Chapter 12. Nursing Care of Patients Having Surgery My Nursing Test Banks

Chapter 12. Nursing Care of Patients Having Surgery

Multiple Choice

Identify the choice that best completes the statement or answers the question.

____ 1. A patient who is NPO (nothing by mouth) for scheduled surgery has been on long-term oral steroid therapy and should receive a dose of Prednisone 10 mg by mouth at 0600. Which action should the nurse take?

a. Notify the registered nurse (RN).
b. Ask why the patient is taking steroid therapy.
c. Give the oral steroid with a small sip of water.
d. Contact the pharmacy to obtain an intravenous (IV) equivalent dose.

____ 2. A patient recovering from an abdominal hysterectomy is experiencing abdominal gas pain. Which action should the nurse take?

a. Offer a hot beverage.
b. Provide an extra blanket.
c. Help the patient ambulate.
d. Apply an abdominal binder.

____ 3. A patient scheduled for surgery the next morning is withdrawn, sad and states a fear of the surgery. How should the nurse respond to this patient?

a. Be happy because this surgery will help you.
b. I would be scared, too. You will make it through.
c. Its normal to be scared. What is it that scares you?
d. Dont be so concerned. Everything will be all right.

____ 4. A patient is prescribed to receive morphine sulfate 8 mg intramuscularly (IM) prior to surgery. The medication available is 10 mg/mL. How many milliliters should the nurse give to the patient?

a. 0.25 mL
b. 0.5 mL
c. 0.8 mL
d. 1.25 mL

____ 5. The nurse is caring for a patient recovering from surgery. Which outcome should the nurse identify as being the most important to address the nursing diagnosis of Pain related to surgical incision?

a. Patient reports pain using a pain scale.
b. Patient states pain relief is satisfactory.
c. Patient states normal coping techniques for pain.
d. Patient states alternative techniques to minimize pain.

____ 6. The nurse answers a patients call light and finds the patient sitting up in bed with a wound evisceration. What action should the nurse take first?

a. Notify the physician immediately.
b. Apply gentle pressure over the wound.
c. Place the patient in low Fowlers position.
d. Cover the wound with sterile saline-soaked towels.

____ 7. A patient recovering from surgery becomes restless, has a drop in blood pressure, increase in heart rate, and is breathing at a rate of 30 per minute. Which action should the nurse take first?

a. Monitor vital signs.
b. Maintain a patent airway.
c. Notify the patients family.
d. Ensure physician is informed.

____ 8. The nurse is contributing to the plan of care for a surgical patient. What should the nurse recognize as the most common human response to the stress associated with surgery?

a. Fear
b. Anxiety
c. Delirium
d. Depression

____ 9. The nurse is caring for a patient who is scheduled for surgery. Which nursing action should the nurse use to address the patients psychological concerns?

a. Provide privacy to allow the patient to ask questions.
b. Use correct, technical medical terminology in explanations.
c. Instruct the patient to ask the surgeon all surgical questions.
d. Provide information to a patient who says, I do not want to know.

____ 10. A patient scheduled for a nephrectomy states that the surgeon said this surgery is considered a curative procedure. Which responses should the nurse make to the patient?

a. It is considered palliative surgery.
b. No, it is an exploratory procedure.
c. No, it is considered diagnostic surgery.
d. Yes, it can be classified as a curative procedure.

____ 11. The nurse is caring for a patient who is scheduled fora liver biopsy. For which category of surgical procedures should the nurse plan care for this patient?

a. Curative
b. Palliative
c. Diagnostic
d. Preventive

____ 12. The nurse identifies the diagnosis of ineffective airway clearance as appropriate for a patient recovering from surgery. Which outcome should the nurse identify for this patient?

a. Explains coughing and deep breathing exercises
b. Explains rationale for coughing and deep breathing exercises
c. Correctly demonstrates coughing and deep breathing exercises
d. Observes demonstration of coughing and deep breathing exercises

____ 13. The nurse is assisting in the preparation of patients for surgery. Which patient should the nurse recognize as being in the best condition for surgery and at lower risk for complications?

a. A 66-year-old patient who is obese
b. A 55-year-old patient who is a marathon runner
c. A 23-year-old patient 30 pounds less than ideal weight
d. A 40-year-old patient who plans to quit smoking after surgery

____ 14. A patient scheduled for surgery is to receive anesthesia that causes a total loss of sensation and a complete loss of consciousness. What term should the nurse use to document this patients type of anesthesia?

a. Local anesthesia
b. Spinal anesthesia
c. General anesthesia
d. Epidural anesthesia

____ 15. The nurse is contributing to the preoperative patients plan of care. Which patient statement should alert the nurse to plan interventions to help prevent postoperative complications?

a. I am 60 years old and in good health.
b. This is my second surgery in 2 years.
c. I have chronic obstructive pulmonary disease.
d. I have not had anything to eat or drink for 8 hours.

