Chapter 37: Care of the Surgical Patient My Nursing Test Banks

Chapter 37: Care of the Surgical Patient

Test Bank

MULTIPLE CHOICE

1. The circulating nurse notes that the anesthetized patient has tensed muscles and irregular respirations. The nurse is aware that the patient has reached stage:

a.

I and the patients hearing is amplified.

b.

II and the surgical environment should be kept quiet.

c.

III and the patient has depressed reflexes.

d.

IV and the patient will not depend on the anesthesia machine of oxygenations.

ANS: B

Quiet must be maintained while the patient is in stage II, because noise may cause the patient to become excited, resulting in instability of vital signs.

DIF: Cognitive Level: Comprehension REF: p. 736, Box 37-3

OBJ: Theory #5 TOP: General Anesthesia

KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity: basic care and comfort

2. In order for the anesthesiologist to accurately calculate the amount of anesthesia needed for an 82-year-old patient, the nurse should have data available on the chart, such as:

a.

time of last meal.

b.

pulse rate and blood pressure.

c.

respiratory rate and oxygen saturation.

d.

height and weight.

ANS: D

Accurate height and weight are significant for calculation of the anesthetic agents needed for elderly patients.

DIF: Cognitive Level: Comprehension REF: p. 736, Elder care

OBJ: Theory #3 TOP: Anesthesia KEY: Nursing Process Step: Assessment

MSC: NCLEX: Physiological Integrity: pharmacological therapies

3. The illiterate patient signs the surgical consent form with an X. The nurse is aware that this X is:

a.

not an acceptable signature.

b.

required to be accompanied by a picture identification.

c.

legal if it is witnessed.

d.

acceptable if the surgeon is willing.

ANS: C

An X is an acceptable signature if it is witnessed.

DIF: Cognitive Level: Comprehension REF: p. 737 OBJ: Theory #8

TOP: Surgical Consent KEY: Nursing Process Step: Implementation

MSC: NCLEX: Safe Effective Care Environment: coordinated care

4. A 16-year-old boy injured in a motorcycle accident is unconscious and cannot sign the emergency surgical consent form; no family members can be located. The nurse anticipates that the:

a.

hospital social worker can sign the permit.

b.

surgeon will write a detailed note about the need for surgery and a registered nurse will then sign the consent.

c.

opinion of a second surgeon is sought regarding the necessity of the surgery.

d.

hospital attorney must authorize the surgery and sign the consent form.

ANS: C

If no family can be found to sign the permit for an unconscious person, a second surgeon can confirm the need for the immediate surgical intervention and the procedure will take place.

DIF: Cognitive Level: Application REF: p. 737 OBJ: Theory #8

TOP: Surgical Consent KEY: Nursing Process Step: Planning

MSC: NCLEX: Safe Effective Care Environment: coordinated care

5. The nurse discovers that the signed operative permit has misspelled the patients name. The nurse must:

a.

request a corrected consent form to be signed.

b.

inform the surgeon of the error.

c.

have the new form attached to the old incorrect one and document it.

d.

allow the patient to be taken to surgery after notifying the circulating nurse.

ANS: A

A new consent form must be made, signed, and witnessed, provided the patient has not been sedated already.

DIF: Cognitive Level: Application REF: p. 737 OBJ: Theory #8

TOP: Incorrect Surgical Consent Form KEY: Nursing Process Step: Implementation

MSC: NCLEX: Safe Effective Care Environment: coordinated care

6. A patient who has recently arrived on the surgical unit after being transferred from the post-anesthesia care unit asks for a drink. The nurse should first check the:

a.

status of the IV fluids.

b.

ability to swallow.

c.

nursing progress notes.

d.

anesthesia record.

ANS: B

Before a post-surgical patient is offered anything to eat or drink, the ability of the patient to swallow should be assessed.

DIF: Cognitive Level: Application REF: p. 749 OBJ: Clinical Practice #3

TOP: NPO Status KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity: basic care and comfort

7. A patient scheduled for surgery has an order for a preoperative surgical skin prep. The nurse may be required to:

a.

shave the entire surgical site.

b.

spray the surgical area with an antimicrobial solution.

c.

scrub the surgical area for 1 minute with antibacterial solution.

d.

instruct the patient in the use of an antimicrobial soap in the shower.

ANS: D

The nurse may be required to instruct in the use of an antimicrobial soap in the shower. Although hair may be clipped away from the incision line, this is usually not done by the floor nurse but accomplished in the surgery suite.

