PERIOPERATIVE_TEST 1

The nurse requests a client to sign the surgical consent form for an emergency appendectomy. Which statement by the client indicates that further teaching is needed?

1. “I will be glad when this is over so that I can go home.”

2. “I will not be able to eat or drink anything prior to my surgery.”

3. “I need to practice relaxing by listening to my favorite music.”

4. “I will need to get up and walk as soon as possible.”

ANS: 1
When recuperating from emergency surgery, the client will be in the hospital for a few days. This is not a day-surgery procedure. The client needs more teaching.

The nurse in the holding area of the surgery department is interviewing a client who requests to keep his religious medal on during surgery. Which intervention should the nurse implement?

1. Notify the surgeon about the client’s request to wear the medal.

2. Tape the medal to the client and allow the client to wear the medal.

3. Request that the family member take the medal prior to surgery.

4. Explain that taking the medal to surgery is against the policy.

ANS: 2
The medal should be taped and the client should be allowed to wear the medal because meeting spiritual needs is essential to this client’s care.

The nurse must obtain surgical consent forms for the following clients who are scheduled for surgery. Which client would not be able to consent to surgery?

1. The 65-year-old client who cannot read or
write.
2. The 30-year-old client who does not
understand English.
3. The 16-year-old client who has a fractured
ankle.
4. The 80-year-old client who is not oriented to
the day.

ANS: 3
A 16-year-old client is not legally able to give permission for surgery unless the adolescent is given an emancipated status by a judge. This information was not given in the stem.

When preparing a client for surgery, which intervention should the nurse implement first?

1. Check the permit for the spouse’s signature.
2. Take and document intake and output.
3. Administer the “on call” sedative.
4. Complete the preoperative checklist.

ANS:4
Completing the preoperative checklist has the highest priority to ensure that all details are completed without omissions.

When interviewing the surgical client in the holding area, which information should the nurse report to the health-care provider? Select all that apply.

1. The client has loose, decayed teeth.
2. The client is experiencing anxiety.
3. The client smokes 2 packs of cigarettes a day.
4. The client has had a chest x-ray that does not
show infiltrates.
5. The client reports using herbs.

ANS: 1,2,3,5

1.Loose teeth or caries need to be reported to the health-care provider so he or she can make provisions to prevent breaking the teeth and causing the client to possibly aspirate pieces.

2. The nurse should report any client who is extremely anxious.

3. Smokers are at a higher risk for complica- tions from anesthesia.

5. Herbs—for example, St. John’s wort, licorice, and ginkgo have serious interactions with anesthesia and with bodily functions such as coagulation.

Which nursing task can the nurse delegate to the unlicensed nursing assistant (NA)?

1. Complete the preoperative checklist.
2. Assess the client’s preoperative vital signs.
3. Teach the client about coughing and deep
breathing.
4. Assist the client to remove clothing and
jewelry.

ANS: 4
The NA can remove clothing and jewelry.

When completing the assessment for the client in the day surgery unit, the client states, “I am really afraid of having this surgery. I’m afraid of what they will find.” Which statement would be the best therapeutic response by the nurse?

1. “Don’t worry about your surgery. It is safe.”
2. “Tell me why you’re worried about your
surgery.”
3. “Tell me about your fears of having this
surgery.”
4. “I understand how you feel. Surgery is
frightening.”

ANS: 3
This statement focuses on the emotion that the client identified and is therapeutic.

The68-year-old client scheduled for intestinal surgery does not have clear fecal contents after three tap water enemas. Which intervention should the nurse implement first?

1. Notify the surgeon of the client’s status.
2. Continue giving enemas until clear.
3. Increase the client’s IV fluid rate. 4. Obtain stat serum electrolytes.

ANS: 1
The nurse should contact the surgeon because the client is at risk for fluid and electrolyte imbalance after three (3) enemas. Clients who are NPO, elderly clients, and pediatric clients are more likely to have these imbalances.

The nurse is caring for a client scheduled for abdominal surgery. Which interventions should the nurse include in the plan of care? Select all that apply.

1. Perform range-of-motion exercises.
2. Discuss how to cough effectively.
3. Explain how to perform deep-breathing
exercises.
4. Teach ways to manage postoperative pain.
5. Discuss events that occur in the post-
anesthesia care unit.

ANS: 1,2,3,4,5

1. These exercises help prevent postoperative DVT
2. Coughing effectively aids in the removal of pooled secretions that can cause pneumonia.
3. Deep-breathing exercises keep the alveoli
inflated and prevent atelectasis.
4. The client’s postoperative pain should be
kept within a tolerable range.
5. These interventions help decrease the
client’s anxiety.

The client is scheduled for total hip replacement. Which behavior indicates to the nurse the need for further preoperative teaching?

1. The client uses the diaphragm and abdominal muscles to inhale through the nose and exhale through the mouth.

2. The client takes three slow, deep, breaths and coughs forcefully after inhaling for the third time.

3. The client uses the incentive spirometer and inhales slowly and deeply so that the piston rises to the preset volume.

4. The client gets out of bed by lifting straight upright from the waist and then swings both legs along the side of the bed.

ANS: 4
The correct way to get out of bed postoperatively is to roll onto the side, grasp the side rail to maneuver to the side, and then push up with one hand while swinging the legs over the side. The client needs further teaching.

While completing the preoperative assessment, the male client tells the nurse that he is allergic to codeine. Which intervention should the nurse implement first?

1. Apply an allergy bracelet on the client’s wrist.
2. Label the client’s allergies on the front of the
chart.
3. Ask the client what happens when he takes
the drug.
4. Document the allergy on the medication
administration record.

ANS: 3
The nurse should first assess the events that occurred when the client took this medication because many clients think that a side effect, such as nausea, is an allergic reaction.

Which laboratory result would require immediate intervention by the nurse for the client scheduled for surgery?

1. Calcium 9.2 mg/dL.
2. Bleeding time 2 minutes.
3. Hemoglobin 15 gm/dL.
4. Potassium 2.4 mEq/L.

ANS: 4
This potassium level is low and should be reported to the health-care provider because potassium is important for muscle function, including the cardiac muscle.

Which activities are the circulating nurse’s responsibilities in the operating room?

1. Monitor the position of the client, prepare the surgical site, and ensure the client’s
safety.

2. Give preoperative medication in the holding area and monitor the client’s response
to anesthesia.

3. Prepare sutures; set up the sterile field; and count all needles, sponges, and instruments.

4. Prepare the medications to be administered by the anesthesiologist and change the
tubing for the anesthesia machine.

ANS: 1
The circulating nurse has many responsibilities in the OR, including coordinating the activities in the OR; keeping the OR clean; ensuring the safety of the client; and maintaining the humidity, lighting, and safety of the equipment.

While working in the operating room the circulating nurse observes the surgical scrub technician remove a sponge from the edge of the sterile field with a clamp and place the sponge and clamp in a designated area. Which action should the nurse implement?

1. Place the sponge back where it was.
2. Tell the technician not to waste supplies.
3. Do nothing because this is the correct
procedure.
4. Take the sponge out of the room
immediately.

ANS: 3
The technician followed the correct procedure. Sponges are counted to maintain client safety, so all sponges must be kept together to repeat the count before the incision site is sutured. The sponge must be removed, not used, and placed in a desig- nated area to be counted later.

While the circulating nurse compares the final sponge count with that of the scrub nurse, a discrepancy in the count is found. Which action should the circulating nurse take first?

1. Notify the client’s surgeon.
2. Complete an Occurrence Report.
3. Contact the surgical manager.
4. Re-count all sponges.

ANS: 4
A recount of sponges may lead to the discovery of the cause of the presumed error. Usually it is just a miscount or a result of a sponge being placed in a location other than the sterile field, such as the floor or a lower shelf.

