Med/surg Mid-Term Review

Front 1

The client asks why the nurse signs the operative consent form under her signature as a witness. What is the nurse’s best response?

a.
“It indicates that you understand teaching about the surgery.”
b.
“It shows that you agreed that the surgery should be done.”
c.
“It confirms that you voluntarily signed the form.”
d.
“It confirms that you have authorized insurance payment for the surgery.”

Back 1

ANS: C
The nurse’s signature as a witness indicates that the consent form was signed by the client voluntarily.

Front 2

The nurse is caring for an older adult client with a history of emphysema who will be undergoing surgery the following day. Which nursing diagnosis is the highest priority for this client?
a.
Risk for caregiver role strain
c.
Risk for anxiety
b.
Risk for activity intolerance
d.
Risk for impaired gas exchange

Back 2

ANS: D
Risk for caregiver role strain, anxiety, and activity intolerance are all lower priority than impaired gas exchange.

Front 3

The nurse is completing preoperative teaching for a client, and it becomes apparent that the client does not understand the surgery that will be performed. What is the priority action for the nurse?
a.
Obtain informed consent from the client.
b.
Teach the client about the surgery to be performed.
c.
Revise the teaching plan for the client.
d.
Notify the surgeon and note the finding in the client’s chart.

Back 3

ANS: D
The surgeon should be notified right away so that the client can be instructed about the surgery to be performed.

Front 4

During the preoperative assessment, the client tells the nurse that he smokes three packs of cigarettes daily. The information alerts the nurse to which potential complication that the client may experience during surgery and recovery?
a.
Decreased pain tolerance
b.
Decreased blood clotting ability
c.
Increased risk for atelectasis and hypoxia
d.
Increased risk for excessive scar formation

Back 4

ANS: C
Smoking increases the client’s risk for atelectasis and hypoxia.

Front 5

When the nurse brings the client’s preoperative medications, the client responds, “I don’t need that. I had a good night’s sleep last night.” What is the nurse’s best response?
a.
“The doctor ordered this medication for you, so you should take it.”
b.
“I will make a note that you refused to take the medication.”
c.
“I will ask your surgeon if you should take the medication.”
d.
“The medication will help prevent some complications during surgery.”

Back 5

ANS: D
Preoperative medications are often given to prevent laryngospasm and help reduce pharyngeal and gastric secretions.

Front 6

The client receiving preoperative medication tells the nurse that she took all the following vitamins and herbs last night before going to bed. Which one will the nurse report to the surgical team?
a.
Valerian root
c.
Garlic
b.
St. John’s wort
d.
Ginseng

Back 6

ANS: C
Garlic interferes with coagulation, increasing the client's risk for bleeding during and after the surgical procedure.

Front 7

The nurse reviews the client’s laboratory results prior to surgery. Which finding will the nurse report immediately?
a.
Prothrombin time (PT): 15.2 seconds
b.
Potassium: 4.1 mEq/L
c.
Hematocrit: 42%
d.
Random blood glucose: 122 mg/dL

Back 7

ANS: A
The prothrombin time is elevated, which could lead to bleeding during or after surgery. The surgeon and anesthesiologist should be notified of this laboratory test result right away.

Front 8

A client is brought to the emergency department (ED) after a motorcycle accident. The client has suffered a ruptured spleen and requires surgery to stop the hemorrhaging. Which type of surgery will the client have?
a.
Emergent surgery
c.
Elective surgery
b.
Palliative surgery
d.
Radical surgery

Back 8

ANS: A
Emergent surgery is indicated when the client may die without immediate intervention.

Front 9

The nurse has just completed preoperative teaching with a female client who will be having surgery the following day. Which statement by the client indicates that additional teaching is needed?
a.
“When I brush my teeth tomorrow, I will be sure to spit out the water.”
b.
“I will wear my lucky earrings tomorrow during the surgery.”
c.
“I will remember to wear my glasses tomorrow instead of my contact lenses.”
d.
“I won’t have to worry about putting my makeup on tomorrow morning.”

Back 9

ANS: B
Jewelry must be removed before surgery, except for rings, which may be taped in place.

Front 10

The nurse is performing preoperative teaching with a client who will be having colon resection surgery the following day. The surgeon has ordered bowel preparation for the client to be taken that night. Which statement by the client indicates that additional teaching is needed?
a.
“I will take my antibiotics with a glass of orange juice tonight.”
b.
“I will expect loose stools and cramping tonight.”
c.
“I will have a bowl of chicken broth for dinner tonight.”
d.
“I should drink extra water tonight if I feel thirsty.”

Back 10

ANS: A
The client will be on a clear liquid diet that night, and orange juice is not a clear liquid.

Front 11

When examining an adult client’s preoperative laboratory results, the nurse notes that the potassium level is 2.9 mEq/mL. What is the nurse’s best action?
a.
Documents the finding
b.
Initiates oxygen therapy by mask
c.
Increases the IV flow rate
d.
Notifies the surgeon and anesthesiologist

Back 11

ANS: A
The normal range for serum sodium in adult clients is 135 to 145 mEq/L.

Front 12

The client scheduled to have surgery within the next 2 hours tells the nurse during the admission interview the following information. What information should the nurse be certain to communicate on the outside of the chart for the entire surgical team to know?
a.
The client is allergic to cats.
b.
The client is hard of hearing.
c.
The client had a glass of wine 12 hours ago.
d.
The client takes 2000 mg of vitamin C each day.