DIF: Cognitive Level: Application REF: p. 741 OBJ: Clinical Practice #2

TOP: Preoperative Surgical Skin Preparation

KEY: Nursing Process Step: Implementation

MSC: NCLEX: Safe Effective Care Environment: safety and infection control

8. To help prevent errors in the surgical procedure, the National Patient Safety Goal instituted a directive that prior to presurgical medication, each patient must:

a.

verbally state the location of the surgical site and the expected procedure.

b.

when still conscious participate in marking the surgical site.

c.

have the unit nurse confirm their identity.

d.

have a photograph of the surgical site on the chart.

ANS: B

Prior to presurgical medication, the conscious patient participates in a marking of the body part and site of the expected surgical procedure.

DIF: Cognitive Level: Comprehension REF: p. 737 OBJ: Theory #6

TOP: Immediate Preoperative Care KEY: Nursing Process Step: Planning

MSC: NCLEX: Safe Effective Care Environment: coordinated care

9. While completing the preoperative checklist, a patient who is almost ready for transport to the operating room states that he does not want to remove his wedding band. The nurse should:

a.

tape it in place on his finger.

b.

remind him it must be removed, and lock it in the narcotic cabinet.

c.

ask a family member to take care of it.

d.

inform him that the hospital cannot be responsible for its loss.

ANS: A

A wedding band may be worn to surgery, but it must be taped to the finger in a manner that does not restrict circulation.

DIF: Cognitive Level: Application REF: p. 747 OBJ: Clinical Practice #2

TOP: Immediate Preoperative Care KEY: Nursing Process Step: Implementation

MSC: NCLEX: Psychosocial Integrity: coping and adaptation

10. The nurse is aware that in both the very young and the elderly surgical patient, the risk is much higher for:

a.

nausea and vomiting.

b.

hydration issues.

c.

delayed healing.

d.

anorexia.

ANS: B

Both the very young and the elderly are at greater risk for dehydration or overhydration and alterations in body temperature control.

DIF: Cognitive Level: Comprehension REF: p. 734 OBJ: Theory #2

TOP: Surgical Risks in Young and Elderly

KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity: reduction of risk

11. A patient undergoing preadmission testing before same-day surgery asks how long he will remain in the recovery area before being allowed to go home. The nurses most informative response would be:

a.

30 to 60 minutes.

b.

1 to 3 hours.

c.

5 to 6 hours.

d.

6 to 8 hours.

ANS: B

The usual recovery time in a same-day surgery recovery area is 1 to 3 hours.

DIF: Cognitive Level: Knowledge REF: p. 748 OBJ: Theory #7

TOP: Postanesthesia Care KEY: Nursing Process Step: Implementation

MSC: NCLEX: Psychosocial Integrity: psychosocial adaptation

12. The circulating nurse is responsible for:

a.

preparing the sterile field.

b.

assisting with sterile draping of the patient.

c.

maintaining an accurate count of sponges.

d.

pointing out the observation of contamination immediately to the personnel involved.

ANS: D

Any break in sterile technique in the operating room should be immediately pointed out and remedied.

DIF: Cognitive Level: Comprehension REF: p. 748 OBJ: Theory #9

TOP: Circulating Nurse KEY: Nursing Process Step: Planning

MSC: NCLEX: Safe Effective Care Environment: safety and infection control

13. When the patient is ready to return from the post-anesthesia care unit (PACU), a minimal Aldrette score of _______ is an indicator that the patient is ready to return to the floor.

a.

2 to 4

b.

4 to 8

c.

9 to 10

d.

11 to 12

ANS: C

Using an Aldrette scoring system of activity, respiration, circulation, consciousness, and skin color being scored from 1 to 3, a score of 9 to 10 is the minimal indicator that the patient is ready to return to the floor.

DIF: Cognitive Level: Comprehension REF: p. 747 OBJ: Theory #10

TOP: Postanesthesia Care KEY: Nursing Process Step: Assessment

MSC: NCLEX: Health Promotion and Maintenance: prevention and early detection of disease

14. A patient who has returned to the surgical nursing unit from the post-anesthesia care unit (PACU) is drowsy and requires verbal stimulation to remain aroused. The best position to maintain an airway for this patient is:

a.

supine.

b.

side-lying.

c.

head of bed at 30 degrees with head and neck midline.

d.

head of bed at 45 degrees with head and neck midline.

ANS: B

The patient should be positioned on the side or with the head turned to the side to prevent aspiration. Maintaining an open airway is a priority measure.

