Chapter 37 My Nursing Test Banks

 

Kozier & Erbs Fundamentals of Nursing, 9/E
Chapter 37

Question 1

Type: MCSA

The nurse is caring for a client who is having surgery and is currently being transported to the operating room suite. The nurse would document that the client is in which operative phase?

1. Preoperative phase

2. Intraoperative phase

3. Postoperative phase

4. Perioperative phase

Correct Answer: 1

Rationale 1: The preoperative phase begins when the decision to have surgery is made and ends when the client is transferred to the operating table.

Rationale 2: The intraoperative phase begins when the client is transferred to the operating table and ends when the client is admitted to the PACU.

Rationale 3: The postoperative phase begins with the admission of the client to the postanesthesia area and ends when healing is complete.

Rationale 4: There is not a specific perioperative phase of surgical care. Perioperative care consists of three phases: preoperative, intraoperative, and postoperative.

Global Rationale: Page Reference: 960

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 02 Describe the phases of the perioperative period.

Question 2

Type: MCSA

The nurse is caring for an 80-year-old client preparing for surgery. The nurse realizes this client is at increased risk because:

1. The physiological deficits of aging increase the surgical risk for older adults.

2. The older adult has increased kidney function.

3. The older adult has an increase in sensory function.

4. The older adult will turn, cough, and deep breathe more effectively.

Correct Answer: 1

Rationale 1: The older adult has more physiological deficits, such as decreased kidney function and decreased thirst, and is at greater risk for fluid and electrolyte imbalances.

Rationale 2: The older client has decreased kidney function.

Rationale 3: The older client has a decline in sensory functioning.

Rationale 4: The older client may not be able to follow directions or understand instruction as well as a younger client.

Global Rationale: Page Reference: 960

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 03 Identify essential aspects of preoperative assessment.

Question 3

Type: MCMA

The nurse is preparing to complete a physical assessment before surgery. Which of the following should the nurse obtain?

Standard Text: Select all that apply.

1. Mini mental status

2. Assessment of hearing

3. Assessment of the respiratory system

4. Gastrointestinal assessment

5. Maintain NPO status

Correct Answer: 1,2,3,4

Rationale 1: A brief or mini mental status examination provides valuable baseline data for evaluating the clients mental status and alertness after surgery. It is also important to evaluate the clients ability to understand what is happening.

Rationale 2: Assessment of hearing helps guide the effectiveness of perioperative teaching.

Rationale 3: Respiratory assessment not only provides baseline data for evaluating the clients postoperative status but may alert care providers to a problem that may affect the clients response to surgery and anesthesia.

Rationale 4: The gastrointestinal status provides baseline data.

Rationale 5: Maintaining NPO status is a nursing intervention. It is not included in the physical assessment.

Global Rationale: Page Reference: 962

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 03 Identify essential aspects of preoperative assessment.

Question 4

Type: MCSA

The nurse is preparing to conduct preoperative teaching. What should be included?

1. Information related to what will happen to the client

2. Referral of the client to the physician for any misconceptions the client may have

3. The role of the nurse during surgery

4. How to perform ADLs following surgery

Correct Answer: 1

Rationale 1: The nurse should provide information including what will happen to the client, when, and what the client will experience.

Rationale 2: The nurse should clarify any misconceptions the client may have.

Rationale 3: The nurse should also explain the roles of the client and support people in preoperative preparation, the surgical procedure, and during the postoperative phase.

Rationale 4: How to perform activities of daily living following surgery is not a part of preoperative teaching.

Global Rationale: Page Reference: 964

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 06 Describe essential preoperative teaching, including pain assessment and management, moving, leg exercises, and deep-breathing and coughing exercises.

Question 5

Type: MCSA

The nurse is preparing a care plan for a client about to undergo surgery. Which nursing diagnosis would take priority during the intraoperative phase of surgery?

1. Ineffective Protection

2. Risk for Aspiration

3. Impaired Skin Integrity

4. Risk for Falls

Correct Answer: 2

Rationale 1: Although appropriate for a client having surgery, the nurse should prioritize care according to the ABCs or airway, breathing, circulation when planning care.

Rationale 2: This is the priority nursing diagnosis for the client having surgery. The Risk for Aspiration would impact the clients airway and breathing.

