurse is assessing the pre-operative checklist of a client. Which of the following observations listed in the pre-operative checklist should the nurse verify? a) If the client has worn a fresh set of clothes |
If the client has urinated properly Explanation: In a pre-operative checklist, the nurse verifies that the client has urinated, is wearing an identification bracelet, has removed his dentures, and is wearing only a hospital gown and hair cover. Nurses assess a client’s response to reversal drugs not when checking the pre-operative checklist but rather when the client is recovering from anesthesia. Reversal drugs are given to clients in case they become overly sedated. 837 |
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Nurses teach patients to restrict food and fluids before surgery. What condition does this measure attempt to avoid? a) Infection |
Aspiration Explanation: Food and fluid are restricted before surgery to ensure that the stomach contains a minimal amount of gastric secretions. This restriction is important to reduce the risk of aspiration. 852 |
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A client with abdominal incisions experiences excruciating pain when he tries to cough. What should the nurse do to reduce the client’s discomfort when coughing? a) Ask the client to drink plenty of water before coughing. |
Administer prescribed pain medication 30 minutes before deliberately attempting to cough. Explanation: Coughing is painful for clients with abdominal or chest incisions. Administering pain medication approximately 30 minutes before coughing, or splinting the incision when coughing, can reduce discomfort. Making the client lie in a lateral position or asking the client to drink plenty of water is not helpful because it will make breathing and coughing even more difficult for the client. 833 |
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Upon assessment, a client reports that he drinks five to six bottles of beer every evening after work. Based upon this information, the nurse is aware that the client may require which of the following? a) Lower doses of anesthetic agents and lower doses of postoperative analgesics |
Larger doses of anesthetic agents and larger doses of postoperative analgesics Explanation: Clients with a large habitual intake of alcohol require larger doses of anesthetic agents and postoperative analgesics, increasing the risk for drug-related complications. 827 |
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The nurse knows the term perioperative phase refers to care given to the client
a) Immediately before an operative procedure |
Before, during, and after the operative phase Explanation: Perioperative nursing includes three distinct phases: preoperative, intraoperative, and postoperative.818 |
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When an elderly client is brought to the recovery room and presents with irregular, loud respirations, the nurse determines that this most likely a result of a) Effects of anesthesia |
Partial airway obstruction Explanation: Loud, irregular respirations may indicate obstruction of the airway, possibly from emesis, accumulated secretions, or client positioning that allows the tongue to fall to the back of the throat.839 |
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A nurse is caring for an elderly client with muscle atrophy. Which of the following conditions can lead to muscle atrophy in elderly clients? a) Being bedridden for 1 or 2 days |
Being bedridden for 1 or 2 days Explanation: Muscle atrophy can occur in older adults who have been on bed rest even for 1 or 2 days. Range of motion and muscle tone can be maintained through routine active or passive range of motion exercises. Elderly clients having age-related skin changes and poor hydration can have slow wound healing. An indwelling catheter in elderly clients can lead to urinary tract infection, not muscle atrophy. 825-826 |
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A client has been taking aspirin since his heart attack in 1997. The client is at risk for what? a) Infection |
Hemorrhage Explanation: Current medication use, especially use of medications that can affect coagulation status (warfarin, nonsteroidal anti-inflammatory drugs, aspirin) is important and should be reported to the surgeon. 852 |
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The nurse is providing education to a client regarding pain control after surgery. What time does the nurse inform the client is the best time to request pain medication? a) After the pain becomes severe and relaxation techniques have failed |
Before the pain becomes severe Explanation: If a pain medication is ordered p.r.n., the client should be instructed to ask for the medication before the pain becomes severe 832 |
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A nurse is assisting a cosmetic surgeon in removing the skin tattoos from a client’s back. What are the advantages offered by laser surgery as compared to conventional surgeries? a) Reduces scarring |
Reduces scarring Explanation: Laser surgery offers advantages such as reduced scarring, minimal blood loss, cost effectiveness, smaller incisions, and less time recuperating. Laser surgery does not eliminate all sensation, but general anesthesia does. Laser surgery has decreased the incidence of, but not eliminated, wound infection. Laser surgery does not provide pain relief, but it can reduce pain to some extent. 821 |
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A nurse is caring for an older adult following hip surgery. Which of the following serious complications would the nurse attempt to avoid by encouraging use of the incentive spirometer? a) Pneumonia |
Pneumonia Explanation: In the older adult patient, postoperative pneumonia can be a very serious complication resulting in death. Therefore, it is especially important to encourage and assist the patient in using the incentive spirometer and with deep-breathing exercises. 833 |
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The nurse has entered the room of a client who is postoperative day one and finds the client grimacing and guarding her incision. The client refuses the nurse’s offer of PRN analgesia, and on discussion, states that this refusal is motivated by his fear of becoming addicted to pain medications. How should the nurse respond to the client’s concerns? a) "You should remind yourself that treating your pain is important now, and that dealing with any resulting dependency can come later." |
"Research has shown that there is very little risk of clients becoming addicted to painkillers after they have surgery." Explanation: There is little danger of addiction to pain medications used in the postoperative management of pain 832 |