Which violation of surgical asepsis would require immediate intervention by the circu- lating nurse?

1. Surgical supplies were cleaned and sterilized prior to the case.

2. The circulating nurse is wearing a long-sleeved sterile gown.

3. Masks covering the mouth and nose are being worn by the surgical team.

4. The scrub nurse setting up the sterile field is wearing artificial nails.

ANS: 4
According to the Centers for Disease Control (CDC), the American Operating Room Nurses Association (AORN), and the Association of Professionals in Infection Control, artificial nails harbor microorganisms, which increase the risk for infection.

The nurse identifies the nursing diagnosis “risk for injury related to positioning” for the client in the operating room. Which nursing action should the nurse implement?

1. Avoid using the cautery unit that does not have a biomedical tag on it.

2. Carefully pad the client’s elbows before covering the client with a blanket.

3. Apply a warming pad on the OR table before placing the client on the table.

4. Check the chart for any prescription or over-the-counter medication use.

ANS: 2
Padding the elbows decreases pressure so that nerve damage and pressure ulcers are prevented. This addresses the etiology of the nursing diagnosis.

When positioning the intraoperative client for surgery, which client should the nurse consider at the highest rank for irreparable nerve damage?

1. The 16-year-old client in the dorsal recumbent position having an appendectomy.

2. The 68-year-old client in the Trendelenburg position having a cholecystectomy.

3. The 45-year-old client in the reverse Trendelenburg position having a biopsy.

4. The 22-year-old client in the lateral position having a nephrectomy.

ANS: 2
The client’s age, along with positioning with increased weight and pressure on the shoulders, puts this client at higher risk.

Which situation demonstrates the circulating nurse acting as the client’s advocate?

1. Plays the client’s favorite audio book during
surgery.
2. Keeps the family informed of the findings of
the surgery.
3. Keeps the operating room door closed at all
times.
4. Calls the client by the first name when the
client is recovering.

ANS: 3
This would keep the client’s dignity by maintaining privacy. With this action, the nurse is speaking for the client while they cannot speak as a result of anesthesia and is an example of client advocacy.

Which statement would be an expected outcome when the circulating nurse evaluates the goal of the intraoperative client?

1. The client has no injuries from the OR
equipment.
2. The client has no postoperative infection.
3. The client has stable vital signs during
surgery.
4. The client recovers from anesthesia.

ANS: 1
This expected outcome addresses the safety of the client while in the OR.

Which nursing intervention has the highest priority when preparing the client for a surgical procedure?

1. Pad the client’s elbows and knees.
2. Apply soft restraint straps to the extremities.
3. Prepare the client’s incision site.
4. Document the temperature of the room.

ANS: 2
This action would prevent the client from falling off the table, which is the highest priority.

When making assignments for nurses working in the OR, which case would the manager assign to the new nurse?

1. The client having open-heart surgery.
2. The client having a biopsy of the breast.
3. The client having laser eye surgery.
4. The client having a laparoscopic knee repair.

ANS: 2
The case of a client having a biopsy of the breast would be a good case for an inexperienced nurse because it is simple.

While working in the operating room, the nurse notices that the client has tachycar- dia and hypotension. Which interventions should the nurse anticipate?

1. Prepare ice packs and mix dantrolene sodium.
2. Request the defibrillator to be brought into
the OR.
3. Draw a PTT and prepare a heparin drip.
4. Obtain fingerstick blood glucose immediately.

ANS: 1
Unexplained tachycardia, hypotension, and elevated temperature are signs of malignant hyperthermia, which is treated with ice packs and Dantrolene sodium.

When developing the plan of care for the surgical client having sedation, which intervention has highest priority for the nurse?

1. Assess the client’s respiratory status.
2. Monitor the client’s urinary output.
3. Take a 12-lead ECG prior to injection.
4. Attempt to keep the client focused.

ANS: 1
Assessing the respiratory rate, rhythm, and depth is the most important action.

When receiving the client from the OR, which intervention should the PACU nurse implement first?

1. Assess the client’s breath sounds.
2. Apply oxygen via nasal cannula.
3. Take the client’s blood pressure.
4. Monitor the pulse oximeter reading.

ANS: 1
The airway should be assessed first. When caring for a client, the nurse should follow the ABCs: airway, breathing, and circulation.

Which assessment data indicate the postoperative client who had spinal anesthesia is suffering a complication of the anesthesia?
1. Loss of sensation on the lumbar (L5) dermatome.
2. Absence of the client’s posterior tibial pulse.
3. The client has a respiratory rate of eight (8).
4. The blood pressure is within 20% of client’s baseline.
ANS: 3
If the effects of the spinal anesthesia move up rather than down the spinal cord, respirations can be depressed and even blocked.

After transferring the client from the PACU to the surgical unit, the client’s vital signs are T 98F, P 106, R 24, and BP 88/40. The client is awake and oriented times three (3). The client’s skin is pale and damp. Which intervention should the nurse implement first?

1. Call the surgeon and report the vital signs.
2. Start an IV of D5RL with 20 mEq KCl at 125 mL/hour.
3. Elevate the feet and lower the head.
4. Monitor the vital signs every 15 minutes.

ANS: 3
By lowering the head of the bed and raising the feet, the blood is shunted to the brain until volume-expanding fluids can be administered, which is the first intervention for a client who is hemorrhaging.

The nurse receives a report that the postoperative client received Narcan, an opioid antagonist, in PACU. Which client problem should the nurse add to the plan of care?

1. Alteration in comfort.
2. Risk for depressed respiratory pattern.
3. Potential for infection.
4. Fluid and electrolyte imbalance.

ANS: 2
Aclientwithrespiratorydepressiontreated with Narcan can have another episode within 15 minutes after receiving the drug as a result of the short half-life of the medication.

The 26-year-old male client in the PACU has a heart rate of 110, has a rising temper- ature, and complains of muscle stiffness. Which interventions should the nurse imple- ment? Select all apply.

1. Give a back rub to the client to relieve stiffness.
2. Apply ice packs to axillary and groin areas.
3. Prepare a nice slush for the client to drink.
4. Prepare to administer Dantrolene, a smooth-muscle
relaxant.
5. Reposition the client on a warming blanket.

ANS: 2,3,4

2. Ice packs should be applied to the axillary and groin areas for a client experiencing malignant hyperthermia.

3. The client would be NPO to prepare for intubation, but an ice slush would be used to irrigate the bladder and stomach per nasogastric tube.

4. Dantrolene is the drug of choice for treatment.

Which data indicate the nursing care has been effective for the client who is one (1) day postoperative surgery?

1. Urine output was 160 mL in the past eight (8) hours.
2. Bowel sounds occur four (4) times per minute.
3. T 99.0F, P 98, R 20, and BP 100/60.
4. Lungs are clear bilaterally in all lobes.

ANS: 4
Lung sounds that are clear bilaterally in all lobes indicate the client has adequate gas exchange, which prevents postoperative complications and indicates effective nursing care.

When working on the surgical floor, which task can the nurse delegate to the unli- censed nursing assistant (NA)?

1. Take vital signs every four (4) hours.
2. Check the Jackson-Pratt insertion site.
3. Hang the client’s next IV bag.
4. Ensure that the client gets pain relief.

ANS: 1
Taking the vital signs of the stable client may be delegated to the NA.

The charge nurse is making the shift assignments. Which postoperative client would be the most appropriate assignment to the graduate nurse?

1. The four (4)-year-old client who had a tonsillectomy and is swallowing frequently.

2. The 74-year-old client with a repair of the left hip who is unable to ambulate.

3. A 24-year-old client who had an uncomplicated appendectomy the previous day.

4. An 80-year-old client with small bowel obstruction and congestive heart failure.

ANS: 3
A young client who had an appendectomy would require routine postoperative care and would be the most appropriate client to assign to the inexperienced nurse.