____ 16. The nurse is caring for a patient who had spinal anesthesia. Which effect from spinal anesthesia may influence the safety of the patient when getting out of bed for the first time after surgery?

a. Hypotension
b. Hypertension
c. Hypoventilation
d. Hyperventilation

____ 17. The nurse is caring for a patient 23 hours after abdominal surgery. Which finding would require the nurse to take action?

a. Report of flatus
b. Lack of appetite
c. Abdominal distention
d. Hypoactive bowel sounds in four quadrants

____ 18. The nurse is planning to witness an adult patients consent for a knee arthroscopy. What should the nurse confirm before witnessing the consent?

a. Which is the operative knee
b. Who is driving the patient home
c. What type of job the patient has
d. When the patient last ate or drank

____ 19. The nurse is caring for a patient recovering from surgery. When the patient is permitted to get out of bed for the first time postoperatively, which measure should the nurse take to ensure patient safety?

a. Teach the patient to request help before rising.
b. Ensure that two caregivers assist the patient to stand.
c. Have the patient put on nonskid slippers before standing.
d. Dangle the patient at the bedside before standing is attempted.

____ 20. The nurse is caring for a patient who has developed an increased temperature during the first 24 hours postoperatively. Which action should the nurse take?

a. Restrict oral fluids.
b. Give antipyretic medication.
c. Encourage coughing and deep breathing.
d. Provide passive range of motion exercises.

____ 21. A patient scheduled for surgery expresses a fear of dying. What action should the nurse take?

a. Ask the family to comfort the patient.
b. Tell the patient everything will be all right.
c. Allow the patient time to express concerns.
d. Explain the national death rate from surgery.

____ 22. The nurse is reviewing the medication history of a preoperative patient who is NPO. The patient is noted to have been on long-term oral steroid therapy. What action should the nurse take?

a. Monitor vital signs and document.
b. Administer the steroid medication topically.
c. Hold steroid medication while the patient is receiving nothing by mouth.
d. Ensure that the physician is informed of the patients history of steroid use.

____ 23. The nurse is contributing to the intraoperative plan of care for a patient undergoing an appendectomy. Which statement would be an appropriate intraoperative outcome for this patient?

a. Verbalizes fears
b. Remains free from injury
c. Demonstrates leg exercises
d. States understanding of discharge instructions

____ 24. The nurse is caring for a patient in the post anesthesia care unit (PACU). What is the nurses priority responsibility for the patient while in this unit?

a. Monitoring urine output
b. Maintaining a patent airway
c. Administering pain medication
d. Assessing readiness for discharge

____ 25. The nurse recommends early ambulation as ordered to be included in the plan of care for a patient recovering from surgery. Which adverse effect is the nurse planning to prevent by early ambulation?

a. Coughing
b. Thrombophlebitis
c. Increased peristalsis
d. Impaired wound healing

____ 26. While dangling a patient in preparation for ambulation after surgery the abdominal incision suddenly eviscerates. What action should the nurse take after positioning the patient supine with flexed knees?

a. Cleanse the abdomen.
b. Administer pain medication.
c. Apply an abdominal binder securely.
d. Apply sterile saline-moistened dressings.

____ 27. The nurse is assisting a patient recovering from surgery on the use of an incentive spirometer. Which patient instruction is appropriate?

a. Do not hold breath after inhaling.
b. Exhale five times before inhaling.
c. Inhale deeply until the target is reached.
d. Exhale deeply until the target is reached.

____ 28. The nurse works on a preoperative unit. For which conditions should the nurse recognize that urgent surgery is needed?

a. Hernia repair
b. Fracture repair
c. Aortic aneurysm
d. Ruptured appendix

____ 29. The nurse is assisting during surgery when a patient develops malignant hyperthermia. Which protocol should the nurse prepare to assist with as directed?

a. Administer oxygen, and continue the anesthesia and surgery.
b. Warm the patient, administer fluids, and then continue surgery.
c. Switch to a different type of anesthetic agent to continue the surgery.
d. Immediately cease anesthesia and surgery, cool patient, and administer dantrolene sodium.

____ 30. The nurse is collecting data from a patient recovering from epidural anesthetic during surgery. What finding should the nurse make a priority to report?

a. Patients blood pressure is 100/60 mm Hg.
b. Patient reports a feeling of heaviness in the legs.
c. Patient reports a feeling of numbness in the legs.
d. Patient experiences chills and shaking postoperatively.

____ 31. A patient recovering from surgery received an IV analgesic in the post-anesthesia care unit. Upon arrival to the medical-surgical care area one hour later the patient rates pain as being 8 on a scale of 0 to 10. The patient is prescribed morphine 10 mg IM injection every 3 hours PRN. What should the nurse do?

a. Give the patient nonnarcotic analgesics.
b. Repeat same IV medication the patient received in the PACU.
c. Explain that IM analgesic cannot be given for another 1.5 hours.
d. Administer the IM medication now and then every 3 hours as ordered.

____ 32. The nurse is caring for a patient after ambulatory surgery. Which oxygen saturation level should the nurse use as evidence that the patient is ready for discharge?

a. 70%
b. 80%
c. 85%
d. 90%

____ 33. The nurse is assisting in the surgical holding area. When should the nurse administer a prophylactic antibiotic to a patient?

a. During surgery
b. 1 hour prior to surgery
c. 4 hours prior to surgery
d. Within the first 2 hours postoperatively

____ 34. A patient recovering from hernia repair surgery reports pain of 4 on a 0-to-10 scale. The patients orders include ibuprofen (Motrin) 400 mg orally every 6 hours prn for pain. Which action should the nurse take?

a. Give the ibuprofen as ordered for pain.
b. Consult the physician for a stronger analgesic.
c. Start the ibuprofen on the second postoperative day.
d. Hold the ibuprofen due to risk of GI upset.