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Following a successful coronary artery bypass graft (CABG), a 71-year-old male patient has been transferred to the postanesthetic care unit (PACU). What is the priority for the patient’s nursing care during this stage of his recovery? a) Positioning the patient to prevent skin breakdown |
Protecting and maintaining the patient’s airway Explanation: As in all nursing contexts, the patient’s airway is the priority. Preventing skin breakdown, treating pain, and performing vigilant infection control are all important aspects of care, but each is superseded by the importance of protecting the patient’s airway 839 |
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A nurse is assessing an older adult client who has undergone major bypass surgery at the healthcare facility. When developing the plan of care for this client in the postoperative period, which of the following would the nurse identify as a priority assessment in the immediate period and for the first few days after the surgery? a) Bowel elimination pattern |
Respiratory function Explanation: During the immediate postoperative period and for the first few days after a major surgery, assessments should focus on the client’s respiratory function, pain, and tissue perfusion. The bowel elimination pattern and the ability to perform self-care and ambulate after discharge are important later in the post-operative course. 839 |
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The nurse is preparing a patient for a colonoscopy. The nurse is familiar with the colonoscopy procedures at the hospital and is aware that which type of anesthesia is commonly used for this procedure? a) Nerve block |
Conscious sedation Explanation: Moderate sedation/analgesia is also known as conscious sedation or procedural sedation. It is used for short-term and minimally invasive procedures such as endoscopy procedures (e.g., colonoscopy).823 |
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In order to prevent the possibility of venous stasis, a nurse is teaching a surgical client how to perform leg exercises. Which of the client’s following statements indicates a sound understanding of leg exercises? a) "I’m pretty sure my stomach muscles are strong enough to lift both of my legs off the bed at the same time." |
"I’ll practice these now and try to start them as soon as I can after my surgery." Explanation: Leg exercises should be begun as soon as possible after surgery, unless contraindications exist. Bed rest does not preclude the performance of leg exercises and the legs should be lifted individually, not simultaneously. The client should perform leg exercises in a semi-Fowler’s, not prone, position. |
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A nurse is caring for a female client who will undergo a curative surgery for cholecystectomy. Which of the following precautions should the nurse take before surgery to prevent venous stasis? a) Recommend that the client wear antiembolism stockings |
Recommend that the client wear antiembolism stockings Explanation: The client should wear antiembolism stockings or the client’s legs should be wrapped in an elastic roller bandage before surgery to prevent venous stasis. Asking the client to wiggle the toes at regular intervals is a secondary precaution. However, enclosing the client’s leg in a pneumatic splint is not correct because pneumatic splints are used to control swelling and bleeding of an injury. If the client wears dentures, some health care agencies remove them to prevent airway obstruction.849-850 |
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Which of the following nursing interventions is most likely to prevent respiratory complications such as pneumonia and atelectasis in a postsurgical client? a) Use of incentive spirometry |
Use of incentive spirometry Explanation: Incentive spirometry improves lung expansion, helps expel anesthetic gases and mucus from the airway, and facilitates oxygenation of body tissues. Pain control and hydration may facilitate lung expansion and mobilization of secretions, but incentive spirometry directly increases lung volume and alveolar expansion.833 |
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Upon admission for an appendectomy, the client provides the nurse with a document that specifies instructions his health care team should follow in the event he is unable to communicate these wishes postoperatively. What is the document best known as? a) An informed consent |
An advance directive Explanation: An advance directive, a legal document, allows the client to specify instructions for his or her health care treatment should he or she be unable to communicate these wishes postoperatively. The advance directive allows the client to discuss his or her wishes with the family members in advance of the surgery. Two common forms of advance directives include living wills and durable powers of attorney for health care.823 |
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Surgery can lead to hypothermia. Of the following clients, who is at greatest risk for hypothermia? a) A young adult with a fractured leg |
An elderly man with a fractured hip Explanation: The risk of hypothermia increases in the very young and the very old.825 |
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The telemetry unit nurse is reviewing laboratory results for a client who is scheduled for an operative procedure later in the day. The nurse notes on the laboratory report that the client has a serum potassium level of 6.5 mEq/L, indicative of hyperkalemia. The nurse informs the physician of this laboratory result because the nurse recognizes hyperkalemia increases the client’s operative risk for which of the following? a) Cardiac problems |
Cardiac problems Explanation: Hyperkalemia or hypokalemia increases the client’s risk for cardiac problems. A decrease in the hematocrit and hemoglobin level may indicate the presence of anemia or bleeding. An elevated white blood cell count occurs in the presence of infection. Abnormal urine constituents may indicate infection or fluid imbalances.829 |
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A nurse teaches deep breathing exercises to a client scheduled for surgery. In which of the following perioperative phases would this action occur? a) Pre-operative |
Pre-operative Explanation: Exercises and physical activities occurring in the pre-operative phase include deep-breathing exercises, coughing, incentive spirometry, turning, leg exercises, and pneumatic compression stockings 833 |
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A client has arrived in the same-day surgery suite. He states to the nurse, "I am so worried about being put to sleep and having the surgery." What would be the nurse’s best response?