Rationale 3: Although appropriate for a client having surgery, the nurse should prioritize care according to the ABCs or airway, breathing, circulation when planning care.

Rationale 4: This nursing diagnosis is not appropriate during the intraoperative phase of care.

Global Rationale: Page Reference: 964

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Diagnosis

Learning Outcome: 04 Give examples of pertinent nursing diagnoses for surgical clients.

Question 6

Type: MCSA

The nurse is preparing the skin of a client for surgery. The nurse knows the purpose of the surgical skin preparation is to:

1. Sterilize the skin.

2. Assess the surgical site before surgery.

3. Reduce the risk of postoperative wound infection.

4. Clean any moles the client may have.

Correct Answer: 3

Rationale 1: The preparation of the skin prior to surgery is not to sterilize the skin.

Rationale 2: The purpose of a surgical skin preparation is not to assess the surgical site before surgery.

Rationale 3: The purpose of a surgical skin preparation is not to clean any moles the client may have.

Rationale 4: The purpose of a surgical skin preparation is to reduce the risk of postoperative wound infection.

Global Rationale: Page Reference: 974

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 07 Describe essential aspects of preparing a client for surgery.

Question 7

Type: MCSA

The nurse is preparing a client for an upper GI endoscopy. Which of the following types of anesthesia would the nurse anticipate the client to receive?

1. Local anesthesia

2. Spinal anesthesia

3. Epidural anesthesia

4. Conscious sedation

Correct Answer: 4

Rationale 1: Local anesthesia is used for minor surgical procedures such as suturing a small wound or performing a biopsy.

Rationale 2: Spinal anesthesia is used for surgeries such as hernia repairs, rectal surgeries, or cesarean sections.

Rationale 3: Epidural anesthesia is the introduction of an anesthetic into the epidural space.

Rationale 4: Conscious sedation is often used for procedures such as endoscopies and incision and drainage of abscesses.

Global Rationale: Page Reference: 973

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 08 Compare various types of anesthesia.

Question 8

Type: MCSA

The nurse is caring for a client in the recovery area. Which position should the unconscious client be placed while in the immediate postanesthesia phase?

1. Supine

2. Prone

3. Side-lying

4. Supine with a pillow under the head

Correct Answer: 3

Rationale 1: In the supine position, the client could occlude the airway.

Rationale 2: In the prone position, the clients operative site may not be readily assessed.

Rationale 3: The unconscious client should be positioned on the side, with the face slightly down.

Rationale 4: A pillow under the head could cause the clients airway to become obstructed.

Global Rationale: Page Reference: 982

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 09 Identify essential nursing assessments and interventions during the immediate postanesthetic phase.

Question 9

Type: MCSA

The nurse is admitting a client to the medical-surgical unit following a cholecystectomy. Which intervention should the nurse perform first?

1. Level of consciousness

2. Dressing

3. Drains

4. Skin color

Correct Answer: 1

Rationale 1: The nurse should assess the clients level of consciousness first.

Rationale 2: The operative dressing is not assessed first.

Rationale 3: An operative drains are not assessed first.

Rationale 4: The clients skin color is not assessed first.

Global Rationale: Page Reference: 977

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 09 Identify essential nursing assessments and interventions during the immediate postanesthetic phase.

Question 10

Type: MCSA

The nurse is caring for a client on the postoperative unit. Which nursing diagnosis is the priority for this client?

1. Self-Care Deficit

2. Disturbed Body Image

3. Ineffective Airway Clearance

4. Risk for Falls

Correct Answer: 3

Rationale 1: After surgery, a client may have a Self-Care Deficit however this is not the priority.

Rationale 2: Depending upon the type of surgery, the client may have Disturbed Body Image however this is not the priority.

Rationale 3: When prioritizing, the nurse should remember the ABCs. Airway should always be the priority.

Rationale 4: A client recovering from surgery may be at Risk for Falls however this is not a priority.

Global Rationale: Page Reference: 980

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Diagnosis

Learning Outcome: 04 Give examples of pertinent nursing diagnoses for surgical clients.

Question 11

Type: MCSA

A client recovering from surgery asks the nurse why turning, deep breathing, and coughing exercises need to be done. What should the nurse respond?