Back 12

ANS: B
The team will need to communicate with the client in the surgical holding area, the operating room, and the postanesthesia recovery unit. Any problem with communication, such as a hearing impairment, should be stressed so that team members can use alternative means to ensure accurate communication with the client.

Front 13

The client will be undergoing palliative surgery to debulk an abdominal tumor. The client’s daughter asks why the surgery is considered to be palliative. What is the nurse’s best response?
a.
“The surgery will relieve the symptoms of the bowel obstruction. It will not cure your father.”
b.
“There are fewer risks with palliative surgery than with reconstructive or restorative surgery.”
c.
“There is no guarantee of the outcome of the surgery.”
d.
“The surgery must be performed immediately to save your father’s life.”

Back 13

ANS: A
The purpose of palliative surgery is to improve the client's quality of life by reducing or eliminating distressing symptoms. It does not cure a health problem and often does not prolong life.

Front 14

Twenty minutes after the client has received a preoperative injection of atropine and midazolam (Versed), the client tells the nurse that he must be allergic to the medication because his mouth is dry and his heart seems to be beating faster than normal. Which is the nurse’s priority action?
a.
Documenting the findings
b.
Assessing the client's pulse and blood pressure
c.
Preparing to administer diphenhydramine (Benadryl)
d.
Explaining to the client that these symptoms are expected

Back 14

ANS: B
Although these are the expected physiologic responses to the preoperative medication, whenever the client states that he or she can feel a change in normal cardiac function, the system should be assessed.

Front 15

The client undergoing preoperative assessment before an elective procedure tells the nurse that she has been taking 10 mg of prednisone daily for rheumatoid arthritis. What is the nurse’s best action?
a.
Tells the client not to take the medication on the day of surgery
b.
Notifies the surgeon and the anesthesiologist
c.
Documents the information in the client’s record
d.
Suggests that the client take aspirin daily instead

Back 15

ANS: B
The surgery does not need to be delayed. However, corticosteroids have many adverse effects so both the surgeon and anesthesiologist should be aware of the medication use prior to surgery.

Front 16

The preoperative client tells the nurse that she has allergies to several substances. Which allergy presents the greatest potential problem considering the scheduled surgery?
a.
Peanuts
c.
Shrimp
b.
Strawberries
d.
Bee stings

Back 16

ANS: C
Many people who have hypersensitivities or allergies to shellfish will have allergies to povidone-iodine, a substance commonly used to cleanse the skin before surgery.

Front 17

The client’s surgery has been delayed because of hyperkalemia. The client asks why. What is the nurse’s best response?
a.
“Potassium affects how the heart works and you could have a heart attack if this is not corrected.”
b.
“Your blood will not clot well when your potassium level is too high.”
c.
“The anesthetist may have difficulty waking you up after your surgery if your potassium is too high.”
d.
“By making sure your potassium level is normal before surgery, your heartbeat will be strong and regular during your surgery.”

Back 17

ANS: D
Hyperkalemia may cause cardiac dysrhythmias, especially during anesthesia. Explaining to the client that correcting this problem will help his heart offers reassurance.

Front 18

The nurse is caring for a client who will be undergoing emergency surgery. Which information is most important for the nurse to teach the client at this time?
a.
NPO status prior to surgery
b.
Importance of early ambulation after surgery
c.
What to expect in the operating and recovery room
d.
Complications that may occur after surgery

Back 18

ANS: C
With only a few minutes before surgery, the nurse should tell the client what to expect in the operating room and recovery room to minimize his or her anxiety.

Front 19

The preoperative client tells the nurse that he has an advance directive with durable power of attorney. The client asks how the advance directive will affect his surgery. What is the nurse’s best response?
a.
“You will not be intubated during general anesthesia for the surgery.”
b.
“Your wife will be responsible for signing all of the surgical consent forms.”
c.
“The surgical staff will do CPR only if your heart stops during the operation.”
d.
“If you are unable to make a decision, your designee will be asked.”

Back 19

ANS: D
The advance directive and durable power of attorney indicates who the client wishes to designate for medical decisions if he is unable to do so for himself.

Front 20

A client is brought to the hospital unconscious and needs emergency surgery. The client’s only family member cannot come to the hospital before the surgery. Which is the best option for obtaining informed consent for the client’s emergent surgery?
a.
Proceed with the surgery and have the family member sign the consent as soon as possible.
b.
Contact the family member by phone and obtain verbal consent with two witnesses.
c.
Obtain written consultation with two surgeons that the surgery is needed.
d.
Have the hospital administrator appoint a temporary legal guardian.

Back 20

ANS: B
In the event that a family member cannot come to the hospital before the surgery needs to begin, verbal consent should be obtained over the phone with two witnesses.

Front 21

The nurse is performing preoperative teaching with a client who will be having sinus surgery the following day. Which is an accurate statement for the nurse to include in preoperative teaching?
a.
“You may take your digoxin (Lanoxin) in the morning with a small sip of water.”
b.
“You should cough and deep-breathe every hour after surgery.”
c.
“Please leave your hearing aids at home tomorrow morning.”
d.
“You should take a deep breath and blow into your spirometer four times every hour after surgery.”

Back 21

ANS: A
Daily cardiac medications may be taken on the day of surgery with a small sip of water. Clients who are having sinus surgery should not be encouraged to cough after surgery.

Front 22

The nurse is preparing to transfer a client to the operating room for surgery. The client has already received the preoperative medications and is becoming drowsy. What is the best method to verify the client’s identity?
a.
Ask the nurse who administered the client’s preoperative medications.
b.
Check the client’s room number and birth date with the name on the chart.
c.
Ask the client to state his or her name and check the client’s ID band.
d.
Check the client’s medical record number and name with the chart and ID band.