a) "Tell me what you are most worried about." |
"Tell me what you are most worried about." Explanation: The nurse should first assess what the client is most worried about, and then provide emotional support. 828 |
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A nurse is caring for an older adult client who has been prescribed fluid restriction before surgery. Which of the following should the nurse check to assess the risks of fluid restriction in elderly clients? a) Anxiety level |
Vital signs Explanation: The nurse should assess the client’s vital signs, weight, and sternal skin turgor prior to fluid restriction to serve as a baseline for comparison. The period of fluid restriction before surgery may be shortened for older adults to reduce their risk of dehydration and hypotension. Nurses check a client’s self-therapy practices and cardiac status to avoid any complications of bleeding and elimination of intravenous fluids given at a standard rate. 826 |
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A nurse is applying a pneumatic compression device to a client. What is the purpose of a pneumatic compression device? a) Enables the client to void |
Promotes circulation of venous blood Explanation: A pneumatic compression device promotes the circulation of venous blood and relocation of excess fluid into the lymphatic vessels. The device does not pump a liquid diet to the client, help the client to void, or reduce swelling and pain. 843-844 |
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While reviewing the medical record of a client who has had abdominal surgery, the nurse notes that the client has developed a paralytic ileus. The nurse interprets this information as indicative of which of the following? a) Bowel functioning ceases due to becoming permanently paralyzed |
Bowel functioning is significantly decreased Explanation: The nurse knows that when a client has paralytic ileus, the bowel functioning decreases significantly. In some cases, intestinal peristalsis may temporarily cease altogether, but it does not become permanently paralyzed. The bowel does not become deflated, but it does become distended and partially paralyzed. Bowel sounds are usually absent. 845 |
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A client is undergoing surgery for an appendectomy. This would be considered what type of surgery? a) Palliative surgery |
Emergency surgery Explanation: An appendectomy is considered emergency or urgent surgery. Elective surgery can be scheduled in advance, and delay has no ill effects. Palliative surgery is done to relieve or reduce the intensity of an illness, and diagnostic surgery is done to make or confirm a diagnosis. 821 |
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A nurse is dressing the wound of a client who is admitted to the outpatient surgical unit. Which of the following is a major advantage of outpatient surgery? a) It allows less opportunity for family contact and support. |
It interferes less with the client’s daily routine. Explanation: A major advantage of outpatient surgery is that it interferes less with the client’s daily routine. It also allows more opportunity for family contact and support. Some disadvantages are that it reduces the time for establishing a nurse-client relationship and requires intensive pre-operative teaching in a short time. |
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When educating a client in the postoperative period, it is important to educate the client to consume a diet high in a) Potassium |
Protein Explanation: After surgery, a diet with sufficient amounts of protein and vitamins A and C helps rebuild tissues and promotes wound healing.845 |
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In the postoperative phase of abdominal surgery, the client complains of severe abdominal pain. In the second postoperative day, the client’s bowel sounds are absent. What does the nurse suspect? a) Paralytic ileus |
Paralytic ileus Explanation: A potential complication after surgery is paralytic ileus, a condition in which there is decreased bowel functioning. 845 |
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The PACU nurse has received a semiconscious client from the operating room and reviews the chart for orders related to positioning of the client. There are no specific orders on the chart related to the client’s position. In this situation, in what position will the nurse place the patient? a) Trendelenburg position |
Side-lying position Explanation: If the client is not fully conscious, place the client in the side-lying position, unless there is an ordered position on the client’s chart. 841 |
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The nurse recognizes the value of leg exercises in the prevention of postoperative thrombophlebitis. When should the nurse teach the correct technique for leg exercises to a client? a) Upon transfer from postanesthetic care unit to the postsurgical unit |
Prior to surgery Explanation: Though leg exercises are begun after surgery, such preventative measures should ideally be taught to the patient during the preoperative period.833 |
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The operating room nurse is aware that which of the following clients is at a greater risk related to a surgical procedure? a) A woman 34 years of age |
A woman 83 years of age Explanation: Infants and older adults are at a greater risk from surgery than are children and young or middle-age adults. Physiologic changes associated with aging increase the surgical risk for older clients. 825 |
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A nurse is caring for a client who has been wrapped with anti-embolism stockings to avoid thrombus formation. Which of the following measures can prevent thrombi? a) Drink plenty of fluids |
Drink plenty of fluids Explanation: Drinking plenty of fluids can help to prevent thrombi because it promotes circulation by increasing the fluid component of blood. Avoiding long periods of sitting, avoiding keeping the legs crossed, especially at the knees, and ambulating are also methods to prevent thrombi. 843 |
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What is the rationale for having the client void before surgery? a) To assess for pregnancy in women |
To prevent bladder distention Explanation: Having the client void before surgery will assist in the prevention of bladder distention during or after the procedure. 834 |