____ 35. The home health nurse is visiting a patient recovering after an abdominal hysterectomy. Which action should the home health nurse take before promoting patient intake of oral fluids?

a. Check for the absence of pain.
b. Verify physicians order for intake.
c. Ensure bowel sounds can be detected.
d. Determine that the patient has passed flatus.

____ 36. A patient with chronic obstructive pulmonary disease is scheduled for total hip replacement. What should the nurse instruct the patient about smoking before the surgery?

a. Do not smoke for 24 hours before the surgery.
b. Do not smoke for 3 to 4 weeks before the surgery.
c. Abstain from smoking for 3 to 4 hours before the surgery.
d. Limit smoking to 1 or 2 cigarettes per day before the surgery.

____ 37. A patient recovering from surgery in the post-anesthesia care unit begins to thrash in bed and pull at the endotracheal tube and IV lines. For which health problem should the nurse provide care for this patient?

a. Delusions
b. Sundowning
c. Hallucinations
d. Emergency delirium

Multiple Response

Identify one or more choices that best complete the statement or answer the question.

____ 38. The nurse is caring for a postoperative patient at risk for deep vein thrombosis. Which actions should the nurse recommend be included in the patients plan of care? (Select all that apply.)

a. Ambulate the patient tid.
b. Apply anti-embolic stockings.
c. Massage the patients legs daily.
d. Place a pillow under the patients knees.
e. Perform leg exercises 10 times hourly while awake.

____ 39. The nurse has reinforced preoperative teaching with a patient about coughing and deep breathing techniques. Which patient statements indicate a correct understanding of the teaching? (Select all that apply.)

a. I should avoid deep breathing after surgery.
b. I should take shallow breaths after surgery to prevent pain.
c. Coughing and deep breathing helps prevent respiratory problems.
d. I should cough and deep breathe 10 times every hour while awake.
e. I should cough and deep breathe beginning 2 days after my surgery.

____ 40. The practical/vocational nurse is preparing a patient for surgery who has asthma and is hard of hearing. Which actions are within the scope of practice for the nurse? (Select all that apply.)

a. Provide emotional support.
b. Send inhaler to surgery with patient.
c. Apply anti-embolism devices as ordered.
d. Reinforce RNs instructions.
e. Provide information for informed consent.
f. Assist patient with insertion of hearing aids.

____ 41. The intraoperative practical/vocational nurse is caring for a patient who is undergoing abdominal surgery with general anesthesia. What interventions should the nurse implement? (Select all that apply.)

a. Encourage leg exercises.
b. Assist physician as directed.
c. Assist with patient positioning.
d. Monitor for unilateral swelling of the calf.
e. Participate in a time out before surgery begins.
f. Assist the patient to change position in bed every 4 hours.

____ 42. A patient recovering from surgery asks the nurse what types of anesthesia cause a loss of sensation in a specific area of the body while the patient remains alert. Which responses should the nurse give? (Select all that apply.)

a. Local anesthesia.
b. Spinal anesthesia.
c. Topical anesthesia.
d. General anesthesia.
e. Epidural anesthesia.

____ 43. The nurse is assisting in preparing the patient for surgery. Which surgical consent should the nurse recognize as being a legal consent? (Select all that apply.)

a. Consent signed by a 17-year-old for her infants surgery.
b. Consent signed by a foster mother for a 17-year-old patient.
c. Consent signed by a 28-year-old for his own elective surgery.
d. Consent signed by 16-year-old patient for his or her own urgent surgery.
e. Consent signed by a 60-year-old patient 1 hour before receiving morphine.
f. Consent signed by 36-year-old patient 1 hour after receiving lorazepam (Ativan).

____ 44. The nurse is witnessing an adult patients surgical consent. What should the nurse confirm before witnessing the surgical consent? (Select all that apply.)

a. The patients next of kin
b. When the patient last ate or drank
c. The last time a sedative was administered
d. Whether the patient is informed about the surgery
e. If family members have questions related to the surgery

____ 45. After surgery a patients surgical dressing covering the Penrose drain is dry and intact. Two hours later, the patient reports pain of 5 on a scale of 0 to 10 at the incisional site and the dressing has a 1 1 inch area of serosanguineous drainage on the dressing. What actions should the nurse take? (Select all that apply.)

a. Apply pressure to the incisional site.
b. Culture the drainage on the dressing.
c. Notify the RN immediately.
d. Monitor the drainage at the incisional site.
e. Review the analgesic administration record.

____ 46. The nurse provides recommendations for the plan of care for a patient scheduled to undergo a cholecystectomy. Why should the nurse include preoperative teaching of deep breathing exercises to prevent postoperative complications for this patient? (Select all that apply.)

a. Incisional pain promotes decreased lung expansion.
b. Anesthesia increases retention of respiratory secretions.
c. Anesthesia decreases production of respiratory secretions.
d. Location of incision contributes to decreased lung expansion.
e. Immobility after surgery promotes retention of respiratory secretions.