Back 22

ANS: D
At least two client identifiers should be used to ensure that the nurse has the correct client. The room number should never be used as a client identifier.

Front 23

The nurse is caring for a client who will be having surgery on his right knee. What is the best method to ensure that the surgery is performed on the correct knee?
a.
Post the client’s knee x-rays in the operating room with the “left” and “right” views clearly labeled.
b.
Ask the client which knee will be operated on just before anesthesia is administered.
c.
Have the surgeon and the client mark a “yes” and their initials with marker on the knee to be operated on.
d.
Verify the operative site with the client’s chart prior to the start of surgery.

Back 23

ANS: C
Having the surgeon and the client mark a “yes” and their initials is the most effective method listed to ensure that the correct knee is operated on.

Front 24

The nurse is conducting a preoperative assessment for a client who will be having surgery in a few days. Which client is at high risk for developing a deep vein thrombosis (DVT) postoperatively?
a.
The client with a latex allergy
b.
The client with body mass index (BMI) of 19
c.
The client with an international normalized ratio (INR) of 2.2
d.
The client undergoing hip replacement surgery

Back 24

ANS: D
The client will have limited mobility following hip replacement surgery, increasing the risk of postoperative deep vein thrombosis (DVT) development.

Front 25

The nurse applies antiembolism stockings to a preoperative client, who complains that the hose are uncomfortable and that he wishes to have them removed. What is the nurse’s best response?
a.
“No problem, I will remove them right now.”
b.
“The stockings should be a little bit tight to help prevent blood clots.”
c.
“I will roll the stockings down a little bit so that they will feel better.”
d.
“They will only be on your legs during surgery and they will be removed in the recovery room.”

Back 25

ANS: D
Thromboembolic disease (TED) stockings should feel slightly tight on the legs to promote venous return and prevent DVT formation.

Front 26

The scrub nurse is overseeing a nursing student who will be shadowing in the operating room. Which observed action indicates that the nursing student is performing the surgical scrub correctly?
a.
A small brush is used to scrub under her acrylic nails and wedding ring.
b.
The surgical mask is put on before starting the surgical scrub.
c.
The soap is rinsed off so that the water runs down to the hands.
d.
A paper towel is used to turn off the faucet handle.

Back 26

ANS: B
The face mask must be donned before the surgical scrub is started.

Front 27

The nurse anesthetist is caring for a client who is under general anesthesia. The nurse notes that the client is becoming tachycardic and the client’s oxygen saturation is dropping. Which medications should the nurse anesthetist prepare to administer?
a.
Regular insulin and potassium chloride
b.
Scopolamine and verapamil (Calan)
c.
Epinephrine and diphenhydramine (Benadryl )
d.
Dantrolene sodium (Dantrium) and sodium bicarbonate

Back 27

ANS: D
Dantrium is the drug of choice for the treatment of malignant hyperthermia (MH). Sodium bicarbonate is used if the client develops metabolic acidosis as a result of MH.

Front 28

The client is having epidural anesthesia for knee replacement surgery. Which action will be the highest priority for the nurse anesthetist during the client’s surgery?
a.
Monitoring the client’s respiratory rate and depth
b.
Ensuring that the client’s endotracheal tube is secured
c.
Minimizing external noise and stimuli in the operating room (OR)
d.
Positioning for safety and comfort

Back 28

ANS: A
With epidural anesthesia, the anesthetic agent may travel up the spinal cord area and cause respiratory difficulty. The nurse must carefully monitor the client’s respiratory status during the surgery.

Front 29

The circulating nurse is observing a new scrub nurse as she sets up the sterile field for the surgical equipment. Which of the following actions indicates that the scrub nurse needs additional teaching about sterile technique?
a.
A small amount of sterile saline is poured out and discarded before it is poured into the basin.
b.
Any equipment packages that are in poor condition are considered to be contaminated.
c.
Sterile surgical supplies are placed in the center of the sterile field.
d.
The sterile saline bottle cap is placed in the center of the sterile field.

Back 29

ANS: D
The outside of the bottle cap is not sterile and should not be placed on the sterile field.

Front 30

Surgery is almost completed for the client, and the surgeon prepares to close a large abdominal incision. What will the scrub nurse prepare to do?
a.
Extubate the client.
b.
Hand sutures or the skin stapler to the surgeon.
c.
Notify the recovery room staff that the client will be arriving shortly.
d.
Document the amount of blood loss and urine output during the surgery.

Back 30

ANS: B
Retention sutures would be appropriate to close a large abdominal incision for a client at high risk for impaired wound healing (obese, diabetic). The scrub nurse would be responsible for getting him or her ready for the surgeon.

Front 31

Before the client’s surgery begins, the circulating nurse notes that the nurse anesthetist did not perform a surgical scrub before coming into the operating room. Which is the best action of the circulating nurse at this time?
a.
Directs the nurse anesthetist to perform the surgical scrub immediately
b.
Proceeds with positioning the client on the operating bed
c.
Notifies the nursing supervisor that sterile technique has been violated
d.
Proceeds with setting up the instruments to be used during the surgery

Back 31

ANS: B
The nurse anesthetist does not need to perform a sterile scrub prior to the client’s surgery. The circulating nurse can proceed with positioning the client on the OR bed.