DIF: Cognitive Level: Application REF: p. 749 OBJ: Theory #10

TOP: Safety: Airway KEY: Nursing Process Step: Implementation

MSC: NCLEX: Health Promotion and Maintenance: prevention and early detection of disease

15. The nurse is assessing the surgical dressing of a patient who arrived on the unit an hour ago. The surgical dressing has serosanguineous drainage on the dressing. The nurse should:

a.

make a note of the drainage on the worksheet to report it at the end of shift.

b.

change the surgical dressing immediately to prevent infection.

c.

outline the area of drainage with a pen and mark it with the date and time.

d.

reinforce the dressing with clean gauze sponges and tape.

ANS: C

The area should be outlined, dated, and timed for future reference and comparisons.

DIF: Cognitive Level: Application REF: p. 750 OBJ: Theory #2

TOP: Safety: Bleeding KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity: reduction of risk potential

16. A nurse is instructing a patient who had surgical removal of a brain tumor on how to prevent respiratory complications from surgery. The nurse would teach the patient to:

a.

turn, cough, and deep breathe.

b.

use humidified oxygen.

c.

turn gently from side to side.

d.

use deep breathing and an incentive spirometer.

ANS: D

Coughing may be contraindicated for patients who have had hernia repair, eye, ear, or brain surgery. This is because the act of coughing could create increased pressure in the surgical area, which is contraindicated. Huffing or the use of an incentive spirometer is effective for post-surgical respiratory health.

DIF: Cognitive Level: Application REF: p. 750 OBJ: Clinical Practice #4

TOP: Promoting Respiratory Function KEY: Nursing Process Step: N/A

MSC: NCLEX: Physiological Integrity

17. A post-operative surgical patient asks how the sequential pneumatic compression boots applied in the operating room will help lower the risk of blood clots forming in the legs. The nurses most appropriate response would be that the boots:

a.

measure pressure in the leg blood vessels and sound an alarm if pressure rises.

b.

alternately compress and release to help blood flow through vessels.

c.

provide gentle continuous compression at low pressure.

d.

provide firm continuous compression at high pressure.

ANS: B

Pneumatic boots alternately compress and release to squeeze the blood vessels and thus propel blood through the vessels back to the heart.

DIF: Cognitive Level: Comprehension REF: p. 751 OBJ: Theory #10

TOP: Promoting Circulation KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity: reduction of risk potential

18. A nurse is monitoring the urinary drainage from a patient who returned to the unit a few hours ago from the post-anesthesia care unit (PACU) following a surgical procedure. The urine total is 54 mL for the last 2 hours. The most appropriate nursing action is to:

a.

increase the flow rate of the IV for 10 to 15 minutes.

b.

irrigate the indwelling urinary catheter.

c.

apply manual pressure to the patients bladder.

d.

notify the surgeon of the findings.

ANS: D

If the urinary flow rate is lower than 60 mL for a 2-hour period, the surgeon is notified.

DIF: Cognitive Level: Analysis REF: p. 751 OBJ: Theory #10

TOP: Inadequate urine output KEY: Nursing Process Step: Implementation

MSC: NCLEX: Health Promotion and Maintenance: prevention and early detection of disease

19. A patient who had surgery earlier in the day using general anesthesia asks whether he can have something to eat. The diet order indicates clear liquids can be taken. Before giving a Jell-O to the patient, the nurse should check for the presence of:

a.

clear lung sounds.

b.

adequate urinary drainage.

c.

bowel sounds in all quadrants.

d.

palpable peripheral pulses.

ANS: C

Before allowing a patient to eat or drink after surgery, the nurse must ensure that bowel sounds are present in all four quadrants. This is because of the risk of paralytic ileus (lack of return of peristalsis) after surgery.

DIF: Cognitive Level: Analysis REF: p. 753 OBJ: Theory #10

TOP: Maintaining Fluid Balance KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity: reduction of risk potential

20. A patient who had abdominal surgery is complaining of gas pains and has distention of the abdomen and flatus. To promote patient comfort, the nurse should advise:

a.

early ambulation.

b.

turning to the left side.

c.

drinking fluids that are very hot.

d.

lying supine with knees flexed.

ANS: A

Ambulation is helpful in expelling gas. Taking large amounts of food or liquid at a time, and drinking fluids that are either very hot or cold, can aggravate the symptoms.

DIF: Cognitive Level: Application REF: p. 754 OBJ: Clinical Practice #5

TOP: Promoting Comfort KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity: basic care and comfort

21. A nurse preparing to get a patient out of bed for the first time since surgery will initially:

a.

assist the patient to sit and dangle his or her legs on the side of the bed.

b.

allow the patient to sit with the head of bed raised to the high-Fowlers position.

c.

assist the patient from a supine position to a standing position.

d.

place a walker at the side of the bed.