____ 47. The nurse is caring for a postoperative patient. When getting the patient out of bed for the first time after surgery, which actions should the nurse take to maintain safety? (Select all that apply.)

a. Use two people to assist patient.
b. Dangle the patient at the bedside.
c. Assist the patient to stand in one motion.
d. Have the patient stand with no assistance.
e. Instruct the patient to place the nurse light on to get up.

____ 48. The nurse is caring for a patient who had abdominal surgery with general anesthesia. What interventions should the nurse implement? (Select all that apply.)

a. Monitor for unilateral swelling of the calf.
b. Monitor first voiding after catheter removal.
c. Position carefully and pad bony prominences.
d. Encourage use of incentive spirometer as ordered.
e. Monitor pain level each hour that patient is awake.
f. Assist the patient to change position in bed every 4 hours.

____ 49. The nurse is contributing to an education program for older adults who are preparing for joint replacement surgery. Which interventions should the nurse use to enhance older patient learning? (Select all that apply.)

a. Avoid repetition in presentation.
b. Utilize medical terminology to promote understanding.
c. Provide handouts with black print on white nonglare paper.
d. Conduct session in a room with bright, fluorescent lighting.
e. Convey positive attitude and self-care promotion for older adults.

____ 50. A patient scheduled for surgery asks if any changes should be made to the diet before the operation occurs. What nutrients should the nurse suggest the patient ingest prior to the operative procedure? (Select all that apply.)

a. Zinc
b. Protein
c. Vitamin C
d. Vitamin E
e. Magnesium

____ 51. The nurse is reinforcing teaching provided to a patient to learn how to get out of bed independently at home after surgery. What should the nurse emphasize in this teaching? (Select all that apply.)

a. Hold breath while sitting.
b. Place the hands flat against the bed.
c. Turn onto the side without a pillow between the knees.
d. Sit for a few minutes to avoid dizziness and falling.
e. Push up while swinging the legs into a sitting position.

____ 52. The nurse is reviewing discharge instructions with a patient recovering from procedural sedation and analgesia for a surgical procedure. What should the nurse emphasize in this teaching? (Select all that apply.)

a. The patient will not eat for 24 hours.
b. An adult must drive the patient home.
c. An adult must be home to provide a safe environment.
d. The patient will not sign legal documents for 24 hours.
e. The patient will not drive or operate heavy machinery for 24 hours.

Chapter 12. Nursing Care of Patients Having Surgery

Answer Section

MULTIPLE CHOICE

1.ANS:A

Patients on chronic oral steroid therapy cannot abruptly stop their medication even though they are told to take nothing by mouth before or after surgery. Serious complications, such as circulatory collapse, can develop if steroids are stopped abruptly. The RN should be notified and will need to clarify the medication with the physician. It is anticipated that the physician will order the patients steroid therapy to be given by a parenteral route as the patient is NPO. B. Asking the patient why the medication has been prescribed does not address the problem. C. The nurse cannot provide the medication since the patient is prescribed to be NPO. D. Pharmacists cannot convert oral steroid doses to IV doses without an order from the physician.

PTS:1DIF:Moderate

KEY: Client Need: Physiological IntegrityPharmacological and Parenteral Therapies | Cognitive Level: Application

2.ANS:C

If gas pains occur, encourage ambulation, have patient lie prone, and pull the knees up to the chest to relieve pain. Encouraging early ambulation helps promote restoration of gastrointestinal (GI) functioning, which is the goal and will help relieve the gas pains. A. B. D. A hot beverage, extra blanket, or abdominal binder will not help relieve the patients abdominal gas pains.

PTS:1DIF:Moderate

KEY: Client Need: Physiological IntegrityReduction of Risk Potential | Cognitive Level: Application

3.ANS:C

The word surgery causes a common emotional reaction in patients. The nurse who understands this can reassure the patient that this is normal and then ask an open-ended question to collect data about this fear to determine what should be done next. B. D. The nurse should not provide false reassurance to the patient. A. This answer is not therapeutic in that it does not explore and identify what is concerning the patient for possible intervention.

PTS:1DIF:Moderate

KEY: Client Need: Psychosocial Integrity | Cognitive Level: Application

4.ANS:C

8 mg 1 mL = 0.8 mL
10 mg

PTS:1DIF:Moderate

KEY: Client Need: Physiological IntegrityPharmacological and Parenteral Therapies | Cognitive Level: Application

5.ANS:B

The outcome for the nursing diagnosis of Pain is met if the patient reports a satisfactory relief of pain. A. C. D. These actions may help achieve pain relief however do not necessary support the overall outcome.

PTS:1DIF:Moderate

KEY: Client Need: Physiological IntegrityBasic Care and Comfort | Cognitive Level: Analysis

6.ANS:C

For evisceration, first place the patient in low Fowlers position with flexed knees. D. Then cover the wound with sterile dressings or towels moistened with warm sterile normal saline. A. Notify the physician immediately. B. Apply gentle pressure over the wound, and keep the patient still and calm.