Front 32

The client asks the nurse why it is better to have spinal anesthesia for knee surgery rather than being put to sleep. Which is the nurse’s best response?
a.
“You won’t have to worry about having an allergic reaction.”
b.
“You will be able to walk sooner after your surgery.”
c.
“You will have less risk of developing pneumonia after surgery.”
d.
“You will have less risk of bleeding with epidural anesthesia.”

Back 32

ANS: C
With epidural anesthesia, the client remains conscious, respiratory function is unaffected, and intubation is not necessary. This results in less risk for atelectasis or pneumonia after surgery.

Front 33

The client is to have a surgical procedure under conscious sedation. The client is anxious and asks the nurse what to expect. What is the nurse’s best response?
a.
“You will be awake and alert during the procedure but you will feel no pain.”
b.
“You will not be able to move your feet or toes during the procedure.”
c.
“You will not be able to swallow or talk during the procedure.”
d.
“You will be very sleepy and we will monitor you closely.”

Back 33

ANS: D
A physician or a specially credentialed registered nurse may administer agents for conscious sedation. This rapid and short-acting type of anesthesia, used for brief but uncomfortable procedures, does not render the client completely unconscious. Clients have a reduction in the intensity or awareness of the pain without loss of defensive reflexes.

Front 34

Before the nurse brings the client to the operating room for knee surgery, the client reports to the nurse that he did not initial the operative knee with his surgeon. What is the priority action of the nurse?
a.
Proceed with transferring the client to the operating room.
b.
Call a “time out” for the entire surgical staff so that the site can be marked before the surgery begins.
c.
Call the surgeon to mark the site with the client before transfer to the operating room.
d.
Have the client mark the site with a permanent marker before transfer to the operating room.

Back 34

ANS: C
The site should be marked by both the client and surgeon before anesthesia is administered and surgery begins.

Front 35

The nurse is preparing to bring a young female client to the operating room for a total abdominal hysterectomy (TAH). The client says to the nurse, “I am so glad that I will still be able to have children after this surgery.” What is the nurse’s best response?
a.
“I am very happy for you. That is very good news.”
b.
“Didn’t anyone teach you about your surgery?”
c.
“Your surgeon should have said that you won’t be able to get pregnant after the surgery.”
d.
“I will call the surgeon to speak with you before I bring you to the operating room.”

Back 35

ANS: D
TAH includes removal of the uterus, which will leave the client unable to have children. The surgeon should be called to speak with the client and explain the surgery before the client is moved to the operating room.

Front 36

The client is being positioned on the operating bed for spinal surgery after general anesthesia is administered. Which action is the highest priority for the nurse?
a.
Placing gel pads under the client’s shoulders
b.
Placing a soft pillow between the client’s knees
c.
Ensuring that the head and neck are in good alignment
d.
Ensuring that the client’s legs are lifted slowly and simultaneously into the stirrups

Back 36

ANS: C
The client will be placed in the prone position for spinal surgery. Maintenance of a secure airway is the highest priority, including making sure that the head and neck are in good alignment so that the endotracheal (ET) tube remains patent.

Front 37

The anesthetized client must be repositioned from the supine to the prone position midway through the surgical procedure. What is the priority action of the nurse?
a.
Log rolling the client to prevent dislocation of the shoulder
b.
Keeping the client covered to maintain dignity and minimize heat loss
c.
Ensuring that the client’s endotracheal tube does not become dislodged or kinked
d.
Making sure that the client’s Foley catheter is kept below the level of the bladder

Back 37

ANS: C
Maintenance of a secure airway is the highest priority.

Front 38

Which action by the surgical nursing staff indicates that additional teaching is required about the nurses’ roles and responsibilities in the operating room?
a.
The circulating nurse and anesthesiologist accompany the client to the postanesthesia care unit.
b.
The circulating nurse goes to the blood bank to pick up two units of fresh-frozen plasma for the client.
c.
The scrub nurse monitors the amount of irrigation fluid that is used during the surgery.
d.
The circulating nurse prepares the surgical site before the client is covered with sterile drapes.

Back 38

ANS: B
The circulating nurse should not leave the OR to pick up fresh-frozen plasma and should delegate the job to unlicensed personnel instead.

Front 39

The nurse is helping position the client on the operating bed when the client states, “I am really nervous about having the breathing tube put down my throat.” What is the nurse’s best response?
a.
“I will give you some medication so that it won’t hurt at all.”
b.
“The tube is very small and you will hardly know it is there.”
c.
“The anesthesiologists are excellent and will take very good care of you.”
d.
“The anesthetist will put the tube in your throat after you are asleep.”

Back 39

ANS: D
Reassuring the client that the ET tube will be placed after the administration of general anesthesia and removed before awakening will help allay the client’s fears.

Front 40

Which of the following statements indicates accountability by the scrub nurse during a surgical procedure?
a.
“The client should have epidural anesthesia rather than general anesthesia.”
b.
“The client’s endotracheal tube is secured and all monitors are in place.”
c.
“I will have retention sutures ready for the surgeon because this client has a history of poor wound healing.”
d.
“A surgical sponge is missing so I will do a recount of all the surgical supplies used during the procedure.”

Back 40

ANS: D
The scrub nurse is responsible for counting all the surgical supplies used during a procedure. Recounting the surgical sponges demonstrates accountability.

Front 41

The nurse is assisting the client to the operating bed when the client states, “I am really anxious right now. I’ve never had an operation before.” What is the nurse’s best response?
a.
“Did you get a chance to talk to the hospital chaplain this morning?”
b.
“Don’t worry. The doctors and nurses at this hospital are excellent.”
c.
“You will be asleep and the surgery will be all over before you know it.”
d.
“I’ll ask the anesthesiologist to give you some medicine to help you relax.”