1. These exercises help prevent pneumonia.

2. The doctor ordered the exercises.

3. All surgical clients must do these exercises.

4. These exercises prevent thrombophlebitis.

Correct Answer: 1

Rationale 1: By increasing lung expansion and preventing accumulation of secretions, deep breathing helps prevent pneumonia and atelectasis.

Rationale 2: These are nursing interventions and do not need to be prescribed by a physician.

Rationale 3: Although this may be true, it does not instruct the client as to the purpose of the exercises.

Rationale 4: Turning, deep breathing, and coughing exercises do not prevent thrombophlebitis.

Global Rationale: Page Reference: 982

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 06 Describe essential preoperative teaching, including pain assessment and management, moving, leg exercises, and deep-breathing and coughing exercises.

Question 12

Type: MCSA

The nurse is assessing an abdominal wound in the postoperative period. Which sign would indicate to the nurse that an infection is present?

1. Absence of bleeding

2. Edges warm to the touch

3. Edges well approximated

4. Sutures in place

Correct Answer: 2

Rationale 1: Absence of bleeding is an indication of healing.

Rationale 2: If the wound becomes warm, red, and edematous, the nurse should suspect an infection and notify the physician.

Rationale 3: Edges that are well approximated is an indication of healing.

Rationale 4: Intact sutures is a sign of healing.

Global Rationale: Page Reference: 988

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 11 Identify potential postoperative complications and describe nursing interventions to prevent them.

Question 13

Type: MCSA

The nurse is preparing a 23-year-old female client for surgery. The nurse would anticipate which of the following diagnostic tests to be ordered?

1. Pregnancy test

2. EEG

3. EKG

4. Pulmonary function tests

Correct Answer: 1

Rationale 1: A pregnancy test is done on all female clients of childbearing age.

Rationale 2: An electroencephalogram is not considered a routine preoperative diagnostic test.

Rationale 3: An electrocardiogram is done on all clients over 40 years of age and/or clients with preexisting cardiac conditions.

Rationale 4: Pulmonary function tests are not routine preoperative diagnostic tests.

Global Rationale: Page Reference: 963

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 05 Identify nursing responsibilities in planning perioperative nursing care.

Question 14

Type: MCSA

Which nursing intervention would the nurse implement to decrease the risk of a surgical client developing thrombophlebitis?

1. Administer an anticoagulant

2. Cough every 2 hours

3. Intake and output every 2 hours

4. Early ambulation

Correct Answer: 4

Rationale 1: Anticoagulant therapy must be prescribed by a physician.

Rationale 2: Coughing every 2 hours will reduce the clients risk of developing pneumonia or atelectasis.

Rationale 3: Measuring intake and output every 2 hours assesses the clients renal function.

Rationale 4: Early ambulation, leg exercises, antiemboli stockings, SCDs, and adequate fluid intake are all interventions to reduce the risk for thrombophlebitis.

Global Rationale: Page Reference: 978

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 11 Identify potential postoperative complications and describe nursing interventions to prevent them.
12 Verbalize the steps used in: Applying antiemboli stockings.

Question 15

Type: MCSA

A client is scheduled for a cholecystectomy. The nurse realizes that the purpose for this surgery is:

1. Diagnostic

2. Palliative

3. Ablative

4. Constructive

Correct Answer: 3

Rationale 1: A diagnostic surgery is done to confirm or establish a diagnosis.

Rationale 2: Palliative surgery is done to relieve or reduce pain or symptoms of a disease. The surgery does not cure an illness.

Rationale 3: When the purpose of surgery is ablative, the diseased body part is removed.

Rationale 4: Constructive surgery restores function or appearance that has been lost or reduced.

Global Rationale: Page Reference: 960

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 01 Discuss various types of surgery according to the purpose, degree of urgency, and degree of risk.

Question 16

Type: MCMA

The nurse is obtaining preoperative assessment data. Which of the following should be included?

Standard Text: Select all that apply.

1. Current health status

2. Allergies

3. Current medications

4. Mental status

5. Previous surgeries

Correct Answer: 1,2,3,4,5

Rationale 1: All options should be obtained when completing a preoperative assessment.

Rationale 2: All options should be obtained when completing a preoperative assessment.

Rationale 3: All options should be obtained when completing a preoperative assessment.