PTS:1DIF:Moderate

KEY: Client Need: Physiological IntegrityPhysiological Adaptation | Cognitive Level: Application

7.ANS:B

The patient is experiencing a complication and must be carefully monitored to ensure that a patent airway is maintained. A. Then vital signs can be obtained. C. The physician should be notified. D. If appropriate, the family can be notified of the change in patients condition.

PTS:1DIF:Moderate

KEY: Client Need: Physiological IntegrityReduction of Risk Potential | Cognitive Level: Analysis

8.ANS:B

Anxiety is a feeling of apprehension or uneasiness resulting from the uncertainties and risks associated with surgery. A. Fear is a feeling of dread from a source known to the patient. This is an extreme reaction to surgery. C. D. Delirium and depression are not typical stress responses to surgery.

PTS:1DIF:Moderate

KEY: Client Need: Psychosocial Integrity | Cognitive Level: Application

9.ANS:A

Allowing the patient to express concerns and ask questions so that the patient has correct information will assist in reducing client anxiety. B. Understandable terms should be used but are not the best action here to reduce anxiety. C. Allowing the patient to ask questions will reveal if general information is needed or if the surgeon needs to further explain information about the surgical procedure. In that case, the nurse would direct all surgical questions to the physician. D. The patient has the right to refuse information.

PTS:1DIF:Moderate

KEY: Client Need: Psychosocial Integrity | Cognitive Level: Application

10.ANS

Curative surgery removes diseased or abnormal tissue. B. C. Diagnostic or exploratory surgery takes tissue samples for study to make a diagnosis, uses scopes to look into areas of the body, or involves an incision to open an area of the body for examination. A. Palliative surgery alleviates symptoms.

PTS:1DIF:Moderate

KEY: Client Need: Psychosocial Integrity | Cognitive Level: Application

11.ANS:C

Diagnostic surgery takes tissue samples for study to make a diagnosis. D. Preventive surgery removes tissue before it causes a problem. A. Curative surgery removes diseased or abnormal tissue. B. Palliative surgery alleviates symptoms.

PTS:1DIF:Moderate

KEY: Client Need: Physiological IntegrityReduction of Risk Potential | Cognitive Level: Application

12.ANS:C

To clear the airway, effective coughing and deep breathing are needed, and demonstration is the best method for verifying correct technique. A. B. D. These actions will not clear the airway.

PTS:1DIF:Moderate

KEY: Client Need: Physiological IntegrityReduction of Risk Potential | Cognitive Level: Analysis

13.ANS:B

Preoperative care focuses on helping the patient achieve the best possible surgical outcome by being in the healthiest possible condition for surgery. The 55-year-old patient who is a marathon runner is in the best condition for surgery due to exercise tolerance. A. C. D. Obesity, malnourishment, and smoking all adversely affect the outcome of surgery which could lead to complications.

PTS:1DIF:Moderate

KEY: Client Need: Physiological IntegrityReduction of Risk Potential | Cognitive Level: Analysis

14.ANS:C

General anesthesia causes the patient to lose sensation, consciousness, and reflexes. A. B. C. These are all types of local anesthesia that do not cause total loss of sensation and a complete loss of consciousness.

PTS:1DIF:Moderate

KEY: Client Need: Physiological IntegrityReduction of Risk Potential | Cognitive Level: Application

15.ANS:C

The patient with chronic obstructive pulmonary disease could develop respiratory complications after surgery. This patient would benefit from learning deep breathing and coughing and how to use an incentive spirometer. A. B. D. These statements would not cause the patient to develop postoperative complications.

PTS:1DIF:Moderate

KEY: Client Need: Physiological IntegrityReduction of Risk Potential | Cognitive Level: Analysis

16.ANS:A

Hypotension results from sympathetic blockade causing vasodilation, which reduces venous return to the heart and therefore reduces cardiac output. Postural hypotension may occur if the patient rises too rapidly, creating a risk for falling. B. C. D. Spinal anesthesia does not cause hypertension, hypo- or hyper-ventilation.

PTS:1DIF:Moderate

KEY: Client Need: Safe and Effective Care EnvironmentSafety and Infection Control | Cognitive Level: Analysis

17.ANS:C

Distention could indicate paralytic ileus which is a postoperative complication. A. B. D. These are normal postoperative findings.

PTS:1DIF:Moderate

KEY: Client Need: Physiological IntegrityPhysiological Adaptation | Cognitive Level: Analysis

18.ANS:A

It is essential as part of ensuring that the consent is correct that the nurse verify the surgical procedure and correct site, especially right or left, are correctly written on the consent. B. C. D. This information is not necessary to know before witnessing a patient sign a consent form.

PTS:1DIF:Moderate

KEY: Client Need: Safe and Effective Care EnvironmentSafety and Infection Control | Cognitive Level: Application

19.ANS:A

When getting out of bed for the first time after surgery, the patient might be weak and dizzy. The patient should be instructed to request help and not get up alone. B. C. D. Then one or two health care workers can assist the patient to put on nonskid slippers and dangle before standing to prevent falls.