Which statement would be an expected outcome for the postoperative client who had general anesthesia?

1. The client will be able to sit in the chair for 30 minutes.
2. The client will have a pulse oximetry reading of 97% on
room air.
3. The client will have a urine output of 30 mL per hour.
4. The client will be able to distinguish sharp from dull
sensations.

ANS: 2
The anesthesia machine takes over the function of the lungs during surgery so the expected outcome should directly reflect the client’s respiratory status; the alveoli can collapse, causing atelectasis.

The postoperative client is transferred from the PACU to the surgical floor. Which action should the nurse implement first?

1. Apply anti-embolism hose to the client.
2. Attach the drain to 20 cm suction.
3. Assess the client’s vital signs.
4. Listen to the report from the anesthesiologist.

ANS: 3
Assessing the client’s status after transfer from the PACU should be the nurse’s first intervention.

Which client problem would be priority for client who is one (1) day postoperative?

1. Potential for hemorrhaging.
2. Potential for injury.
3. Potential for fluid volume excess.
4. Potential for infection.

ANS: 1
All clients who undergo surgery are at risk for hemorrhaging, which is the priority problem.

The unlicensed nursing assistant reports the vital signs for a first-day postoperative client of T 100.8F, P 80, R 24, and B/P 148/80. Which intervention would be most appropriate for the nurse to implement?

1. Administer the antibiotic earlier than scheduled.
2. Change the dressing over the wound.
3. Help the client turn, cough, and deep breathe q2h
4. Encourage the client to ambulate in the hall.

ANS: 3
Having the client turn, cough, and deep breathe is the best intervention for the nurse to implement because if a client has a fever within the first day, it is usually caused by a respiratory problem.

The client is complaining of left shoulder pain. Which response would be best for the nurse to assess the pain?

1. Request that the client describe the pain.
2. Inquire if the pain is intense, throbbing, or stabbing.
3. Ask if the client wants pain medication.
4. Instruct the client to complete the pain questionnaire.

ANS: 1
This request allows the client to use terms and descriptions so that the nurse can eval- uate the pain and the effectiveness of the treatment.

When preparing the plan of care for the client in acute pain as a result of surgery, the nurse should include which intervention?

1. Administer pain medication as soon as the time frame
allows.
2. Use nonpharmacological methods to replace medications.
3. Use cryotherapy after heat therapy because it works
faster.
4. Instruct family members to administer medication with the
PCA.

ANS: 1
Pain medications should be administered at the frequency ordered by the HCP, not just when the client requests them, especially for acute pain.

Which situation is an example of the nurse fulfilling the role of client advocate?

1. The nurse brings the client pain medication when it is
due.
2. The nurse collaborates with other disciplines during the
care conference.
3. The nurse contacts the health-care provider when pain
relief is not obtained.
4. The nurse teaches the client to ask for medication before
the pain gets to a “5.”

ANS: 3
When the nurse contacts the HCP about unrelieved pain, the nurse is speaking when the client cannot, which is the definition of a client advocate.

Which statement would be an expected outcome for a client experiencing acute pain?

1. The client will have decreased use of medication.
2. The client will participate in self-care activities.
3. The client will use relaxation techniques.
4. The client will repeat instructions about medications.

ANS: 2
Clients experiencing acute pain will not be involved in self-care because of their reluctance to move, which increases the pain; therefore, participation indicates the client’s pain is tolerable.

Which intervention has the highest priority when administering pain medication to a client experiencing acute pain?

1. Monitor the client’s vital signs.
2. Verify the time of the last dose.
3. Check for the client’s allergies.
4. Discuss the pain with the client.

ANS: 3
The face scale is the best way to assess pain for a four (4)-year-old child.

Which intervention should the nurse delegate to the unlicensed nursing assistant when caring for the client experiencing acute pain?

1. Take the pain medication to the room.
2. Apply an ice pack to the site of pain.
3. Check on the client 30 minutes after he or she takes the pain medication.
4. Observe the patient’s ability to use the PCA.

ANS: 2
This task does not require teaching, evaluating, or nursing judgment and therefore could be delegated.

When administering an opioid narcotic, which interventions should the nurse imple- ment to provide for client safety? Select all that apply.

1. Compare the hospital number on the MAR to the client’s
bracelet.
2. Have a witness verify the wasted portion of the narcotic.
3. Assess the client’s vital signs prior to administration.
4. Determine if the client has any allergies to medications.
5. Clarify all orders with the health-care provider.

ANS: 1,3,4

1.This procedure ensures client safety by preventing medication from being given to the wrong client.

3. This intervention would prevent giving a narcotic to a client who is unstable or compromised.

4. Determining allergies addresses client safety.

Which intervention would be the best way for the nurse to assess a four (4)-year-old client for acute pain?

1. Use words that a four (4)-year-old child can remember.
2. Explain the 0-10 pain scale to the child’s parent.
3. Have the child point to the face that describes the pain.
4. Administer the medication every four (4) hours.

ANS: 3
The face scale is the best way to assess pain for a four (4)-year-old child.

Which nursing intervention would be priority for the client experiencing acute pain?

1. Assess verbal and nonverbal behavior.
2. Wait for the client to request pain medication.
3. Bring the pain medication on a scheduled basis.
4. Teach the client to use only imagery every hour for the
pain.

ANS: 1
Assessing verbal and nonverbal cues is the priority intervention because pain is subjective.

While conducting an interview with a 75-year-old client admitted with acute pain, which question would have priority when assisting with pain management?

1. “Have you ever had difficulty getting your pain controlled?”
2. “What types of surgery have you had in the last 10 years?”
3. “Have you ever been addicted to narcotics?”
4. “Do you have a list of your prescription medications?”

ANS: 1
The answer to this request would indicate if the client has had a negative experience that may influence the client’s pain man- agement.

At the end of the shift, the nurse clears the PCA and discovers that the client has used only a small amount of medication. Which intervention should the nurse implement?

1. Determine why the client is not using the PCA.
2. Document the amount and take no action.
3. Chart that the client is not having pain.
4. Contact the HCP and request oral medication.

ANS: 1
Assessing why the client is not using the medication is a priority and then, based on the client’s response, a plan of care can be determined.

During the preoperative interview, a patient scheduled for an elective hysterectomy tells the nurse, “I am afraid that I will die in surgery like my mother did!” Which response by the nurse is most appropriate?

a. “Tell me more about what happened to your
mother.”
b. “You will receive medications to reduce your
anxiety.”
c. “You should talk to the doctor again about
the surgery.”
d. “Surgical techniques have improved a lot in
recent years.”

ANS: A

The patient’s statement may indicate an unusually high anxiety level or a family history of problems such as malignant hyperthermia, which will require precautions during surgery. The other statements also may address the patient’s concerns, but further assessment is needed first.

A patient arrives at the ambulatory surgery center for a scheduled outpatient surgery. Which information is of most concern to the nurse?

a. The patient has not had outpatient surgery
before.
b. The patient is planning to drive home after
surgery.
c. The patient’s insurance does not cover
outpatient surgery.
d. The patient had a glass of water a few hours
before arriving.

ANS: B

After outpatient surgery, the patient should not drive home and will need assistance with transportation and home care. The patient’s experience with outpatient surgery is assessed, but it does not have as much application to the patient’s physiologic safety. The patient’s insurance coverage is important to establish, but this is not usually the nurse’s role or a priority in nursing care. Having clear liquids a few hours before surgery does not usually increase risk for aspiration.