Rationale 4: All options should be obtained when completing a preoperative assessment.

Rationale 5: All options should be obtained when completing a preoperative assessment.

Global Rationale: Page Reference: 963

Cognitive Level: Analyzing

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 03 Identify essential aspects of preoperative assessment.

Question 17

Type: MCSA

The nurse is caring for a client in the immediate postoperative period (PACU). Which intervention would the nurse implement to reduce the risk of thrombophlebitis?

1. Leg exercises

2. Cough every 2 hours

3. Ambulate every 2 hours

4. Oxygen by mask

Correct Answer: 1

Rationale 1: Leg exercises may be implemented in the PACU to help prevent thrombophlebitis.

Rationale 2: Coughing every 2 hours does not prevent thrombophlebitis.

Rationale 3: Ambulation is not done in the post anesthesia care unit.

Rationale 4: Oxygen does not prevent thrombophlebitis.

Global Rationale: Page Reference: 978

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 11 Identify potential postoperative complications and describe nursing interventions to prevent them.

Question 18

Type: MCSA

The nurse is preparing to apply antiemboli stockings to a postoperative client. What should be done first, before applying the stockings?

1. Measure the calf.

2. Assess for circulatory problems.

3. Assess the clients blood pressure.

4. Clean the stockings.

Correct Answer: 2

Rationale 1: Measuring the calf is the first step of implementing antiemboli stockings.

Rationale 2: Before applying antiemboli stockings, determine any potential or present circulatory problems and the surgeons orders involving the lower extremities.

Rationale 3: Assessing the blood pressure is not done before applying antiemboli stockings.

Rationale 4: The client should be given clean stockings, the nurse should not have to wash stockings before using.

Global Rationale: Page Reference: 971

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 12 Verbalize the steps used in: Applying antiemboli stockings.

Question 19

Type: MCSA

The nurse has just inserted a nasogastric tube for gastric suction. What is the most reliable test for confirming tube placement?

1. Place the stethoscope over the stomach and listen while inserting water into the tube for a swishing sound.

2. Place the stethoscope over the stomach and listen while inserting air into the tube for a swishing sound.

3. Aspirate stomach contents and check the acidity using a pH test strip.

4. Connect the tube to suction and observe the contents.

Correct Answer: 3

Rationale 1: Water should not be inserted into the tube until placement is confirmed.

Rationale 2: This is done to ensure placement however it is not the most reliable test.

Rationale 3: Aspirate stomach contents and check the acidity using a pH test strip is the most reliable test to confirm tube placement.

Rationale 4: Connecting the tube to suction should not be done until tube placement has been confirmed.

Global Rationale: Page Reference: 985

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 12 Verbalize the steps used in: Managing gastrointestinal suction.

Question 20

Type: MCSA

The nurse is preparing a 6-year-old child for a tonsillectomy. Which strategy would the nurse use for teaching this client?

1. Pamphlets

2. Play

3. Books

4. Videotapes

Correct Answer: 2

Rationale 1: Pamphlets would be appropriate to supplement instruction to an adult or older client.

Rationale 2: Play is an effective teaching tool with children.

Rationale 3: Books would be more appropriate to supplement instruction to a school-age child.

Rationale 4: Videotapes would be appropriate for adolescent or adult clients.

Global Rationale: Page Reference: 968

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 06 Describe essential preoperative teaching, including pain assessment and management, moving, leg exercises, and deep-breathing and coughing exercises.

Question 21

Type: MCSA

When planning the care for a client during the postoperative period, the nurse would identify what as the goal for care?

1. Provide necessary preoperative teaching.

2. Assist the client to achieve the most optimal health status possible.

3. Ensure client safety.

4. Maintain an aseptic environment.

Correct Answer: 2

Rationale 1: Providing necessary preoperative teaching is an activity associated with the preoperative phase.

Rationale 2: The goal of postoperative care is to assist the client to achieve the most optimal health status possible.

Rationale 3: Ensuring client safety is a goal off the intraoperative phase.

Rationale 4: Maintaining an aseptic environment is an action within the intraoperative phase.

Global Rationale: Page Reference: 976

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 09 Identify essential nursing assessments and interventions during the immediate postanesthetic phase.