Back 41

ANS: D
The nurse should reassure the client that anxiety is normal before surgery and that the nurse will stay with the client until anesthesia is administered.

Front 42

Surgery is almost completed for an obese client with diabetes, and the surgeon prepares to close a large abdominal incision. What should the scrub nurse have ready for the surgeon?
a.
Steri strips
c.
Retention sutures
b.
Absorbable sutures
d.
Surgical glue

Back 42

ANS: C
The obese client with diabetes is at high risk for poor wound healing. Retention sutures would be appropriate to reduce the risk of dehiscence or evisceration.

Front 43

The nurse is caring for a client who will be having surgery shortly with spinal anesthesia. The client says to the nurse, “I changed my mind—I don’t want to be awake during surgery!” What is the nurse’s best response?
a.
“Spinal anesthesia is safer than being put to sleep with general anesthesia, and you won’t feel a thing.”
b.
“The anesthesiologist has already determined that spinal anesthesia is the best for your surgery.”
c.
“It’s too late to change the anesthesia plan now, because the anesthesiologist has all the equipment ready.”
d.
“I’ll ask the anesthesiologist to give you medication to make you sleepy during the surgery.”

Back 43

ANS: D
The nurse should recognize the client’s concerns and pass them on to the anesthesiologist. Light sedation may be given to clients undergoing surgery with spinal anesthesia to reduce anxiety and increase comfort.

Front 44

The circulating nurse is assisting the surgeon as he dons surgical attire in the OR. Which of the following actions by the circulating nurse indicates best practice?
a.
Assists the surgeon with the surgical mask after the sterile gown is donned
b.
Helps the surgeon apply sterile gloves before the sterile gown
c.
Inspects the gloves for nicks or tears after they are on the surgeon’s hands
d.
Helps the surgeon place the sleeves of the gown over the sterile gloves

Back 44

ANS: C
The surgeon’s gloves should be inspected to make sure that they are intact and not nicked or torn during application.

Front 45

The nurse is caring for a client who had surgery 24 hours ago. Which is the best indicator for the nurse to know that the client’s pain is well controlled?
a.
The client received pain medication 2 hours ago.
b.
The client states that she has no pain.
c.
The client’s respiratory rate is 8 breaths/min.
d.
The client is sleeping.

Back 45

ANS: B
Client reports of pain are the most accurate assessment tools for rating discomfort. The fact that the client received pain medication recently does not mean that the pain has been relieved sufficiently. Respiratory rate and sleep do not necessarily indicate pain relief.

Front 46

Immediately after the surgical procedure has been concluded for a client who received a general anesthetic, the client begins to shiver intensely. What will the nurse do first?
a.
Increase the oxygen flow rate.
c.
Take the client’s temperature.
b.
Increase the IV fluid rate.
d.
Apply warmed blankets.

Back 46

ANS: D
Shivering is a common normal response after anesthesia and exposure to cold air in the operating room. Warm blankets are applied for client comfort.

Front 47

The nurse is caring for an older adult client who has just returned to the medical-surgical unit from the postanesthesia recovery unit. The client does not remember that he just had surgery. What is the nurse’s best action?
a.
Notifying the surgeon immediately
b.
Documenting the observation as the only action
c.
Reorienting the client as needed and check the client frequently
d.
Holding all the client’s narcotic pain medications

Back 47

ANS: C
Many older adult clients experience temporary changes in mental status immediately after surgery as a result of the anesthetic and hospital environment. This is common, and the best action is to reorient the client frequently.

Front 48

The nurse assesses a client who has just been brought to the postanesthesia care unit (PACU). Which assessment finding is the best indicator that the client’s circulatory status may be compromised?
a.
The blood pressure decreased from 136/80 to 122/80 mm Hg.
b.
The urine output decreased from 40 to 10 mL/hr.
c.
The client’s respirations are irregular.
d.
The client’s temperature has risen from 99.4° to 99.8° F.

Back 48

ANS: B
One of the most sensitive and earliest indicators of vascular volume loss is a decreased urine output. The nurse is concerned about urinary outputs less than 30 mL/hr because this may indicate that the kidneys are not being perfused.

Front 49

The nurse is caring for a client who has just been brought to the PACU after surgery. What is the best indicator that the client is demonstrating adequate oxygenation?
a.
The client is able to speak clearly and coherently.
b.
The client is alert and oriented to person, place, and time.
c.
The client’s oxygen saturation is 96%, and hemoglobin and hematocrit are within normal limits.
d.
The client’s lung sounds are clear, and respirations are even and unlabored.

Back 49

ANS: C
Oxygen saturation is the most definitive assessment finding for whether or not the client is adequately oxygenated. However, because oxygen saturation is based on the amount of hemoglobin in the blood, this indicator needs to be evaluated in addition to the saturation. If a client has low hemoglobin, even if the percentage of saturation is high, the client is still underoxygenated.

Front 50

The client is brought to the PACU after surgery that took place with the client in the lithotomy position. Which change in assessment findings alerts the nurse to a possible complication of this surgical position?
a.
The client’s electrocardiogram (ECG) shows atrial fibrillation.
b.
The client’s dorsalis pedis pulses are not palpable.
c.
The client’s lung sounds are diminished with faint wheezes.
d.
The client has hypoactive bowel sounds.