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A nurse is reinforcing wound edges and applying a blinder to the separated incisions of a client after a surgery. Which of the following postoperative complications has the client developed? a) Shock |
Dehiscence Explanation: The nurse is taking care of a client with dehiscence. Hypoxemia develops when there is inadequate oxygenation of blood. Evisceration occurs when there is protrusion of abdominal organs through a separated wound. A client has shock when there is inadequate blood flow. 845 |
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Following a successful coronary artery bypass graft (CABG), a 71-year-old male patient has been transferred to the postanesthetic care unit (PACU). What is the priority for the patient’s nursing care during this stage of his recovery? a) Preventing incisional infection and monitoring for signs and symptoms of infection |
Protecting and maintaining the patient’s airway Explanation: As in all nursing contexts, the patient’s airway is the priority. Preventing skin breakdown, treating pain, and performing vigilant infection control are all important aspects of care, but each is superseded by the importance of protecting the patient’s airway 839 |
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A nurse from the ambulatory surgical center is preparing discharge instructions for a client who has had pelvic surgery. Which criterion would the client need to demonstrate to ensure that she is ready for discharge? a) Verbalize absence of pain |
Void normally Explanation: Before discharge from an ambulatory surgical unit, the client should be able to void normally after a pelvic surgery. It is natural for the client to experience pain after surgery; however, the client should also have the comfort level to control it. The client may not be in a position to eliminate nausea and vomiting completely before discharge, but should suffer minimally from them. The client may have some bleeding or drainage, which should not be excessive at the time of discharge from an ambulatory surgical unit.845 |
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Which of the following nursing interventions occurs in the postoperative phase of the surgical experience? a) Airway/oxygen therapy/pulse oximetry |
Airway/oxygen therapy/pulse oximetry Explanation: Airway/oxygen therapy/pulse oximetry occur in the postanesthesia unit in the postoperative phase. Teaching deep-breathing exercises and reviewing the meaning of p.r.n. orders for medications occur in the preoperative phase. Putting in IV lines and administering fluids occurs in the intraoperative phase. 854 |
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Which of the following nursing action provides the greatest assistance in healing? a) Maintaining a restful environment |
Maintaining a restful environment Explanation: The nurse should plan for adequate periods of rest and sleep, maintaining a quiet, restful environment. 827 |
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Which of the following surgical clients will return to activities in their everyday lives more quickly? a) Right nephrectomy |
Laparoscopic cholecystectomy Explanation: Clients who have surgery using a laparoscope are able to return to previous activity levels much sooner. 823 |
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A female client age 54 years has been scheduled for a bunionectomy (removal of bone tissue from the base of the great toe) which will be conducted on an ambulatory basis. Which of the following characteristics applies to this type of surgery? a) The surgery is classified as urgent rather than elective. |
The client will be admitted the day of surgery and return home the same day. Explanation: Outpatient surgeries, also known as ambulatory surgeries, are conducted with admission and discharge on the same day. Such surgeries have become increasingly common in recent years, and some surgeries of increasing complexity and risk are conducted on an outpatient basis. General anesthesia is possible, and common. This approach is more common for elective surgeries than urgent surgeries. 823 |
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Choice Multiple question – Select all answer choices that apply. a) Pruritus |
• Local inflammation • Redness • Pruritus Explanation: When a person is allergic to natural rubber latex products, the allergy is manifested by local inflammation, pruritus, and redness. Cough and headache are not allergic reactions caused by latex products 847 |
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Choice Multiple question – Select all answer choices that apply. a) Raised temperature |
• Obesity • Bleeding tendencies • Low hemoglobin Explanation: Certain surgical risk factors, such as obesity, bleeding tendencies, low hemoglobin, smoking, diabetes, cardiopulmonary disease, drug and alcohol abuse, and diabetes, increase the likelihood of perioperative complications. Raised temperature and anxiety are causes for postponing or cancelling the surgery. 825 |
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A nurse is assisting a physician in an emergency surgery for a client with intestinal perforation. Which of the following descriptions is most suitable to the type of surgery performed? a) Surgery performed at the client’s request |
Surgery required immediately for survival Explanation: An emergency surgery is a surgery required immediately for survival. Elective surgery is planned at the client’s convenience; whereas, an optional surgery is performed at the client’s request. When urgent surgery is required, it is necessary and done within one or two days. 821 |
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A nurse is caring for a client who is scheduled to undergo a breast biopsy. Which of the following major tasks does the nurse perform immediately during the pre-operative period? a) Conduct a nursing assessment. |
Conduct a nursing assessment. Explanation: During the immediate pre-operative period, the nurse conducts a nursing assessment. Nurses obtain the signature of the client, nearest blood relative, or someone with durable power of attorney before the administration of any pre-operative sedatives. They also administer medications as ordered by the physician regardless of their toxicity. They assist the client with psychosocial preparation and complete the surgical checklist, which is reviewed by the operating room personnel. 836 |