Question 22

Type: MCMA

The nurse is planning a perioperative clients needs upon discharge. What should be included when determining these needs?

Standard Text: Select all that apply.

1. Clients abilities to provide self-care.

2. Date of anticipated discharge.

3. Physician performing the surgery.

4. Financial resources.

5. Need for homecare services.

Correct Answer: 1,4,5

Rationale 1: Discharge planning incorporates an assessment of the clients abilities for self-care.

Rationale 2: Discharge planning does not include the clients anticipated date of discharge.

Rationale 3: Discharge planning does not include the name of the physician performing the surgery.

Rationale 4: Discharge planning incorporates an assessment of the clients financial resources.

Rationale 5: Discharge planning incorporates an assessment of the clients need for home health care.

Global Rationale: Page Reference: 982

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 06 Describe essential preoperative teaching, including pain assessment and management, moving, leg exercises, and deep-breathing and coughing exercises.

Question 23

Type: MCMA

The nurse has identified the goals of maintaining client safety and homeostasis during the intraoperative phase of client care. What nursing activities would support these goals?

Standard Text: Select all that apply.

1. Maintain the sterile field.

2. Perform instrument counts.

3. Instruct in postoperative exercises.

4. Position the client appropriately for surgery.

5. Perform preoperative skin preparation.

Correct Answer: 1,2,4,5

Rationale 1: Maintaining the sterile field will support the goals of maintaining client safety and homeostasis.

Rationale 2: Performing instrument counts will support the goals of maintaining client safety and homeostasis.

Rationale 3: Instructing in postoperative exercises will not support the goals of maintaining client safety and homeostasis.

Rationale 4: Positioning the client appropriately for surgery will support the goals of maintaining client safety and homeostasis.

Rationale 5: Performing preoperative skin preparation will support the goals of maintaining client safety and homeostasis.

Global Rationale: Page Reference: 974-975

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Evaluation

Learning Outcome: 02 Describe the phases of the perioperative period.
05 Identify nursing responsibilities in planning perioperative nursing care.

Question 24

Type: MCMA

A client is anxious about receiving general anesthesia for a surgical procedure. What should the nurse explain are the advantages of having this type of anesthesia?

Standard Text: Select all that apply.

1. The client remains conscious.

2. Respiratory rate can be regulated easily.

3. It is used for minor surgical procedures.

4. The anesthesia can be adjusted to the length of the operation.

5. It focuses on a single nerve or nerve group.

Correct Answer: 2,4

Rationale 1: The clients remaining conscious is an advantage of regional anesthesia.

Rationale 2: An advantage of general anesthesia is that the respiratory rate can be regulated easily.

Rationale 3: Regional anesthesia is used for minor surgical procedures.

Rationale 4: An advantage of general anesthesia is the anesthesia can be adjusted to the length of the procedure.

Rationale 5: A nerve block focuses on a single nerve or nerve group.

Global Rationale: Page Reference: 973

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 08 Compare various types of anesthesia.

Question 25

Type: MCSA

During the assessment of a client recovering from surgery, the nurse notes decreased breath sounds in both lower lobes bilaterally. What should the nurse do?

1. Coach the client to deep-breathe and cough.

2. Restrict fluids.

3. Remind the client to perform leg exercises.

4. Maintain on bed rest.

Correct Answer: 1

Rationale 1: The reduction of breath sounds could indicate the pooling of secretions in the lower lobes. The nurse should coach the client to deep-breathe and cough.

Rationale 2: Restricting fluids could cause the pulmonary secretions to thicken, making them more difficult for the client to cough and remove.

Rationale 3: Leg exercises will not improve breath sounds.

Rationale 4: Bed rest will not improve the clients breath sounds.

Global Rationale: Page Reference:978

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 11 Identify potential postoperative complications and describe nursing interventions to prevent them.

Question 26

Type: SEQ

The nurse is preparing to change the dressing on a clients postoperative wound. Place in order the steps the nurse should perform when removing the soiled dressing.

Standard Text: Click and drag the options below to move them up or down.

Choice 1. Assess the location, type, and odor of wound drainage.

Choice 2. Remove the outer dressing.

Choice 3. Discard the under dressing in a moisture-proof bag, and remove and discard gloves.

Choice 4. Remove the under dressing.