A 36-year-old woman is admitted for an outpatient surgery. Which information obtained by the nurse during the preoperative assessment is most important to report to the anesthesiologist before surgery?

a. The patient’s lack of knowledge about
postoperative pain control measures
b. The patient’s statement that her last
menstrual period was 8 weeks previously
c. The patient’s history of a postoperative
infection following a prior cholecystectomy
d. The patient’s concern that she will be unable
to care for her children postoperatively

ANS: B

This statement suggests that the patient may be pregnant, and pregnancy testing is needed before administration of anesthetic agents. Although the other data also may be communicated with the surgeon and anesthesiologist, they will affect postoperative care and do not indicate a need for further assessment before surgery.

A patient who is scheduled for surgery in a week tells the nurse doing the preoperative assessment about an allergy to bananas, kiwifruit, and latex products. Which action is most important for the nurse to take?

a. Notify the dietitian about the food allergies.
b. Alert the surgery center about the latex
allergy.
c. Reassure the patient that all allergies are
noted on the medical record.
d. Ask whether the patient uses antihistamines
to reduce allergic reactions.

ANS: B

When a patient is allergic to latex, special nonlatex materials are used during surgical procedures and the staff will need to know about the allergy in advance to obtain appropriate nonlatex materials and have them available on the surgical date. The other actions also may be appropriate, but prevention of allergic reaction (either contact dermatitis or anaphylaxis) during surgery is the most important action.

Any patient guilt about having a therapeutic abortion may be identified when the nurse assesses the functional health pattern of _____________.

a. value-belief.
b. cognitive-perceptual.
c. sexuality-reproductive.
d. coping-stress tolerance.

ANS: A

The value-belief pattern includes information about conflicts between a patient’s values and proposed medical care. In the cognitive-perceptual pattern, the nurse will ask questions about pain and sensory intactness. The sexuality-reproductive pattern includes data about the impact of the surgery on the patient’s sexuality. The coping-stress tolerance pattern assessment will elicit information about how the patient feels about the surgery.

During the preoperative assessment of a patient scheduled for a colon resection, the patient tells the nurse about using St. John’s wort to prevent depression. The nurse should alert the staff in the postanesthesia recovery area that the patient may

a. experience increased pain.
b. have hypertensive episodes.
c. take longer to recover from the anesthesia.
d. have more postoperative bleeding than
expected.

ANS: C

St. John’s wort may prolong the effects of anesthetic agents and increase the time to waken completely after surgery. It is not associated with increased bleeding risk, hypertension, or increased pain.

On the day of surgery, the nurse is admitting a patient with a history of cigarette smoking. Which action is most important at this time?

a. Auscultate for adventitious breath sounds.
b. Ask whether the patient has smoked recently.
c. Remind the patient about harmful effects of
smoking.
d. Calculate the cigarette smoking history in
pack-years.

ANS: A

Abnormal breath sounds may indicate the presence of an acute respiratory infection or chronic lung disease that will affect the choice of anesthesia and/or proceeding with the scheduled surgery. The other nursing actions also are appropriate but will not affect the immediate surgical procedure as much as the presence of abnormal breath sounds.

A patient is seen at the health care provider’s office several weeks before hip surgery for preoperative assessment. The patient reports use of echinacea, saw palmetto, and glucosamine/chondroitin. The nurse should

a. ascertain that there will be no interactions
with anesthetic agents.
b. discuss the supplement use with the patient’s
health care provider.
c. teach the patient that these products may be
continued preoperatively.
d. advise the patient to stop the use of all herbs
and supplements at this time.

ANS: B

The nurse should discuss the medication use with the patient’s health care provider because saw palmetto is used to decrease prostatic hyperplasia, and the patient may need to continue taking the medication or a prescription medication to prevent urinary retention. The nurse should not advise the patient to stop the supplements or to continue them without consulting with the health care provider. Determining the interactions between the supplements and anesthetics is not within the nurse’s scope of practice.

Before the administration of preoperative medications, the nurse is preparing to witness the patient signing the operative consent form when the patient says, “I do not really understand what the doctor said.” Which action is best for the nurse to take?

a. Provide an explanation of the planned
surgical procedure.
b. Notify the surgeon that the informed consent
process is not complete.
c. Administer the prescribed preoperative
antibiotics and withhold any ordered sedative
medications.
d. Notify the operating room staff that the
surgeon needs to give a more complete
explanation of the procedure.

ANS: B

The surgeon is responsible for explaining the surgery to the patient, and the nurse should wait until the surgeon has clarified the surgery before having the patient sign the consent form. The nurse should communicate directly with the surgeon about the consent form rather than asking other staff to pass on the message. It is not within the nurse’s legal scope of practice to explain the surgical procedure. No preoperative medications should be administered until the patient signs the consent form.

Which topic is most important for the nurse to discuss preoperatively with a patient who is scheduled for a colon resection?

a. Care for the surgical incision
b. Medications used during surgery
c. Deep breathing and coughing techniques
d. Oral antibiotic therapy after discharge home

ANS: C

Preoperative teaching, demonstration, and redemonstration of deep breathing and coughing are needed on patients having abdominal surgery to prevent postoperative atelectasis. Incisional care and the importance of completing antibiotics are better discussed after surgery, when the patient will be more likely to retain this information. The patient does not usually need information about medications that are used intraoperatively.

Ten minutes after receiving the ordered preoperative opioid by intravenous (IV) injection, the patient asks to get up to go to the bathroom to urinate. The most appropriate action by the nurse is to

a. assist the patient to the bathroom and stay
with the patient to prevent falls.
b. offer a urinal or bedpan and position the
patient in bed to promote voiding.
c. allow the patient up to the bathroom because
the onset of the medication takes more than
10 minutes.
d. ask the patient to wait because
catheterization is performed at the beginning
of the surgical procedure.

ANS: B

The patient will be at risk for a fall after receiving the opioid, so the best nursing action is to have the patient use a bedpan or urinal. Having the patient get up either with assistance or independently increases the risk for a fall. The patient will be uncomfortable and risk involuntary incontinence if the bladder is full during transport to the operating room.

An alert 82-year-old who has poor hearing and vision is receiving preoperative teaching from the nurse. His wife answers most questions directed to the patient. Which action should the nurse take when doing the teaching?

a. Use printed materials for instruction so that the patient will have more time to review the material.

b. Direct the teaching toward the wife because she is the obvious support and caregiver for the patient.

c. Provide additional time for the patient to understand preoperative instructions and carry out procedures.

d. Ask the patient’s wife to wait in the hall in order to focus preoperative teaching with the patient himself.

ANS: C

The nurse should allow more time when doing preoperative teaching and preparation for older patients with sensory deficits. Because the patient has visual deficits, he will not be able to use written material for learning. The teaching should be directed toward both the patient and the wife because both will need to understand preoperative procedures and teaching.

A diabetic patient who uses insulin to control blood glucose has been NPO since midnight before having a mastectomy. The nurse will anticipate the need to

a. withhold the usual scheduled insulin dose
because the patient is NPO.
b. obtain a blood glucose measurement before
any insulin administration.
c. give the patient the usual insulin dose
because stress will increase the blood
glucose.
d. administer a lower dose of insulin because
there will be no oral intake before surgery.

ANS: B

Preoperative insulin administration is individualized to the patient, and the current blood glucose will provide the most reliable information about insulin needs. It is not possible to predict whether the patient will require no insulin, a lower dose, or a higher dose without blood glucose monitoring.

The clinic nurse reviews the complete blood cell count (CBC) results for a patient who is scheduled for surgery in a few days. The results are white blood cell count (WBC) 10.2 ⋅ 103/µL; hemoglobin 15 g/dL; hematocrit 45%; platelets 150 ⋅ 103/µL. Which action should the nurse take?

a. Send the CBC results to the surgery facility.
b. Call the surgeon and anesthesiologist
immediately.
c. Ask the patient about any symptoms of a
recent infection.
d. Discuss the possibility of blood transfusion
with the patient.

ANS: A

The nurse should be sure that the CBC results, which are normal, are available at the surgical facility to avoid delay of the procedure. With normal results, there is no need to notify the surgeon or anesthesiologist, discuss blood transfusion, or ask about recent infection.