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A nurse teaches deep-breathing exercises to a preoperative patient. Which of the following accurately describes a step in this exercise? a) Instruct the patient to place the palms of both hands along the upper posterior rib cage. |
Instruct the patient to exhale gently and completely before breathing in. Explanation: The nurse should assist the patient to sit up and place the palms of both hands along the lower anterior rib cage. The patient should then exhale gently and completely and breathe in through the nose as deeply as possible, holding the breath for 3 seconds. 833 |
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Choice Multiple question – Select all answer choices that apply. a) Diagnostic tests |
• Prior laboratory tests • Diagnostic tests • Meet anesthesiologist Explanation: Many people who have inpatient surgery undergo prior laboratory and diagnostic tests. Some clients meet the anesthesiologist or anesthetist, a nurse specialist who administers anesthesia under the direction of a physician. Most clients will have received preoperative instructions from either the surgeon’s office nurse or a hospital nurse. Meeting family members is not part of inpatient surgery; neither is a home care note. A home care note is given to a client when he or she is discharged from the health care facility as part of the outpatient surgery routine. 825 |
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The nurse monitors the urine output of a postoperative patient. What condition does urine output indicate? a) Kidney failure |
Tissue perfusion Explanation: Urine output is a good indicator of tissue perfusion. Patient may need more fluid or may need medication to increase blood pressure if it is low. 840 |
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A nurse caring for a patient postoperatively notes that the patient’s wound dressing was clean before but now has a large amount of fresh blood. What intervention should be taken by the nurse in this situation along with notifying the primary care provider? a) Change dressing |
Reinforce dressing Explanation: The nurse should not remove the dressing, but instead should reinforce the dressing with more bandages. Removing the bandage could dislodge any clot that is forming and lead to further blood loss. 840 |
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A nurse is assisting a physician during a cesarean section for a client. The client is administered epidural anesthesia. Which of the following is an advantage of epidural anesthesia? a) It decreases the risk of gastrointestinal complications. |
It decreases the risk of gastrointestinal complications. Explanation: Epidural anesthesia is a regional anesthesia administered to a client before surgery; it decreases the risk of gastrointestinal complications in clients. Reversal drugs are medications that counteract the effects of those used for conscious sedation. General anesthesia acts on the central nervous system to produce loss of sensation; it prevents clients from remembering their initial recovery period. 822 |
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Upon admission for an appendectomy, the client provides the nurse with a document that specifies instructions his health care team should follow in the event he is unable to communicate these wishes postoperatively. What is the document best known as? a) A Patient’s Bill of Rights |
An advance directive Explanation: An advance directive, a legal document, allows the client to specify instructions for his or her health care treatment should he or she be unable to communicate these wishes postoperatively. The advance directive allows the client to discuss his or her wishes with the family members in advance of the surgery. Two common forms of advance directives include living wills and durable powers of attorney for health care.823 |
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Which of the following clients will see the greatest permanent changes in lifestyle following surgery? a) Left mastectomy |
Ileostomy Explanation: Permanent changes in the client’s activity level may occur as a result of surgery. The client with an ileostomy will encounter the greatest changes in lifestyle.845 |
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A nurse is caring for a client with a chest incision. Which action should the nurse ask the client to perform to induce forced coughing? a) Pull the abdomen inward |
Pull the abdomen inward Explanation: To induce forced coughing, the nurse should ask the client to pull the abdomen inward and lean slightly forward, not backward. The nurse could also tell the client to take a slow deep breath through the nose and exhale through the mouth and cough three times in a row while exhaling.834 |
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A nurse is preparing an obese male client for gastric banding surgery. Which of the following would the nurse be least likely to include in the client’s preoperative teaching plan? a) Techniques for effective deep breathing and turning |
Appropriate procedure to care for the surgical site Explanation: Preoperative client teaching helps the client understand what will occur during each phase of the surgical experience and how they can participate in their own recovery. Preoperative teaching includes a general orientation and explanation of the surgical experience, discussion of preoperative activities to prepare the patient for surgery, and description of postoperative care to promote optimal function and recovery. Teaching the client about the appropriate procedure to care for the surgical site would be more appropriate in the postoperative phase.849 |
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A client in the immediate postoperative period begins to complain of nausea and ultimately begins vomiting. The nausea and vomiting is most likely related to a) Movement of bowels during surgery |
The effects of anesthetic agents Explanation: Nausea and vomiting can occur postoperatively from the effects of anesthetic agents.822 |
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Choice Multiple question – Select all answer choices that apply. a) Cholecystectomy |
• Cholecystectomy • Hernia repairs • Appendectomy Explanation: Surgeries such as cholecystectomies, appendectomies, and hernia repairs, which were once performed only in big healthcare centers, are now performed in ambulatory surgical centers. Rhinoplasty involves the repair of physical deformities of the nose. It is usually done in private clinics and physicians’ offices. Endoscopy involves confirmation of suspected diagnoses. It can be done in clinics and in physician’s offices, not necessarily in ambulatory surgical centers. Ambulatory surgical centers save money and time, which is the reason they are known as one-day surgical units or surgicenters. 823 |