Back 50

ANS: B
The lithotomy position can compromise the client's peripheral circulation in the lower extremities, leading to weak pedal pulses.

Front 51

The nurse assesses a client who has just undergone brain surgery and been admitted to the PACU. The nurse notes that the right pupil is 5 mm and the left pupil is 3 mm. What is the nurse’s best first action?
a.
Comparing these findings to the client’s baseline neurologic assessment
b.
Raising the head of the bed up to a 30-degree angle
c.
Testing the client’s deep tendon reflexes on all four extremities
d.
Notifying the surgeon immediately

Back 51

ANS: A
Any abnormal neurologic assessment finding discovered postoperatively should be compared with the client’s preoperative neurologic status.

Front 52

The nurse is caring for several clients on the postoperative unit. Which client does the nurse assess first because of their elevated risk of respiratory complications after general anesthesia?
a.
An older woman taking a calcium channel blocker for hypertension
b.
A middle-aged man with a deviated nasal septum
c.
A middle-aged woman who takes St. John’s wort daily for depression
d.
A young adult with a body mass index of 40

Back 52

ANS: D
Clients who are extremely obese have heavy chest walls that make it difficult to expand the lungs fully.

Front 53

One hour after admission to the PACU, the postoperative client has become very restless. What is the nurse’s best first action?
a.
Asking the client if he or she needs to go to the bathroom
b.
Checking the client’s oxygen saturation level
c.
Documenting the finding as the only action
d.
Administering pain medication as ordered

Back 53

ANS: B
The most common causes of restlessness in the immediate postoperative period are hypoxemia and pain. Although pain control is very important, determining the adequacy of ventilation in this case has higher priority.

Front 54

The nurse is caring for a client in the PACU 2 hours after abdominal surgery. The nurse auscultates the client’s abdomen and notes that there are no bowel sounds. What is the nurse’s best first action?
a.
Positioning the client on the right side with the bed flat
b.
Inserting a nasogastric tube to low intermittent suction
c.
Palpating the bladder and measuring abdominal girth
d.
Documenting the finding as the only action

Back 54

ANS: D
Absence of bowel sounds 2 hours after abdominal surgery is an expected finding that should be documented. No intervention specific to this finding is needed at this time.

Front 55

The nurse is changing the client’s dressing on the second postoperative day and notes a small amount of serosanguineous drainage. What is the nurse’s best action?
a.
Cleaning the suture line gently with sterile saline and applying a new dry sterile dressing
b.
Culturing the drainage and then gently cleaning the incision with half-strength peroxide and saline
c.
Removing the sutures from the incision and covering the incision with a clear transparent dressing
d.
Applying a binder over the incision and notify the surgeon immediately

Back 55

ANS: A
A small amount of serosanguineous drainage is a normal assessment finding on the second postoperative day. The incision should be cleaned and dressed.

Front 56

The nurse is caring for a client who has had abdominal surgery 3 days ago and has a large abdominal incision. When the nurse enters the client’s room, he tells the nurse, “I felt my incision pop when I coughed a little while ago.” What is the nurse’s best response?
a.
“It is good that you are coughing and deep-breathing to prevent pneumonia.”
b.
“That is a normal feeling in the incision whenever you are moving.”
c.
“Be sure to splint the incision with a pillow or your hands when you cough.”
d.
“Lie down flat on the bed with your knees up and let me examine your incision.”

Back 56

ANS: D
Although wound dehiscence is not a common complication after surgery, it is usually painless and felt as a “popping” or “splitting” sensation. Any client report of such a sensation should be immediately investigated to avoid evisceration.

Front 57

The nurse has administered 6 mg of morphine subcutaneously to the client 1 hour ago for complaints of severe pain. When the nurse returns to reassess the client, the respiratory rate is 8 breaths/min. What is the nurse’s priority action?
a.
Administers naloxone (Narcan) 1 mg IV
b.
Attempts to awaken the client
c.
Checks the client’s oxygen saturation
d.
Starts oxygen via nasal cannula

Back 57

ANS: C
Many clients experience some degree of respiratory depression with opioid analgesics. If the client can be aroused with minimally intrusive techniques and the oxygen saturation is above 90%, no further intervention is required.

Front 58

The nurse is teaching the client how to use patient-controlled analgesia (PCA) to manage postoperative pain. Which client statement indicates that additional teaching is required?
a.
“I will push the button when the pain is beginning.”
b.
“I will use the PCA until my pain can be relieved with pain pills.”
c.
“I will ask my family to push the button for me when I am sleeping.”
d.
“I will let the nurse know if my pain is not relieved with the PCA.”

Back 58

ANS: C
Clients should be instructed to push the button to release medication when pain begins rather than waiting until the pain becomes so great that the dose administered by the pump cannot control the pain. The potential for overdose exists when family members push the PCA button for the client.

Front 59

A diabetic client has undergone surgery 24 hours ago. Which precautions should the nurse take to help prevent postoperative complications for this client?
a.
Begin a toileting schedule for the client during the daytime.
b.
Use sterile technique during dressing changes.
c.
Pad the siderails and have suction available at the bedside.
d.
Instruct the client to use an electric razor and a soft toothbrush.

Back 59

ANS: B
The diabetic client is at higher risk for impaired wound healing and the development of wound infections. Sterile technique should be used during dressing changes to help prevent wound infection.

Front 60

The nurse is providing discharge teaching for a client who will be going home with a Jackson-Pratt (JP) drain. Which statement indicates that the client understands how to care for the drain correctly?
a.
“I will flush the drain tubing to make sure that it stays open.”
b.
“I will measure the drainage before I dump it out.”
c.
“I will close the drain valve and then compress the bulb to create suction.”
d.
“I will make sure that the drain is connected to a suction machine at night.”