As the nurse prepares a patient the morning of surgery, the patient refuses to remove a wedding ring, saying, “I have never taken it off since the day I was married.” The nurse should

a. have the patient sign a release and leave the
ring on.
b. tape the wedding ring securely to the
patient’s finger.
c. tell the patient that the hospital is not liable
for loss of the ring.
d. suggest that the patient give the ring to a
family member to keep.

ANS: B

The ring can be taped to the patient’s finger and noted on the preoperative checklist. There is no need for a release form or to discuss liability with the patient. Wearing the ring is obviously important to the patient, so the nurse should tape the ring in place rather than have a family member keep the ring for the patient.

A patient is to receive atropine before surgery. The nurse teaches the patient to expect

a. dizziness.
b. weakness.
c. dry mouth.
d. forgetfulness.

ANS: C

Anticholinergic medications decrease oral secretions, so the patient is taught that a dry mouth is an expected side effect. Weakness, forgetfulness, and dizziness are side effects associated with other preoperative medications such as opioids and benzodiazepines.

The nurse is obtaining the health history for a patient who is scheduled for outpatient knee surgery. Which statement by the patient is most important to report to the health care provider?

a. “I had a heart valve replacement last year.”
b. “I had bacterial pneumonia 6 months ago.”
c. “I have knee pain whenever I walk or jog.”
d. “I have a strong family history of breast
cancer.”

ANS: A

A patient with a history of valve replacement is at risk for endocarditis associated with invasive procedures and may need antibiotic prophylaxis. A current respiratory infection may affect whether the patient should have surgery, but a history of pneumonia is not a reason to postpone surgery. The patient’s knee pain is the likely reason for the surgery. A family history of breast cancer does not have any implications for the current surgery.

When the nurse interviews a patient who is to have outpatient surgery using a general anesthetic, which info is most important to communicate to the surgeon and anesthesiologist before surgery?

a. The patient drinks 3 or 4 cups of coffee every morning before going to work.

b. The patient takes a baby aspirin daily but stopped taking aspirin 10 days ago.

c. The patient drank 4 ounces of apple juice 3 hours before coming to the hospital.

d. The patient’s father died after receiving general anesthesia for abdominal surgery.

ANS: D

The information about the patient’s father suggests that there may be a family history of malignant hyperthermia and that precautions may need to be taken to prevent this complication. Current research indicates that having clear liquids 3 hours before surgery does not increase the risk for aspiration in most patients. Patients are instructed to discontinue aspirin 1 to 2 weeks before surgery. The patient should be offered caffeinated beverages postoperatively to prevent a caffeine-withdrawal headache, but this does not have preoperative implications.

Which information about medication use in a preoperative patient is most important to communicate to the health care provider?

a. The patient uses acetaminophen (Tylenol) occasionally for aches and pains.

b. The patient takes garlic capsules daily but did not take any on the surgical day.

c. The patient has a history of cocaine use but quit using the drug over 10 years ago.

d. The patient took a sedative medication the previous night to assist in falling asleep.

ANS: B

Chronic use of garlic may predispose to intraoperative and postoperative bleeding. The use of a sedative the previous night, occasional acetaminophen use, and a distant history of cocaine use will not usually affect the surgical outcome.

A 24-year-old who takes a diuretic and a β-blocker to control blood pressure is scheduled for abdominal surgery. Which patient information is most important to communicate to the health care provider before surgery?

a. Pulse rate 59
b. Hematocrit 35%
c. Blood pressure 142/78
d. Serum potassium 3.3 mEq/L

ANS: D

The low potassium level may increase the risk for intraoperative complications such as dysrhythmias. Slightly elevated blood pressure is common before surgery because of patient anxiety. The heart rate would be expected in a patient taking a β-blocker. The hematocrit is in the low normal range but does not require any intervention before surgery.

The perioperative nurse encourages a family member or a friend to remain with a patient in the preoperative holding area until the patient is taken into the operating room primarily to

a. ensure the proper identification of the patient before surgery.

b. protect the patient from cross-contamination with other patients.

c. assist the perioperative nurse to obtain a complete patient history.

d. help relieve the stress of separation for the patient and significant others.

ANS: D

The presence of a family member or friend reduces the stress associated with the preoperative period. Although the family may give information about the patient’s name and history, this information is obtained and confirmed by the nurse in other ways. Nursing staff, rather than family members, are responsible for prevention of cross-contamination.

Which description best defines the role of the nurse anesthetist as a member of the surgical team?

a. Functions independently in the administration of anesthetics

b. Has the same credentials and responsibilities as an anesthesiologist

c. Is responsible for intraoperative administration of anesthetics ordered by the anesthesiologist

d. Requires supervision by the anesthesiologist or surgeon while administering anesthesia to a patient

ANS: A

The certified registered nurse anesthetist (CRNA) is independently responsible for all aspects of the administration of anesthetic agents. Although the responsibilities of a CRNA and an anesthesiologist have some overlap, the credentialing and roles are different. No supervision by a health care provider is necessary during anesthetic administration by a CRNA. The CRNA assesses the patient and makes the choice of anesthetic agent.

Which outcome measure will be best for the operating room (OR) nurse manager to use in determining the effectiveness of the physical environment and traffic control measures in the operating room?

a. Smooth functioning of the OR team
b. Effective protection of patient privacy
c. Rapid completion of surgical procedure
d. Low incidence of perioperative infection

ANS: D

The primary focus when setting up the OR is the prevention of cross-contamination and transmission of infection to the patient. Patient privacy, efficient completion of procedures, and smooth functioning of the OR team also are important, but the priority is protection of the patient from infection.

Which action will the scrub nurse use to maintain aseptic technique during surgery?

a. Use waterproof shoe covers.
b. Wear personal protective equipment.
c. Insist that all operating room (OR) staff
perform a surgical scrub.
d. Change gloves after touching the upper arm
of the surgeon’s gown.

ANS: D

The sleeves of a sterile surgical gown are considered sterile only to 2 inches above the elbows, so touching the surgeon’s upper arm would contaminate the nurse’s gloves. Shoe covers are not sterile. Personal protective equipment is designed to protect caregivers, not the patient, and is not part of aseptic technique. Staff members such as the circulating nurse do not have to perform a surgical scrub before entering the OR.

After orienting a new staff member to the scrub nurse role, the nurse preceptor will know that the teaching was effective if the new staff member

a. documents all patient care accurately.
b. labels all specimens to send to the lab.
c. keeps both hands above the operating table
level.
d. takes the patient to the postanesthesia
recovery area.

ANS: C

The scrub nurse role includes maintaining asepsis in the operating field. The other actions would be appropriate to the circulating nurse role.

Data that were obtained during the perioperative nurse’s assessment of a patient in the preoperative holding area that would indicate a need for special protection techniques during surgery include

a. a stated allergy to cats and dogs.
b. a history of spinal and hip arthritis.
c. verbalization of anxiety by the patient.
d. having a sip of water 2 hours previously.

ANS: B

The patient with arthritis may require special positioning to avoid injury and postoperative discomfort. Preoperative anxiety and having a sip of water 2 to 3 hours before surgery are not unusual for the preoperative patient. An allergy to cats and dogs will not impact the care needed during the intraoperative phase.

The nurse from the general surgical unit is asked to bring the patient’s hearing aid to the surgical suite. The nurse will take the hearing aid to the

a. clean core.
b. scrub sink areas.
c. nursing station or information desk.
d. corridors of the operating room area.

ANS: C

The nurse from the general unit would not be wearing surgical scrub attire or a head covering and would be restricted to the nursing station or information desk, which are unrestricted areas. The clean care, scrub sink area, and corridors are semirestricted areas that require staff members wear surgical scrub attire and head coverings.