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A physician has ordered a nurse to administer conscious sedation to a client. Which of the following is possible after administering conscious sedation to a client? a) Client’s consciousness level can be monitored by equipment. |
Client is relaxed, emotionally comfortable, and conscious. Explanation: Conscious sedation refers to a state in which the client is sedated in a state of relaxation and emotional comfort, but is not unconscious. The client is free of pain, fear, and anxiety and can tolerate unpleasant diagnostic and short therapeutic surgical procedures, such as an endoscopy or bone marrow aspiration. The client can respond verbally and physically. However, no equipment can replace a nurse’s careful observations for monitoring clients. 823 |
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Choice Multiple question – Select all answer choices that apply. a) Preventing injuries |
• Providing emotional support • Maintaining asepsis • Preventing injuries Explanation: Nursing interventions during the intraoperative period focus on providing emotional support, ensuring a safe environment, and preventing injury to the client. Selecting the type of anesthesia used is usually done during the pre-operative period, not during the intra-operative period. The nurse assesses the blood loss and prepares an effective care plan for the client in the post-operative period, not during the intra-operative period. 838 |
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A client returning to the floor after orthopedic surgery is complaining of nausea. The nurse is aware that an appropriate intervention is to do which of the following? a) Avoid strong smelling foods. |
Avoid strong smelling foods. Explanation: Nursing care for a xlient with nausea includes avoiding strong smelling foods, providing oral hygiene, administering prescribed medications (especially medications ordered for nausea and vomiting), and avoiding use of a straw. 846 |
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A client states he has a latex allergy. What action should the nurse take? a) Place an allergy identification band on the client. |
Place an allergy identification band on the client. Explanation: Assist the client with allergies to medications, food, and latex before the surgical procedure, and clearly mark them on the client record, and on the client identification band. 848 |
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A nurse is assigned to be the circulating nurse, assisting a surgeon in the operating room. The nurse would be responsible for which of the following? a) Providing sponges and drains to the surgical team in the operating room |
Controlling the temperature and humidity in the operating room Explanation: The circulating nurse manages client care in the operating room by controlling the temperature, humidity, and lighting in the operating room. The scrub person provides sponges and drains to the surgical team members. The scrub person also prepares the sterile tables in the operating room before surgery and anticipates the needs of other members of the surgical team. 838 |
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Which of the following clients most likely requires special pre-operative assessment and treatment as a result of his or her existing medication regimen? a) A woman who takes daily thyroid supplements to treat her longstanding hypothyroidism |
A woman who takes daily anticoagulants to treat atrial fibrillation Explanation: Anticoagulants present a risk of hemorrhage. This risk supersedes that posed by thyroid supplements, ACE inhibitors, or most NSAIDs. 826 |
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What nursing action will assist in pain management for a client in the postoperative phase? a) Client teaching |
Relaxation techniques Explanation: Nursing interventions vital in helping clients cope with pain include administering medications, positioning, relaxation techniques, psychological support, distraction techniques, and appropriate referrals to other health professionals. 828 |
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A patient has presented to a clinic for a presurgical consult, during which the patient has expressed concern about having to fast before surgery. Current recommendations for preoperative fasting include which of the following? a) Preoperative fasting is still often recommended, even though it is medically unnecessary. |
Patients can usually eat or drink up to 2 hours prior to surgery. Explanation: Current practice is to allow patients to drink liquids or eat food up to 2 hours before surgery depending on the type of surgery and with the permission of the physician. 852 |
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A patient is scheduled for cardiac surgery in an acute-care facility. What intervention would occur in the intraoperative phase of this patient’s perioperative care? a) Visit by the anesthesiologist |
Skin preparation Explanation: The intraoperative phase begins when the patient is transferred to the OR bed until transfer to the postsurgical recovery area. One of the interventions performed in this phase is skin preparation. The preoperative phase provides patient teaching regarding the surgical experience, including a visit by the anesthesiologist. The postoperative phase begins immediately after the surgical procedure is completed. Assessments and therapies (listed in answers A and C) are performed in this phase. 836 |
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In what phase of the surgical experience would advance directives be discussed with the patient? a) Intraoperative |
Preoperative Explanation: An advance directive provides written communication of the patient’s wishes to the healthcare team related to the patient’s desire for extraordinary life-sustaining treatments if the patient’s condition is deemed unsalvageable. This should be discussed in the preoperative phase.818 |