Choice 5. Apply clean gloves.

Choice 6. Place the soiled dressing in a moisture-proof bag.

Correct Answer: 5,2,6,4,1,3

Rationale 1: Once the under dressing is removed, the nurse should assess the location, type, and odor of any wound drainage.

Rationale 2: The nurse should then remove the outer dressing.

Rationale 3: The nurse should then discard the under dressing in a moisture-proof bag and remove and discard the gloves.

Rationale 4: The nurse should next remove the under dressing.

Rationale 5: The nurse first should apply clean gloves.

Rationale 6: The nurse should place the soiled outer dressing in a moisture-proof bag.

Global Rationale: Page Reference: 988

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 12 Verbalize the steps used in: Cleaning a sutured wound and changing a dressing on a wound with a drain.

Question 27

Type: MCMA

The nurse is planning to remove the sutures from a clients surgical wound. What should the nurse do before removing the sutures?

Standard Text: Select all that apply.

1. Apply clean gloves.

2. Verify the order for suture removal.

3. Ambulate the client to the bathroom.

4. Read the order to determine whether a dressing is to be applied after removal.

5. Remove the dressing and clean the incision.

Correct Answer: 2,4,5

Rationale 1: The nurse is to apply sterile gloves for suture removal.

Rationale 2: Before removing skin sutures, the nurse should verify that there is an order for suture removal.

Rationale 3: The client is not to be ambulated to the bathroom for suture removal.

Rationale 4: Before removing skin sutures, the nurse should verify whether a dressing is to be applied following the suture removal.

Rationale 5: Before removing skin sutures, the nurse should remove the dressing and clean the incision.

Global Rationale: Page Reference: 988

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 12 Verbalize the steps used in:
e. Removing sutures and staples.

Question 28

Type: MCSA

The nurse determines that preoperative instruction regarding leg exercises has been effective when what is assessed?

1. Lower extremity swollen and hot to touch.

2. Vein feels hard.

3. No cramping or pain with ambulation.

4. Pain in calf with dorsiflexion.

Correct Answer: 3

Rationale 1: Lower extremity swelling and heat would indicate the presence of thrombophlebitis.

Rationale 2: A hard vein would indicate the presence of thrombophlebitis, and that leg exercises were not effective.

Rationale 3: The absence of cramping or pain with ambulation indicates that leg exercises instructed prior to surgery were effective to prevent the onset of thrombophlebitis.

Rationale 4: Pain in the calf with dorsiflexion would indicate the presence of thrombophlebitis, and that leg exercises were not effective.

Global Rationale: Page Reference: 978

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Evaluation

Learning Outcome: 13 Evaluate the effectiveness of perioperative nursing interventions.

Question 29

Type: MCSA

The nurse determines that interventions to prevent postoperative constipation have been effective when what is assessed?

1. Abdominal distention present.

2. Gas pains present.

3. Client vomiting.

4. Bowel movement occurred 24 hours after resuming a normal diet.

Correct Answer: 4

Rationale 1: Abdominal distention is an indication of postoperative constipation.

Rationale 2: Gas pain is an indication of postoperative constipation.

Rationale 3: Vomiting is an indication of postoperative constipation.

Rationale 4: A bowel movement that occurs within 48 hours after resuming a normal diet is evidence that postoperative constipation has been prevented.

Global Rationale: Page Reference: 979

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Evaluation

Learning Outcome: 13 Evaluate the effectiveness of perioperative nursing interventions.

Question 30

Type: MCMA

The nurse is caring for a postoperative client with an abdominal wound and a drain. What can the nurse delegate to unlicensed assistive personnel?

Standard Text: Select all that apply.

1. Clean the wound.

2. Assess the skin around the wound.

3. Determination of effectiveness of pain medication.

4. Report if the dressing is soiled.

5. Report if the dressing is loose.

Correct Answer: 4,5

Rationale 1: Cleaning a newly sutured wound, especially one with a drain, requires application of knowledge, problem solving, and aseptic technique. This procedure should not be delegated to UAP.

Rationale 2: The nurse is responsible for assessment of the wound.

Rationale 3: The nurse is responsible for evaluation of medication provided.

Rationale 4: The nurse can ask the UAP to report soiled dressings that need to be changed.