A preoperative patient in the holding area asks the nurse, “Will the doctor put me to sleep with a mask over my face?” The most appropriate response by the nurse is,

a. “A drug will be given to you through your IV line, which will cause you to go to sleep almost immediately.”

b. “Only your surgeon can tell you for sure what method of anesthesia will be used. Should I ask your surgeon?”

c. “General anesthesia is now given by injecting medication into your veins, so you will not need a mask over your face.”

d. “Masks are not used anymore for anesthesia. A tube will be inserted into your throat to deliver a gas that will put you to sleep.”

ANS: A

The first step in general anesthesia is the injection of an intravenous (IV) induction agent, which rapidly induces sleep. The anesthesiologist (not the surgeon) determines the method of anesthesia used. Masks may still be used for inhalation, although many patients are intubated. Total IV anesthesia may be used for some patients but inhalation anesthetics also are commonly used.

A surgical patient received a volatile liquid as an inhalation anesthetic during surgery. Postoperatively the nurse should monitor the patient for

a. tachypnea.
b. myoclonia.
c. hypertension.
d. incisional pain.

ANS: D

Because volatile liquid inhalation agents are rapidly metabolized, postoperative pain occurs soon after surgery. Hypertension and tachypnea are not associated with general anesthetics. Myoclonia may occur with nonbarbiturate hypnotics but not with the inhaled inhalation agents.

When the nurse caring for a patient before surgery has a question about a sedative medication to be given before sending the patient to the surgical suite, the nurse will communicate with the

a. surgeon.
b. anesthesiologist.
c. circulating nurse.
d. registered nurse first assistant (RNFA).

ANS: B

The anesthesiologist is responsible for prescribing preoperative medications. The RNFA and surgeon are responsible for the surgery, but not for the preoperative sedation. The circulating nurse does not have authority to make a change in any medication.

A patient with a dislocated shoulder is prepared for a closed, manual reduction of the dislocation with monitored anesthesia care (MAC). The nurse anticipates the administration of

a. IV midazolam (Versed).
b. inhaled desflurane (Suprane).
c. epidural lidocaine (Xylocaine).
d. eutectic mixture of local anesthetics (EMLA).

ANS: A

IV sedatives such as the benzodiazipines are administered for MAC. Inhaled, epidural, and topical agents are not included in MAC.

Which action will the nurse include in the plan of care immediately after surgery for a patient who received ketamine (Ketalar) as an anesthetic agent?

a. Administer larger doses of analgesic agents.
b. Monitor for severe slowing of the heart rate.
c. Provide a quiet environment in the
postanesthesia care unit.
d. Avoid the use of benzodiazepines in the
postoperative period.

ANS: C

Hallucinations are an adverse effect associated with the dissociative anesthetics such as ketamine, so the postoperative environment should be kept quiet to decrease the risk of hallucinations. Since ketamine causes profound analgesia lasting into the postoperative period, larger doses of analgesics are not needed. Ketamine causes an increase in heart rate. Benzodiazepine use with ketamine may be used to decrease the incidence of hallucinations and nightmares.

A patient’s family history reveals that the patient may be at risk for malignant hyperthermia (MH) during anesthesia. The nurse explains to the patient that

a. anesthesia can be administered with minimal risks with the use of appropriate precautions and medications.

b. as long as succinylcholine (Anectine) is not administered as a muscle relaxant, the reaction should not occur.

c. surgery must be performed under local anesthetic to prevent development of a sudden, extreme increase in body temperature.

d. surgery will be delayed until the patient is genetically tested to determine whether he or she is susceptible to malignant hyperthermia

ANS: A

General anesthesia can be administered to patients with MH as long as precautions to avoid MH are taken and preparations are made to treat MH if it does occur. Other factors besides succinylcholine administration are associated with MH. Predictions about whether MH will occur based on family history are inconsistent, and it may not be possible to delay surgery.

A patient in surgery receives a neuromuscular blocking agent as an adjunct to general anesthesia. At completion of the surgery, it is most important that the nurse monitor the patient for

a. nausea.
b. confusion.
c. bronchospasm.
d. weak chest-wall movement.

ANS: D

The most serious adverse effect of the neuromuscular blocking agents is weakness of the respiratory muscles leading to postoperative hypoxemia. Nausea and confusion are possible adverse effects of these drugs, but they are as great a concern as respiratory depression. Because these medications decrease muscle contraction, laryngospasm and bronchospasm are not concerns.

Which action by an inexperienced member of the surgical team requires rapid intervention by the charge nurse?

a. Wearing street clothes into the nursing station
b. Wearing a surgical mask into the holding room
c. Walking into the hallway outside an operating room without the hair covered
d. Putting on a surgical mask, cap, and scrubs before entering the operating room

ANS: C

The corridors outside the OR are part of the semirestricted area where personnel must wear surgical attire and head coverings. Surgical masks may be worn in the holding room, although they are not necessary. Street clothes may be worn at the nursing station, which is part of the unrestricted area. Wearing a mask and scrubs is essential when going into the OR.

Which nursing action should the operating room (OR) nurse manager delegate to the registered nurse first assistant (RNFA)?

a. Make surgical incisions and suture incisions as needed.
b. Coordinate transfer of the patient to the operating table.
c. Provide postoperative teaching about coughing to the patient.
d. Set up instrument tables at the beginning of the surgical procedure.

ANS: A

The role of the RNFA includes skills such as making and suturing incisions and maintaining hemostasis. The other actions should be delegated to other staff members such as the circulating nurse, scrub nurse, or surgical technician.

Which of these actions included in the perioperative patient plan of care can the perioperative nurse delegate to a surgical technologist?

a. Complete the patient’s admission
assessment.
b. Pass sterile instruments and supplies to the
surgeon.
c. Teach the patient about what to expect in the
operating room (OR).
d. Give the postoperative report to the
postanesthesia care unit (PACU) nurse.

ANS: B

The education and certification for a surgical technologist includes the scrub and circulating functions in the OR. Patient teaching, communication with other departments about a patient’s condition, and the admission assessment require RN level education and scope of practice.

When preparing the patient for surgery, which actions will the nurse include in the surgical time-out procedure (select all that apply)?

a. Check for placement of IV lines.
b. Have the surgeon identify the patient.
c. Confirm the hospital chart identification (ID)
number.
d. Have the patient state name and DOB
e. Ask the patient to state the surgical
procedure.
f. Verify the patient ID band number.

ANS: C, D, E, F

These actions are included in surgical time out. IV line placement and identification of the patient by the surgeon are not included in the surgical time-out procedure.

A 42-year-old patient is recovering from anesthesia in the postanesthesia care unit (PACU). On admission to the PACU, the blood pressure (BP) is 124/70. Thirty minutes after admission, the blood pressure falls to 112/60, with a pulse of 72 and warm, dry skin. The most appropriate action by the nurse at this time is to

a. increase the rate of the IV fluid replacement.
b. continue to take vital signs every 15 minutes.
c. administer oxygen therapy at 100% per mask.
d. notify the anesthesia care provider (ACP)
immediately.

ANS: B

A slight drop in postoperative BP with a normal pulse and warm, dry skin indicates normal response to the residual effects of anesthesia and requires only ongoing monitoring. Hypotension with tachycardia and/or cool, clammy skin would suggest hypovolemic or hemorrhagic shock and the need for notification of the ACP, increased fluids, and high-concentration oxygen administration.

During recovery from anesthesia in the postanesthesia care unit (PACU), a patient’s vital signs are blood pressure 118/72, pulse 76, respirations 12, and SpO2 91%. The patient is sleepy but awakens easily. Which action should the nurse take at this time?

a. Place the patient in a side-lying position.
b. Encourage the patient to take deep breaths.
c. Prepare to transfer the patient from the
PACU.
d. Increase the rate of the postoperative IV
fluids.