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A client is being discharged following surgery for cancer care. The client will require extensive dressing changes two times per day. The client is on a fixed income and cannot afford to purchase dressing supplies. The nurse contacts the local Peregrine Society to assist in the provision of dressings. This contribution in care will assist in improving the client’s a) Self-concept |
Self-concept Explanation: In addition to providing the client with the necessary technical care, teaching, extensive rehabilitation, and emotional support, nursing interventions may also include referral to agencies and support groups that can benefit the client after surgery and discharge from the acute care facility. 824 |
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A nurse asks a preoperative patient what medications he is currently taking. Which of the following is an accurate guideline for patient teaching regarding these medications? a) Aspirin is generally stopped 1 month before surgery. |
Certain respiratory drugs may be taken the day of surgery per physician’s order. Explanation: Adjustments in taking medications may be needed before surgery. Anticoagulants are stopped days before surgery. Certain cardiac and respiratory drugs may be taken the day of surgery per physician’s order. If the patient is diabetic and takes insulin, the insulin dosage may be reduced 826 |
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A nurse is taking care of a client during the immediate post-operative period. Which of the following duties performed during the immediate post-operative period is most important? a) Prepare a room for the client’s return. |
Monitor the client for complications. Explanation: The immediate post-operative period refers to the first 24 hours after surgery. During this time, the nurse monitors the client for complications as he or she recovers from anesthesia. Once the client is stable, the nurse prepares a room for the client’s return and assesses the client to prevent or minimize potential complications. The nurse ensures the safe recovery of the client after the client has stabilized. 839-840 |
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A nurse explains the effects of conscious sedation to a patient undergoing a colonoscopy. Which of the following occurs with conscious sedation? a) Lowered pain threshold |
Altered mood Explanation: Conscious sedation is a type of anesthesia used for short procedures; the intravenous administration of sedatives and analgesics raises the pain threshold and produces an altered mood and some degree of amnesia, but the patient maintains cardiopulmonary function and can respond to verbal commands. 823 |
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A nurse is caring for an elderly client who had a surgery for the removal of a cataract in the left eye. When can the client return home after outpatient surgery? a) After 2 days |
The same day Explanation: Outpatient surgery, also called ambulatory surgery and same-day surgery, is the term used for operative procedures performed on clients who return home the same day. It generally is reserved for clients in an optimal state of health whose recovery is expected to be uneventful.821-822 |
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A nurse is caring for an infant who is postoperative following cardiac surgery. What is the most common postoperative complication found in this age group? a) Circulatory complications |
Respiratory complications Explanation: According to Dunn (2005), most postoperative complications are related to the respiratory system in infants. After receiving general anesthesia, premature infants are at greater risk for apnea. 825 |
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Choice Multiple question – Select all answer choices that apply. a) Ablative |
• Diagnostic • Ablative Explanation: Ablative surgery involves the removal of a diseased body part (i.e., breast tissue) while diagnostic surgery, such as biopsy of a lymph node, involves the removal of tissue for determining a diagnosis or the extent of disease involvement. This patient is not receiving constructive, reconstructive, or palliative surgery at this time. 821 |
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The nurse is preparing to send a client to the operating room for an exploratory laparoscopy. The nurse recognizes that there is no informed consent for the procedure on the client’s chart. The nurse informs the physician who is performing the procedure. The physician asks the nurse to obtain the informed consent signature from the client. What is the nurse’s best action to the physician’s request? a) Call the house officer to obtain the signature. |
Inform the physician that it is his or her responsibility to obtain the signature. Explanation: The responsibility for securing informed consent from the client lies with the person who will perform the procedure. The nurse’s best action is to inform the physician that it is his or her responsibility to obtain the signature.823 |
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A nurse is assessing the pre-operative checklist of a client. Which of the following observations listed in the pre-operative checklist should the nurse verify? a) If the client has worn a fresh set of clothes |
If the client has urinated properly Explanation: In a pre-operative checklist, the nurse verifies that the client has urinated, is wearing an identification bracelet, has removed his dentures, and is wearing only a hospital gown and hair cover. Nurses assess a client’s response to reversal drugs not when checking the pre-operative checklist but rather when the client is recovering from anesthesia. Reversal drugs are given to clients in case they become overly sedated. 837 |
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What is the rationale for having the client void before surgery? a) To assess for urinary tract infection |
To prevent bladder distention Explanation: Having the client void before surgery will assist in the prevention of bladder distention during or after the procedure. 834 |
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Which of the following postoperative exercises promotes venous return, and decreases complications related to venous stasis? a) Coughing |
Leg exercises Explanation: Leg exercises assist in preventing muscle weakness, promote venous return, and decrease complications related to venous stasis. Coughing helps remove retained mucus from the respiratory tract. Incentive spirometry and deep-breathing exercises improve lung expansion and volume.833 |