Rationale 5: The nurse can ask the UAP to report if the dressing is loose and needs to be reinforced.

Global Rationale: Page Reference: 988

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 12 Verbalize the steps used in:
d. Cleaning a sutured wound and changing a dressing on a wound with a drain.

Question 31

Type: MCSA

The nurse manager of the operating suite is planning the intraoperative care of a client. What role can the manager assign to UAP during the surgical procedure of this client?

1. Scrub person.

2. Circulating person.

3. First assistant.

4. Anesthesia administration.

Correct Answer: 1

Rationale 1: The scrub person is usually UAP. The role is to assist the surgeon.

Rationale 2: The role of circulating person cannot be assigned to UAP, because this person coordinates activities and manages client care by continually assessing client safety, aseptic practice, and the environment.

Rationale 3: The first assistant is a registered nurse, and has had additional education and training to deliver surgical care. This person assists the surgeon by controlling bleeding, using instruments, handling and cutting tissues, and suturing during the procedure.

Rationale 4: Anesthesia administration is the role of the anesthesiologist or certified registered nurse anesthetist.

Global Rationale: Page Reference: 974

Cognitive Level: Applying

Client Need: Safe Effective Care Environment

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 14 Recognize when it is appropriate to delegate infection control skills to unlicensed assistive personnel.

Question 32

Type: MCMA

The nurse has removed the sutures from a clients surgical wound. What should the nurse document about this procedure?

Standard Text: Select all that apply.

1. Number of sutures removed.

2. Appearance of the incision.

3. Client teaching.

4. Client tolerance of the procedure.

5. Name of the surgeon.

Correct Answer: 1,2,3,4

Rationale 1: The nurse should document the number of sutures removed.

Rationale 2: The nurse should document the appearance of the incision.

Rationale 3: The nurse should document any client teaching.

Rationale 4: The nurse should document the clients tolerance of the procedure.

Rationale 5: The nurse does not need to document the name of the surgeon.

Global Rationale: Page Reference: 993

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 12 Verbalize the steps used in:
e. Removing sutures and staples.
15 Demonstrate appropriate documentation and reporting of perioperative skills.

Question 33

Type: MCMA

A client in the post-anesthesia care unit is to have suction applied through a nasogastric tube. When documenting, the nurse should include:

Standard Text: Select all that apply.

1. The time suction was started.

2. Characteristics of wound drainage.

3. Pressure on the suction.

4. Integrity of the surgical dressing.

5. Color and consistency of drainage.

Correct Answer: 1,3,5

Rationale 1: For the nasogastric tube placed to suction, the nurse should document the time suction was started.

Rationale 2: The characteristics of the wound drainage are not related to the nasogastric tube suction.

Rationale 3: For the nasogastric tube placed to suction, the nurse should document the pressure on the suction.

Rationale 4: The integrity of the surgical dressing is not related to the nasogastric tube suction.

Rationale 5: For the nasogastric tube placed to suction, the nurse should document the color and consistency of the drainage.

Global Rationale: Page Reference: 987

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 12 Verbalize the steps used in:
c. Managing gastrointestinal suction.
15 Demonstrate appropriate documentation and reporting of perioperative skills.

Question 34

Type: MCMA

When obtaining preoperative assessment data from a client, the nurse should include:

Standard Text: Select all that apply.

1. Current health status.

2. Allergies.

3. Current medications.

4. Mental status.

5. Respiratory rate.

Correct Answer: 1,2,3,4

Rationale 1: When documenting the current health status, essential information includes general health status and the presence of any chronic diseases that might affect the clients response to surgery or anesthesia.

Rationale 2: When documenting allergies, the nurse should include allergies to prescription and nonprescription drugs, food allergies, and allergies to tape, latex, soaps, or antiseptic agents.

Rationale 3: All current medications should be listed. Herbal remedies and over-the-counter preparations are also a part of this assessment.

Rationale 4: The clients current mental status is a part of this assessment.

Rationale 5: Respiratory rate is part of the physical assessment.

Global Rationale: Page Reference: 963

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 03 Identify essential aspects of preoperative assessment.

Kozier & Erbs Fundamentals of Nursing, 9/E Test Bank

Copyright 2012 by Pearson Education, Inc.

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