ANS: B

The patient’s borderline SpO2 and sleepiness indicate hypoventilation. The nurse should stimulate the patient and remind the patient to take deep breaths. Placing the patient in a lateral position is needed when the patient first arrives in the PACU and is unconscious. The stable BP and pulse indicate that no changes in fluid intake are required. The patient is not fully awake and has a low SpO2, indicating that transfer from the PACU is not appropriate.

After a new nurse has been oriented to the postanesthesia care unit (PACU), the charge nurse will evaluate that the orientation has been successful when the new nurse

a. places a patient in the Trendelenburg position when the blood pressure (BP) drops.

b. assists a patient to the prone position when the patient is nauseated.

c. turns an unconscious patient to the side when the patient arrives in the PACU.

d. positions a newly admitted unconscious patient supine with the head elevated.

ANS: C

The patient should initially be positioned in the lateral “recovery” position to keep the airway open and avoid aspiration. The prone position is not usually used and would make it difficult to assess the patient’s respiratory effort and cardiovascular status. The Trendelenburg position is avoided because it increases the work of breathing. The patient is placed supine with the head elevated after regaining consciousness.

A 75-year-old is to be discharged from the ambulatory surgical unit following left eye surgery. The patient tells the nurse, “I do not know if I can take care of myself with this patch over my eye.” The most appropriate nursing action is to

a. refer the patient for home health care
services.
b. discuss the specific concerns regarding self-
care.
c. give the patient written instructions
regarding care.
d. assess the patient’s support system for care
at home.

ANS: B

The nurse’s initial action should be to assess exactly the patient’s concerns about self-care. Referral to home health care and assessment of the patient’s support system may be appropriate actions but will be based on further assessment of the patient’s concerns. Written instructions should be given to the patient, but these are unlikely to address the patient’s stated concern about self-care.

After removal of the nasogastric (NG) tube on the second postoperative day, the patient is placed on a clear liquid diet. Four hours later, the patient complains of sharp, cramping gas pains. Which action should the nurse take?

a. Reinsert the NG tube.
b. Give the PRN IV opioid.
c. Assist the patient to ambulate.
d. Place the patient on NPO status.

ANS: C

Ambulation encourages peristalsis and the passing of flatus, which will relieve the patient’s discomfort. If distention persists, the patient may need to be placed on NPO status, but usually this is not necessary. Morphine administration will further decrease intestinal motility. Gas pains are usually caused by trapping of flatus in the colon, and reinsertion of the NG tube will not relieve the pains.

Following gallbladder surgery, a patient’s T-tube is draining dark green fluid. Which action should the nurse take?

a. Place the patient on bed rest.
b. Notify the patient’s surgeon.
c. Document the color and amount of drainage.
d. Irrigate the T-tube with sterile normal saline.

ANS: C

A T-tube normally drains dark green to bright yellow drainage, so no action other than to document the amount and color of the drainage is needed. The other actions are not necessary.

In intervening to promote ambulation, coughing, deep breathing, and turning by a postoperative patient on the first postoperative day, which action by the nurse is most helpful?

a. Discuss the complications of immobility and
poor cough effort.
b. Teach the patient the purpose of respiratory
care and ambulation.
c. Administer ordered analgesic medications
before these activities.
d. Give the patient positive reinforcement for
accomplishing these activities.

ANS: C

The most essential nursing action in encouraging these postoperative activities is administration of adequate analgesia to allow the patient to accomplish the activities with minimal pain. Even with motivation provided by proper teaching, positive reinforcement, and concern about complications, patients will have difficulty if there is a great deal of pain involved with these activities.

The nurse evaluates that the interventions for the nursing diagnosis of ineffective airway clearance in a postoperative patient have been successful when the

a. patient drinks 2 to 3 L of fluid in 24 hours.
b. patient uses the spirometer 10 qh
c. patient’s breath sounds are clear to
auscultation.
d. patient’s temperature is less than 100.4° F
orally.

ANS: C

One characteristic of ineffective airway clearance is the presence of adventitious breath sounds such as rhonchi or wheezes, so clear breath sounds are an indication of resolution of the problem. Spirometer use and increased fluid intake are interventions for ineffective airway clearance but may not improve breath sounds in all patients. Elevated temperature may occur with atelectasis, but a normal or near-normal temperature does not always indicate resolution of respiratory problems.

A patient who has begun to awaken after 30 minutes in the postanesthesia care unit (PACU) is restless and shouting at the nurse. The patient’s oxygen saturation is 99%, and recent lab results are all normal. Which action by the nurse is most appropriate?

a. Insert an oral or nasal airway.
b. Notify the anesthesia care provider.
c. Orient the patient to time, place, and person.
d. Be sure that the patient’s IV lines are secure.

ANS: D

Because the patient’s assessment indicates physiologic stability, the most likely cause of the patient’s agitation is emergence delirium, which will resolve as the patient wakes up more fully. The nurse should ensure patient safety through interventions such as raising the bed rails and securing IV lines. Emergence delirium is common in patients recovering from anesthesia, so there is no need to notify the ACP. Insertion of an airway is not needed because the oxygen saturation is good. Orientation of the patient is needed but is not likely to be effective until the effects of anesthesia have resolved more completely.

Which action should the postanesthesia care unit (PACU) nurse delegate to nursing assistive personnel (NAP) who help with the transfer of a patient to the surgical unit?

a. Help with the transfer of the patient onto a
stretcher.
b. Give a verbal report to the surgical unit
charge nurse.
c. Document the appearance of the patient’s
incision in the chart.
d. Ensure that the receiving nurse understands
the postoperative orders.

ANS: A

The scope of practice for nursing assistants includes repositioning and moving patients under the supervision of an RN. Providing report to another RN, assessing and documenting the wound appearance, and clarifying physician orders with another RN require RN level education and scope of practice.

When a patient is transferred from the postanesthesia care unit (PACU) to the clinical surgical unit, the first action by the nurse on the surgical unit should be to

a. assess the patient’s pain.
b. take the patient’s vital signs.
c. read the postoperative orders.
d. check the rate of the IV infusion.

ANS: B

Because the priority concerns after surgery are airway, breathing, and circulation, the vital signs are assessed first. The other actions should take place after the vital signs are obtained and compared with the vital signs before transfer.

An 83-year-old who had a surgical repair of a hip fracture 2 days previously has restrictions on ambulation. Based on this information, the nurse identifies the priority collaborative problem for the patient as

a. potential complication: hypovolemic shock.
b. potential complication: venous
thromboembolism.
c. potential complication: fluid and electrolyte
imbalance.
d. potential complication: impaired surgical
wound healing.

ANS: B

The patient is older and relatively immobile, two risk factors for development of deep vein thrombosis. The other potential complications are possible postoperative problems, but they are not supported by the data about this patient.

A patient who is just waking up after having a general anesthetic is agitated and confused. Which action should the nurse take first?

a. Check the O2 saturation.
b. Administer the ordered opioid.
c. Take the blood pressure and pulse.
d. Notify the anesthesia care provider.

ANS: A

Emergence delirium may be caused by a variety of factors. However, the nurse should first assess for hypoxemia. The other actions also may be appropriate, but are not the best initial action.

A postoperative patient has not voided for 7 hours after return to the postsurgical unit. Which action should the nurse take first?

a. Notify the surgeon.
b. Perform a bladder scan.
c. Assist the patient to ambulate to the
bathroom.
d. Insert a straight catheter as indicated on the
PRN order.

ANS: B

The initial action should be to assess the bladder for distention. If the bladder is distended, providing the patient with privacy (by walking with them to the bathroom) will be helpful. Catheterization should only be done after other measures have been tried without success because of the risk for urinary tract infection. There is no indication to notify the surgeon about this common postoperative problem unless all measures to empty the bladder are unsuccessful.