PTS:1DIF:Moderate

KEY: Client Need: Safe and Effective Care EnvironmentSafety and Infection Control | Cognitive Level: Application

20.ANS:C

Usually, increased temperature during the first 24 hours postoperatively indicates atelectasis if no other cause exists, so coughing and deep breathing should be encouraged to open the alveoli and prevent pneumonia. D. Range of motion exercises will not affect the temperature. B. Antipyretic medication does not affect the cause. A. Fluids should be encouraged as ordered, as dehydration can increase temperature.

PTS:1DIF:Moderate

KEY: Client Need: Physiological IntegrityReduction of Risk Potential | Cognitive Level: Application

21.ANS:C

Allowing patients to express concerns offers an opportunity to dispel inaccurate information about the surgical procedure. B. False reassurance does not help the patients fears. D. National statistics are not likely helpful to the individual patient situation. A. The nurse should collect data first about the fear to help with planning care and not pass the issue to the family.

PTS:1DIF:Moderate

KEY: Client Need: Psychosocial Integrity | Cognitive Level: Application

22.ANS

Patients on chronic oral steroid therapy cannot abruptly stop their medication even though they are told to take nothing by mouth before or after surgery. Serious complications, such as circulatory collapse, can develop if steroids are stopped abruptly. The physician should be informed so the patients steroid therapy can be given by a parenteral route if the patient is NPO. A. The nurse needs to do more than monitor and document vital signs. B. The nurse cannot change the route of a prescribed medication. C. The nurse needs to do more than hold the medication.

PTS:1DIF:Moderate

KEY: Client Need: Physiological IntegrityPharmacological and Parenteral Therapies | Cognitive Level: Application

23.ANS:B

Risk for perioperative-positioning injury related to positioning, chemicals, electrical equipment, and effect of being anesthetized is an intraoperative concern of the nurse and has an outcome of being free from injury. A. C. These are preoperative outcomes. D. This is a postoperative outcome.

PTS:1DIF:Moderate

KEY: Client Need: Physiological IntegrityReduction of Risk Potential | Cognitive Level: Application

24.ANS:B

Ensuring a patent airway is the highest priority. A. C. D. These actions will be performed by the PACU nurse and are not the highest priority.

PTS:1DIF:Moderate

KEY: Client Need: Physiological IntegrityReduction of Risk Potential | Cognitive Level: Analysis

25.ANS:B

B. Early postoperative ambulation helps prevent thrombosis. C. Peristalsis should increase to prevent the development of an ileus. A. The patient should be encouraged to cough to prevent respiratory problems. D. Wound healing is not directly aided by early ambulation.

PTS:1DIF:Moderate

KEY: Client Need: Physiological IntegrityReduction of Risk Potential | Cognitive Level: Analysis

26.ANS

After placing the patient in the low Fowlers position with the knees flexed the nurse should cover the wound with sterile dressings or towels moistened with warm sterile normal saline. Notify the physician immediately of this surgical emergency. Apply gentle pressure over the wound, and keep the patient still and calm. A. The abdomen should not be cleansed. B. Pain medication can be provided after the immediate problem is addressed. C. An abdominal binder should not be applied at this time.

PTS:1DIF:Moderate

KEY: Client Need: Physiological IntegrityReduction of Risk Potential | Cognitive Level: Application

27.ANS:C

Instructions for incentive spirometer use include the following: Sit upright, at 45 degrees minimum, if possible. Take two normal breaths. Place mouthpiece of spirometer in mouth. Inhale deeply until target, designated by spirometer light or rising ball is reached, and hold breath for 3 to 5 seconds. Exhale completely. Perform 10 sets of breaths each hour. A. B. D. These are incorrect instructions when teaching on the use of an incentive spirometer.

PTS:1DIF:Moderate

KEY: Client Need: Physiological IntegrityReduction of Risk Potential | Cognitive Level: Application

28.ANS:B

Urgent surgery is the need for an operation within 24 to 30 hours. C. D. An aortic aneurysm and ruptured appendix require emergency surgery. A. A hernia repair is elective surgery.

PTS:1DIF:Moderate

KEY: Client Need: Physiological IntegrityReduction of Risk Potential | Cognitive Level: Analysis

29.ANS

With malignant hyperthermia, surgery is stopped, and anesthesia is discontinued immediately. Oxygen is given, and the patient is cooled. Dantrolene sodium (Dantrium), a muscle relaxant, is given.

A. B. C. These protocols are not appropriate for the patient experiencing malignant hyperthermia.

PTS:1DIF:Moderate

KEY: Client Need: Physiological IntegrityReduction of Risk Potential | Cognitive Level: Application

30.ANS:A

Hypotension can result after epidural anesthesia and is caused by sympathetic blockade causing vasodilation which reduces venous return to the heart and therefore reduces cardiac output. This finding must be reported. B. C. As the block wears off, patients feel as if their legs are very heavy and numb. This is normal. D. This is not related to the epidural.

PTS:1DIF:Moderate

KEY: Client Need: Physiological IntegrityPharmacological and Parenteral Therapies | Cognitive Level: Analysis

31.ANS

For the first dose of an IM analgesic postoperatively, patients in pain should not have to wait the ordered time interval of the IM dose after an IV analgesic dose (i.e., 3 hours if the IM order is morphine 10 mg IM q3hr PRN). Having to wait when the IV analgesic is no longer effective can cause needless pain. IV analgesics usually have a shorter duration than IM analgesics. A. It is not known if the patient is prescribed nonnarcotic analgesics. B. The patient is not prescribed IV pain medication. C. The patient does not have to wait for pain medication.