Back 60

ANS: B
The drainage from the JP should be measured before it is discarded.

Front 61

The nurse is caring for a client who has had surgery the previous day. The client tells the nurse, “Breathing in using this tube thing (incentive spirometer) is a ridiculous waste of time.” What is the nurse’s best response?
a.
“The spirometer will help you cough.”
b.
“The spirometer will help your lungs expand.”
c.
“The spirometer will help prevent a blood clot from developing.”
d.
“The spirometer will help improve blood flow through your lungs.”

Back 61

ANS: B
The primary purpose of using an incentive spirometer is to promote lung expansion. The incentive spirometer assists the client in seeing how much air he or she can inhale. The nurse can encourage the client by setting a volume and encouraging the client to reach it. Although many clients may cough while using this, it does not help them cough. Clients begin to cough after taking deep breaths. The spirometer will help with airflow into the lungs, not blood flow.

Front 62

After discharge from the PACU, the client returned to the surgical nursing unit at 10 AM. It is now 6 PM and the client is not experiencing any complications or difficulties. How often should the nurse assess the client’s vital signs?
a.
Every 15 minutes
c.
Every hour
b.
Every 30 minutes
d.
Every 4 hours

Back 62

ANS: D
Vital sign monitoring on the postoperative nursing unit should initially be hourly for 4 hours and then every 4 hours. As the client’s condition stabilizes, frequency of assessment will usually decrease to once a shift until discharge.

Front 63

In the PACU, the nurse receives a client who has just had surgery with general anesthesia. What will the nurse assess first?
a.
The client’s dressing for bleeding
b.
The client’s vital signs
c.
The client’s airway and oxygen saturation
d.
The client’s urine output

Back 63

ANS: C
On arrival in the PACU, the client’s airway and oxygenation should be assessed first.

Front 64

The nurse is teaching a client who has had complications from gastric surgery. The client has lost weight and still has a poor appetite. Which dietary recommendations should the nurse make for this client?
a.
“Take a multivitamin every day and eat small frequent meals.”
b.
“Make sure you have enough fiber in your diet and avoid artificial sweeteners.”
c.
“Drink at least 3 liters of fluid every day, especially with meals.”
d.
“Do not eat between meals so your stomach can rest and avoid snacking at bedtime.”

Back 64

ANS: A
The client should eat small frequent meals so that nausea does not develop and the gastrointestinal (GI) system will not be overwhelmed. Multivitamins will facilitate optimum wound healing.

Front 65

The nurse is caring for clients in the postanesthesia care unit. Which client is ready to be extubated?
a.
The client with an oxygen saturation of 90%
b.
The client with a respiratory rate of 14 breaths/min
c.
The client who is alert and oriented
d.
The client who is coughing and gagging

Back 65

ANS: D
Coughing and gagging on the endotracheal (ET) tube indicates readiness for extubation. Oxygen saturation should be at least 95% before extubation. Respiratory rate and orientation status are not sufficient criteria for extubation.

Front 66

The nurse is working in the PACU and receives a client from the operating room (OR) with many lines and tubes in place. Which should the nurse assess first?
a.
The client’s endotracheal tube
b.
The client’s nasogastric tube
c.
The client’s Foley catheter
d.
The Hemovac drain at the client’s incision site

Back 66

ANS: A
The first priority for this client is to assess airway, breathing, and circulation postoperatively. Therefore, the patency of the client’s ET tube should be determined first.

Front 67

The nurse is caring for a postoperative client who vomits, resulting in a 2-inch opening of the abdominal incision. Some fatty tissue is visible and a small amount of serosanguineous drainage is present. What is the nurse’s best first action?
a.
Preparing the client for emergency surgery
b.
Covering the wound with sterile moist dressings
c.
Giving the client medication for nausea
d.
Reassuring the client that there is no hemorrhaging

Back 67

ANS: B
The wound has undergone dehiscence and should be covered with sterile moist dressings.

Front 68

The nurse is changing the dressing on a postoperative client’s abdominal incision. The incision has sutures and a JP drain, and there is a moderate amount of serosanguineous drainage. What is the nurse’s best action for cleaning this incision site?
a.
Cleaning the incision with hydrogen peroxide and sterile saline
b.
Cleaning from the JP drain toward the suture line using sterile water
c.
Cleaning the incision with Betadine after obtaining a wound culture
d.
Cleaning the incision from the center outward using sterile normal saline

Back 68

ANS: D
Sterile saline should be used to clean wounds because it is not harmful to granulating tissues. The incision should be cleaned from the least contaminated area to the most contaminated area, inside the incision toward the surrounding skin.

Front 69

The nurse is changing the dressing for a client’s incision on the third postoperative day. The incision is intact with staples and a minimal amount of serosanguineous drainage. What is the best dressing to use for this incision?
a.
A wet to dry dressing
c.
A dry sterile dressing
b.
A hydrocolloid dressing
d.
A gel-impregnated gauze dressing

Back 69

ANS: C
A dry sterile dressing is appropriate because there is minimal drainage from the wound. The other dressings are intended for wounds with significant amounts of drainage.