ANS: B

The first step is to raise the head of the bed and let the body adjust to the position change. After a few minutes, the patient can be assisted to sit on the side of the bed with his or her legs dangling (with feet on floor). Finally, the patient is assisted to a standing position.

DIF: Cognitive Level: Application REF: p. 754 OBJ: Clinical Practice #6

TOP: Rest and Activity KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity: reduction of risk potential

22. A patient is ready for discharge following same-day surgery. The teaching plan for this patient includes:

a.

limiting wine intake for 12 hours.

b.

reporting temperatures greater than 99 F.

c.

not driving or making important decisions for 24 hours.

d.

that vomiting might be an expected symptom.

ANS: C

Patients should not drive or make important decisions for at least 24 hours after surgery, until all residual effects of anesthesia have worn off.

DIF: Cognitive Level: Application REF: p. 735, Home Care

OBJ: Clinical Practice #7 TOP: Same-Day Surgery Discharge

KEY: Nursing Process Step: Planning

MSC: NCLEX: Physiological Integrity: physiological adaptation

MULTIPLE RESPONSE

23. The nurse explains that the informed surgical consent form should include information relative to: (Select all that apply.)

a.

the procedure to be performed.

b.

the related risks of the procedure.

c.

consent to blood transfusion.

d.

time and date signed.

e.

marital status.

ANS: A, B, D

The consent must include the procedure to be performed and the related risks of the procedure; it must also be timed, dated, and witnessed. Consent for transfusion is another permit entirely.

DIF: Cognitive Level: Comprehension REF: p. 754 OBJ: Theory #38

TOP: Surgical Consent KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity: reduction of risk potential

24. The nurse preparing the surgical patients room for the patients return from the post-anesthesia unit should: (Select all that apply.)

a.

fan fold the sheets on the near side of the bed.

b.

lower the bed for easy transfer of the patient.

c.

place an IV pole at the head of the bed.

d.

gather an emesis basin, tissues, and a small towel.

e.

collect extra dressing supplies and place them on the bedside table.

ANS: C, D

The post-surgical room should be prepared with the sheets fan folded on the far side of the heightened bed. IV poles, emesis basins, oxygen, and suction equipment should be ready to use; a thermometer, sphygmomanometer, and stethoscope should be available.

DIF: Cognitive Level: Application REF: p. 738, Table 37-2

OBJ: Theory #3 TOP: Room Preparation

KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity: basic care and comfort

COMPLETION

25. A post-operative patient experiences separation of the layers of his abdominal surgical wound during coughing. Separation of the layers of a surgical wound is known as ___________.

ANS:

dehiscence

Dehiscence is separation of the layers of the surgical wound that may occur when the patient is coughing, particularly if the abdominal incision is not properly splinted.

DIF: Cognitive Level: Knowledge REF: p. 735, Box 37-1

OBJ: Theory #2 TOP: Postoperative Care KEY: Nursing Process Step: N/A

MSC: NCLEX: N/A

26. The patient informs the admitting nurse that she has been drinking feverfew tea for the herbal treatment of migraine headaches. The nurse reports this to the surgeon because this herb can cause ___________.

ANS:

bleeding

The herb feverfew can inhibit platelet aggregation and increase the possibility of bleeding.

DIF: Cognitive Level: Comprehension REF: p. 737 OBJ: Theory #2

TOP: Herbal Substances KEY: Nursing Process Step: Assessment

MSC: NCLEX: Physiological Integrity: reduction of risk potential

27. To help prevent surgical site infections in the diabetic patient, the glycemic should be maintained with a blood glucose of less than _____ mg/dL.

ANS:

200

A diabetic patient can be better protected from surgical site infection by maintaining blood glucose below 200 mg/dL.

DIF: Cognitive Level: Comprehension REF: p. 737 OBJ: Theory #3

TOP: Glucose Control KEY: Nursing Process Step: N/A

MSC: NCLEX: N/A

28. The nurse reminds the patient that the member of the surgical team who is responsible for obtaining the surgical consent is the ___________.

ANS:

surgeon

The surgeon is the person responsible for obtaining an informed surgical consent.

DIF: Cognitive Level: Knowledge REF: p. 743 OBJ: Theory #8

TOP: Surgical Consent Form KEY: Nursing Process Step: Implementation

MSC: NCLEX: Psychosocial Integrity: coping and adaptation

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