PTS:1DIF:Moderate

KEY: Client Need: Physiological IntegrityPharmacological and Parenteral Therapies | Cognitive Level: Application

32.ANS

Oxygen saturation must be above 90% for discharge. A. B. C. These oxygen saturation levels do not meet the criteria to discharge from the ambulatory surgical center.

PTS:1DIF:Moderate

KEY: Client Need: Physiological IntegrityReduction of Risk Potential | Cognitive Level: Application

33.ANS:B

Studies have shown that preventing surgical site infections include giving prophylactic antibiotics within 1 hour prior to surgery (which means the actual incision time). A. The antibiotic is to be given before the surgery begins. C. This period of time is too long before the surgery begins. D. An antibiotic given after the surgery would not be a prophylactic dose.

PTS:1DIF:Moderate

KEY: Client Need: Physiological IntegrityPharmacological and Parenteral Therapies | Cognitive Level: Application

34.ANS:A

Ibuprofen can be effectively used for postoperative pain relief. B. The nurse does not need to consult the physician since the patients pain level is 4. C. The medication is prescribed ibuprofen which the nurse should provide. D. There is no evidence to suggest that the patient will experience GI upset from the medication.

PTS:1DIF:Moderate

KEY: Client Need: Physiological IntegrityPharmacological and Parenteral Therapies | Cognitive Level: Application

35.ANS:B

Patients can be hydrated and fed early for nutrition to promote healing and faster recovery. The nurse just needs to check the physicians orders for oral intake. C. D. Traditionally after GI surgery, bowel sounds were monitored by the nurse and the patient was kept NPO until flatus and bowel sounds returned. No evidence exists to support this practice. However, research about this practice shows that bowel sounds are not correlated with bowel motility and a patients ability to safely drink and eat postoperatively. A. Pain is expected after surgical intervention and should be treated with analgesics.

PTS:1DIF:Moderate

KEY: Client Need: Physiological IntegrityReduction of Risk Potential | Cognitive Level: Application

36.ANS:B

Patients should be encouraged to avoid smoking for at least 3 to 4 weeks before surgery if they have a chronic lung disorder. A. C. This patient needs to avoid smoking for longer than 3 to 4 or 24 hours. D. The patient should not smoke at all for 3 to 4 weeks before the surgery.

PTS:1DIF:Moderate

KEY: Client Need: Health Promotion and Maintenance | Cognitive Level: Application

37.ANS

Until its effects wear off, anesthesia can alter neurologic function. Patients may arrive in the PACU awake, arousable, or sleeping. Patients who are sleeping should become more alert during their stay in the PACU. As they emerge from anesthesia, they may become agitated or wild acting for a short time; this is called emergence delirium. Once resolved, the patient returns to calm state and has no recollection of the episode. A. B. C. The patient recovering from anesthesia is not experiencing delusions, sundowning, or hallucinations.

PTS:1DIF:Moderate

KEY: Client Need: Physiological IntegrityReduction of Risk Potential | Cognitive Level: Application

MULTIPLE RESPONSE

38.ANS:A, B, E

For the patient at risk of developing deep vein thrombosis, it is important to encourage hourly leg exercises while awake, assist with early ambulation, apply knee- or thigh-length anti-embolic stockings, and give low molecular weight heparin if ordered. D. It is also important to avoid pressure under the knee from pillows to prevent clot formation. C. Legs should not be massaged, as a clot, if present, could be dislodged and become an embolus.

PTS:1DIF:Moderate

KEY: Client Need: Physiological IntegrityReduction of Risk Potential | Cognitive Level: Application

39.ANS:C, D

Deep breathing helps prevent the development of atelectasis. Coughing moves secretions to prevent pneumonia. They are done 10 times hourly while the patient is awake for 24 to 48 hours postoperatively. A. These exercises should be done after surgery. B. Shallow breaths are not recommended. E. This exercise should be done up to 2 days after the surgery.

PTS:1DIF:Moderate

KEY: Client Need: Physiological IntegrityReduction of Risk Potential | Cognitive Level: Analysis

40.ANS:A, B, C, D, F

All actions are within the scope of practice for a practical/vocational except for providing informed consent. E. The physician provides information for informed consent.

PTS:1DIF:Moderate

KEY: Client Need: Safe and Effective Care EnvironmentManagement of Care | Cognitive Level: Application

41.ANS:A, B, E

The surgical (second assistant) technician: assists physician (may be an RN, LPN/LVN, or surgical technologist). Encouraging leg exercises and participating in surgical time out are focused on preventing complications for this patient in surgery. The practical/vocational nurse can participate in positioning as directed. Everyone must participate in the time out. C. D. F. These actions are postoperative interventions for respiratory and circulatory complications, not intraoperative interventions. Also, the patient should move more than every 4 hours.