While caring for a patient with abdominal surgery the first postoperative day, the nurse notices new bright-red drainage about 6 cm in diameter on the dressing. In response to this finding, the nurse should first

a. reinforce the dressing.
b. take the patient’s vital signs.
c. recheck the dressing in 1 hour for increased
drainage.
d. notify the patient’s surgeon of a potential
hemorrhage.

ANS: B

New bright-red drainage may indicate hemorrhage, and the nurse should initially assess the patient’s vital signs for tachycardia and hypotension. The surgeon should then be notified of the drainage and the vital signs. The dressing may be changed or reinforced, based on the surgeon’s orders or institutional policy. The nurse should not wait an hour to recheck the dressing.

When caring for a patient during the second postoperative day after abdominal surgery, the nurse obtains an oral temperature of 100.8° F. Which action should the nurse take first?

a. Have the patient use the incentive
spirometer.
b. Assess the surgical incision for redness and
swelling.
c. Administer the ordered PRN acetaminophen
(Tylenol).
d. Notify the patient’s health care provider
about the fever.

ANS: A

A temperature of 100.8° F in the first 48 hours is usually caused by atelectasis, and the nurse should have the patient cough and deep breathe. This problem may be resolved by nursing intervention, and therefore notifying the health care provider is not necessary. Acetaminophen will reduce the temperature, but it will not resolve the underlying respiratory congestion. Because evidence of wound infection does not usually occur before the third postoperative day, assessment of the incision is not likely to be useful.

The nurse notes that the oxygen saturation is 88% in an unconscious patient who was transferred to the postanesthesia care unit (PACU) 10 minutes previously. Which action should the nurse take first?

a. Elevate the patient’s head.
b. Suction the patient’s mouth.
c. Increase the oxygen flow rate.
d. Perform the jaw-thrust maneuver.

ANS: D

In an unconscious postoperative patient, a likely cause of hypoxemia is airway obstruction by the tongue, and the first action is to clear the airway by maneuvers such as the jaw thrust or chin lift. Increasing the oxygen flow rate and suctioning are not helpful when the airway is obstructed by the tongue. Elevating the patient’s head will not be effective in correcting the obstruction but may help with oxygenation after the patient is awake.

While caring for a patient who had abdominal surgery on the second postoperative day, which information about the patient is most important to communicate to the health care provider?

a. The right calf is swollen, warm, and painful.
b. The patient’s temperature is 100.3° F
c. The 24-hour oral intake is 600 ml greater
than the total output.
d. The patient complains of abdominal pain at
level 6 (0-10 scale).

ANS: A

The calf pain, swelling, and warmth suggest that the patient has a deep vein thrombosis, which will require health care provider orders for diagnostic tests and anticoagulants. Because the stress response causes fluid retention for the first 2 to 5 days postoperatively, the difference between intake and output is expected. A temperature elevation to 100.3° F on the second postoperative day suggests atelectasis, and the nurse should have the patient deep breathe and cough. Pain with ambulation is normal, and the nurse should administer the ordered analgesic before patient activities.

A patient complains of dizziness when ambulating in the room on the first postoperative day. In what order will the nurse accomplish the following activities? ____________________

a. Take the patient’s blood pressure (BP).
b. Have the patient sit down in a chair.
c. Give the patient something to drink.
d. Notify the patient’s health care provider.

ANS: B, A, C, D

The first priority for the patient with syncope is to prevent a fall, so the patient should be assisted to a chair. Assessment of the BP will determine whether the dizziness is due to orthostatic hypotension, which occurs because of hypovolemia. Increasing the fluid intake will help prevent orthostatic dizziness. Because this is a common postoperative problem that is usually resolved through nursing measures such as increasing fluid intake and making position changes more slowly, there is no urgent need to notify the health care provider.

A patient’s blood pressure in the PACU has dropped from an admission blood pressure of 138/84 to 100/58 with a pulse change of 68 to 94. SpO2 is 98% on 3L of oxygen. In which order should the nurse take these actions?

a. Raise the IV infusion rate.
b. Assess the patient’s dressing.
c. Increase the oxygen flow rate.
d. Check the patient’s temperature.

ANS: A, C, B, D

The first nursing action should be to increase the IV infusion rate. Since the most common cause of hypotension is volume loss, the IV rate should be increased. The next action should be to increase the oxygen flow rate to maximize oxygenation of hypoperfused organs. Because hemorrhage is a common cause of postoperative volume loss, the nurse should check the dressing. Finally, the patient should be assessed for vasodilation caused by rewarming.

Five minutes after receiving a preoperative sedative medication by IV injection, a patient asks to get up to go to the bathroom to urinate. Which of the following is the most appropriate action for the nurse to take?

A. Offer the patient to use the urinal/bedpan after explaining the need to maintain safety.

B. Assist the patient to the bathroom and stay next to the door to assist patient back to bed when done.

C. Allow the patient to go to the bathroom since the onset of the medication will be more than 5 minutes.

D. Ask the patient to hold the urine for a short period since a urinary catheter will be placed in the operating room.

ANS: A

The prime issue after administration of either sedative or opioid analgesic medications is safety. Because the medications affect the central nervous system, the patient is at risk for falls and should not be allowed out of bed, even with assistance.

Which of the following is the primary reason for accurately recording the patient’s current medications during a preoperative assessment?

A. Some medications may alter the patient’s perceptions about surgery.

B. Many anesthetics alter renal and hepatic function, causing toxicity of other drugs.

C. Some medications may interact with anesthetics, altering the potency and effect of the drugs.

D. Routine medications are withheld the day of surgery, requiring dosage and schedule adjustments after surgery.

ANS: A.

Drug interactions may occur between prescribed medications and anesthetic agents used during surgery. For this reason, it is important to take a careful medication history and check that they have been communicated to the anesthesia care provider.

As the nurse is preparing a patient for surgery, the patient refuses to remove a wedding ring. Which of the following is the most appropriate action by the nurse?

A. Insist the patient remove the ring for safety
purposes.
B. Explain that the hospital will not be
responsible for the ring.
C. Tape the ring securely to the finger and
document this on the preoperative checklist.
D. Note the presence of the ring in the nurse’s
notes of the chart and on the preoperative
checklist.

ANS: C.

It is customary policy to tape a patient’s wedding band to the finger and make a notation on the preoperative checklist that the ring is taped in place.

While performing preoperative teaching, the patient asks when she needs to stop drinking water before the surgery. Based on the most recent practice guidelines established by the American Society of Anesthesiologists, the nurse tells the patient that

A She must be NPO after breakfast.
B She needs to be NPO after midnight. I
C She can drink clear liquids up to 2 hours
before surgery.
D She can drink clear liquids up until she is
moved to the OR.

ANS: C.

Practice guidelines for preoperative fasting state the minimum fasting period for clear liquids is 2 hours. Evidence-based practice no longer supports the long-standing practice of requiring patients to be NPO after midnight.

The nurse receives report on 4 clients. Which client should the nurse see first? 1. Client admitted 12 hours ago with acute asthma exacerbation who needs a dose of IV methylprednisolone [21%] 2. Client admitted 2 days ago with congestive …

A patient with acute shortness of breath is admitted to the hospital. Which action should the nurse take during the initial assessment of the patient? a. Ask the patient to lie down to complete a full physical assessment. b. Briefly …

A client is diagnosed with Cushing syndrome. Which clinical manifestation does the nurse expect to increase in a client with Cushing syndrome? Glucose level After surgical clipping of a ruptured cerebral aneurysm, a client develops the syndrome of inappropriate secretion …

1. Which item below correctly describes the U.S. Bureau of Labor Statistics predictions by 2020? a. Positions that historically required registered nurses will be filled by unlicensed personnel. b. The job growth rate for RNs will surpass job growth in …

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