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A nurse is preparing a client for endotracheal intubation. The anesthesiologist has ordered an anticholinergic medication for this client. Which of the following is an action of this medication? a) It decreases respiratory secretions. |
It decreases respiratory secretions. Explanation: An anticholinergic medication decreases respiratory secretions and prevents vagal nerve stimulation during endotracheal intubation. Antianxiety drugs slow motor activity and promote the induction of anesthesia. Histamine-2 receptor antagonists decrease gastric acidity and volume. Sedatives promote sleep or conscious sedation. 836 |
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A pediatric nurse is preparing a child for cleft palate repair surgery. The nurse recognizes that this type of surgery is categorized as which of the following? a) Constructive surgery |
Constructive surgery Explanation: Cleft palate repair is considered constructive surgery because the goal is to restore function in congenital anomalies. Reconstructive surgery serves to restore function to traumatized or malfunctioning tissues and includes plastic surgery or skin grafting. Transplant surgery replaces organs or structures that are diseased or malfunctioning, such as a liver or kidney transplant. Palliative surgery is not curative and seeks to relieve or reduce the intensity of an illness, such as debridement of necrotic tissue. 821 |
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A nurse is preparing to receive a client in post-anesthesia care unit (PACU). The client is diabetic and has undergone knee surgery. Which information would be most important for the receiving nurse to obtain to develop an appropriate plan of care for this client? a) Chronic disease history |
Amount of blood loss Explanation: To plan care effectively in the postoperative period, the nurse needs to know about the amount of blood lost during the surgery, the type of surgery that was performed on the client, and whether there were any surgical or anesthetic complications. Information on chronic disease history and allergy history are done in the pre-operative period, not in the postoperative period. Information on the environment in the operation room is checked by the circulatory nurse during the intra-operative care plan; it is not associated with the postoperative care plan. 842 |
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Choice Multiple question – Select all answer choices that apply. a) Move both feet continually in clockwise circles |
• Point toes toward the mattress and then toward the head • Rest both legs on the bed Explanation: The nurse should instruct the client to move both feet in clockwise and then counter-clockwise circles, point the toes toward the mattress and then toward the head, and rest both legs on the bed to reduce the risk of forming a thrombus. Surgical clients have reduced circulatory volume because of the preoperative restriction of food and fluids and blood loss during surgery. Also, blood tends to pool in the lower extremities because of the stationary position during surgery and the clients’ reluctance to move afterward. Teaching the client to lean forward and take deep breathes and raising the lower abdomen are part of forced coughing, not leg exercises. 835 |
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A nurse finds that a patient’s temperature is increasing more than 1°C per hour when using a forced-air warming device to treat his postsurgery hypothermia. What condition might occur if this patient’s temperature increases too rapidly? a) Hypertension |
Hypotension Explanation: If the patient’s temperature increases too rapidly, it can lead to a vasodilation effect that will cause the patient to become hypotensive. 840 |
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Which statement accurately represents a recommended guideline when providing postoperative care for the following clients? a) Force fluids for an adult client who has a urine output of less that 30 mL per hour. |
If vital signs are progressively increasing or decreasing from baseline, notify the physician of possible internal bleeding. Explanation: A continued decrease in blood pressure or an increase in heart rate could indicate internal bleeding, and the physician should be notified. If an adult client has a urine output of less than 30 mL per hour, the physician should be notified, unless this is expected. If the client is febrile within 12 hours of surgery, the nurse should assist the client with coughing and deep-breathing exercises. When large amounts of fresh blood are present, the dressing should be reinforced with more bandages and the physician notified. 842 |
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A nurse assists a patient with leg exercises. What condition does this intervention help to prevent? a) Ateleclasis |
Thrombophlebitis Explanation: During surgery, venous blood return from the legs slows; in addition some surgical positions decrease venous return. Thrombophlebitis and resultant emboli are potential complications from this circulatory stasis in the legs. Leg exercises increase venous return through flexion and contraction of the quadriceps and gastrocnemius muscle 833 |
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The nurse-anesthetist is monitoring his client during surgery. He notices a ventricular dysrhythmia and unstable blood pressure. He notifies the surgeon. The operative team suspects a) Myocardial infarction |
Malignant hyperthermia Explanation: The symptoms of malignant hyperthermia are masseter muscle rigidity, ventricular dysrhythmia, tachypnea, cyanosis, skin mottling, and unstable blood pressure. 827 |
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A nurse asks a client to remove the dentures before administering anesthesia. What is the main reason the dentures must be removed prior to the administration of anesthesia? a) To retain oral fluids |
To prevent airway obstruction Explanation: Depending on agency policy and the preference of the anesthesiologist or surgeon, the nurse ensures that the client removes full or partial dentures before administration of anesthesia. Doing so prevents the dentures from causing airway obstruction during administration of a general anesthetic. On the contrary, some anesthesiologists prefer that well-fitting dentures remain in place to preserve facial contours. Keeping the dentures on does not cause blood contamination or retain oral fluids. 837 |
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