PTS:1DIF:Moderate

KEY: Client Need: Physiological IntegrityReduction of Risk Potential | Cognitive Level: Application

42.ANS:A, B, C, E

Local anesthesia causes a loss of sensation in a specific area of the body while the patient remains alert. Epidural and spinal anesthesia are forms of local anesthesia. D. General anesthesia causes a loss of consciousness.

PTS:1DIF:Moderate

KEY: Client Need: Physiological IntegrityPharmacological and Parenteral Therapies | Cognitive Level: Application

43.ANS:A, C, E

The 60-year-old patient is an adult and no narcotics have been given that may impair judgment, so it is a legal consent. The consent was signed by a 17-year-old who is the childs legal parent. The 28-year- old patient is an adult signing for his own surgery without evidence of impairment. B. It is not known if the foster mother is the legal guardian for the 17-year-old patient. D. The patient is 16 years old and cannot give consent because of being a minor. F. The patient received medication to affect mentation. This consent is not legal.

PTS:1DIF:Moderate

KEY: Client Need: Safe and Effective Care EnvironmentManagement of Care | Cognitive Level: Analysis

44.ANS:C, D

As the patients advocate, ensure before the consent is signed that the patient is informed about the surgery and has no further questions for the physician. If the patient has questions, the consent should not be signed, and the physician should be contacted to answer the patients questions. The consent cannot be signed if the patient is under the influence of sedatives or narcotics, so timing of their administration must be verified. A. B. E. The nurse does not need to confirm the patients next of kin, when the patient last ingested food or fluids, or if the family members have questions about the surgery.

PTS:1DIF:Moderate

KEY: Client Need: Safe and Effective Care EnvironmentManagement of Care | Cognitive Level: Application

45.ANS, E

Moderate serosanguineous drainage is expected from a Penrose drain, so monitoring the dressing is all that is needed at this time, as this is a small amount of drainage. The pain level requires intervention, and verifying the last time pain medication was administered is the first step. A. Pressure does not need to be applied to the incisional site. B. The drainage does not need to be cultured. C. The RN does not need to be notified.

PTS:1DIF:Moderate

KEY: Client Need: Physiological IntegrityReduction of Risk Potential | Cognitive Level: Application

46.ANS:B, D, E

Lung expansion is needed to prevent complications such as pneumonia. During anesthesia, the patient is not taking deep breaths, so secretions are not being mobilized. The high incisional location near the diaphragm will decrease the patients willingness to take deep breaths, especially if painful. Immobility from anesthesia and recovery promotes the retention of respiratory secretions. A. Incisional pain does not promote decreased lung expansion. C. Anesthesia does not decrease the production of respiratory secretions.

PTS:1DIF:Moderate

KEY: Client Need: Physiological IntegrityReduction of Risk Potential | Cognitive Level: Analysis

47.ANS:A, B, E

When a patient is getting up after surgery for the first time dizziness and weakness may occur. The patient is a fall risk at this time. Ideally, two health care workers should assist the patient to dangle before standing to prevent falls the first time getting up. C. The patient should not stand up in one motion. D. The patient needs assistance to stand.

PTS:1DIF:Moderate

KEY: Client Need: Safe and Effective Care EnvironmentSafety and Infection Control | Cognitive Level: Application

48.ANS:A, B, D, E

Monitoring for calf swelling, voiding after catheter removal, use of incentive spirometer, and pain level are focused on preventing postoperative complications for this patient. C is an intraoperative intervention. F. The patient should move more than every 4 hours.

PTS:1DIF:Moderate

KEY: Client Need: Physiological IntegrityReduction of Risk Potential | Cognitive Level: Application

49.ANS:C, E

The nurse should provide handouts with black print on white non-glare paper and convey a positive attitude and self-care promotion or older adults. A. B. D. These actions should be avoided.

PTS:1DIF:Moderate

KEY: Client Need: Health Promotion and Maintenance | Cognitive Level: Application

50.ANS:A, B, C

Patients should be well nourished to adequately heal and recover from surgery. Higher levels of protein (tissue repair and healing), vitamin C (collagen formation), and zinc (tissue growth, skin integrity, and cell-mediated immunity) are required. D. E. Vitamin E and magnesium are not identified as nutrients that specifically aid in wound healing or recovery from surgery.

PTS:1DIF:Moderate

KEY: Client Need: Health Promotion and Maintenance | Cognitive Level: Application

51.ANS:B, C, D, E

To make it easier for the patient to get out of bed and to reduce strain on the incision, the patient should be instructed to turn onto the side without pillows between knees, place hands flat against the bed, push up while swinging legs out of bed into a sitting position, and sit for a few minutes after changing position to avoid dizziness and falling. A. The patient should be instructed to deep breathe while sitting to expand the lungs.

PTS:1DIF:Moderate

KEY: Client Need: Health Promotion and Maintenance | Cognitive Level: Application

52.ANS:B, C, D, E

Instructions after procedural sedation and analgesia are to include that an adult must drive the patient home and provide a safe environment, and the patient must not and will not drive or operate heavy machinery or sign legal documents for 24 hours. A. There is no reason for the patient to abstain from eating for 24 hours after receiving procedural sedation and analgesia.

PTS:1DIF:Moderate

KEY: Client Need: Physiological IntegrityReduction of Risk Potential | Cognitive Level: Application

Leave a Reply