Front 70

The nurse receives report that the client’s Foley catheter was emptied just prior to transfer to the medical-surgical unit. Two hours later, the nurse notes that the client’s urinary output is 30 mL. What is the nurse’s best first action?
a.
Increasing the IV fluid rates
b.
Notifying the surgeon immediately
c.
Taking the client’s vital signs
d.
Checking the patency of the Foley catheter

Back 70

ANS: D
Before increasing the IV fluid rate, checking the client’s vital signs, or calling the physician, the nurse should check to ensure that the client’s catheter tubing is patent.

Front 71

The nurse is ambulating a postoperative client in the hallway when he coughs and says to the nurse, “I feel like something ripped in my incision.” A large amount of blood is suddenly apparent on the client’s gown over the incision. What is the best first action of the nurse?
a.
Eases the client to the floor and call for assistance
b.
Covers the incision with moistened sterile gauze and call the physician
c.
Assesses the client’s vital signs and reinforce the dressing
d.
Removes the dressing and covers the incision with sterile towels

Back 71

ANS: A
The first action of the nurse should be to ease the client to the floor to reduce tension on the incision. This will also help keep organs in the abdominal cavity and help prevent the client from fainting and falling to the floor.

Front 72

In the postanesthesia care unit, the client states concerns about postoperative pain management to the nurse. Which instructions should the nurse provide for the client so that the postoperative pain will be controlled most effectively?
a.
“You should not ask for IV pain medication more than once every 4 or 5 hours.”
b.
“You should not take the pain medication if you are nauseated.”
c.
“You should wait until you get to your room before asking for pain medication.”
d.
“You should ask for pain medication before the pain becomes severe.”

Back 72

ANS: D
Pain medications are most effective when they are administered before the pain becomes severe.

Front 73

The nurse is caring for multiple postoperative clients on the medical-surgical unit. At the beginning of the shift, the nurse needs to determine which client should be seen first. The nurse should assess which of the following clients first?
a.
A client who has new maroon drainage from the nasogastric tube
b.
A client who received pain medication 20 minutes ago
c.
A client who needs to be ambulated in the hallway
d.
A client who needs instruction about discharge teaching

Back 73

ANS: A
New maroon drainage in the nasogastric tube should be assessed and communicated to the physician immediately because it may indicate gastric bleeding.

Front 74

The following postoperative pain medication orders were written by the physician on the client’s chart. Which one is written correctly and appropriately?
a.
Darvocet 2 tablets PO PRN pain
b.
Demerol 75-100 mg every 3-4 hours PRN pain
c.
MS 0.5 mg SQ every 1-3 hours PRN pain
d.
Dilaudid 1 mg PO Q 4 hours PRN pain

Back 74

ANS: D
The Darvocet order does not have a frequency (PRN is not sufficient). The Demerol order does not have a route. MS must be spelled out (morphine sulfate), and the dosage must be written as 0.5 mg. The Dilaudid order includes the drug name, dosage, route, and frequency all correctly written out.

Front 75

The nurse is caring for a client who is complaining of severe pain at the incision site. The nurse reviews the medication administration sheet and notes that the order states that the client is to receive Demerol (meperidine) 500 mg IM q 3-4 hours PRN pain. Which is the best action of the nurse?
a.
Calling the physician to clarify the order
b.
Giving the medication as ordered
c.
Refusing to give the medication
d.
Calling the hospital pharmacist

Back 75

ANS: A
The order must be clarified before the medication is given because the Demerol dosage is beyond the safe parameters.

Front 76

The nurse is changing the dressing on the client’s abdominal incision. Which of the following is an appropriate step for the nurse to perform in maintaining sterile asepsis?
a.
Putting sterile gloves on before opening the packages of sterile dressings
b.
Pouring out a small amount of sterile saline and discard it before pouring it on the dressings
c.
Placing the sterile saline cap in the middle of the sterile field
d.
Placing the sterile dressings on the edge of the sterile field

Back 76

ANS: B
Lipping the bottle is recommended before pouring out sterile solutions to eliminate any microorganisms that might be on the rim of the bottle.

Front 77

The nurse is caring for the client in the PACU after abdominal surgery. Two hours after the client arrives in the PACU, the nurse auscultates for bowel sounds and hears none. What is the nurse’s best first action?
a.
Positioning the client on the right side with the bed flat
b.
Checking the dressing and applying an abdominal binder
c.
Palpating the bladder and measuring abdominal girth
d.
Documenting the finding in the client’s record

Back 77

ANS: D
Absence of bowel sounds 2 hours after abdominal surgery is an expected finding that should be documented. No intervention specific to this finding is needed at this time.

Front 78

Which instruction will the nurse provide to the client to prevent postoperative deep vein thrombosis?
a.
“Cough and deep-breathe six times every hour after surgery.”
b.
“Use your incentive spirometer at least six times every day.”
c.
“Get up and walk to the bathroom at least three times a day.”
d.
“Keep the sterile dressing on your incision.”

Back 78

ANS: C
Ambulation will help prevent formation of blood clots in the legs, the most common site for postoperative deep vein thrombosis. Coughing and deep breathing will help prevent atelectasis, and sterile dressings will help prevent wound infection.

Front 79

The nurse is completing a physical assessment for a client who will be undergoing surgery shortly. Which preoperative assessment findings will the nurse report immediately? (Select all that apply.)
a.
Chest resonant to percussion over lung fields
b.
Use of accessory muscles with respirations
c.
Kussmaul respirations
d.
Split S2 heart sound
e.
Unequal chest expansion with respirations
f.
Vesicular breath sounds heard over lung fields
g.
Distended external jugular veins

Back 79

ANS: B, C, E, G
Abnormal physical assessment findings should be reported to the surgeon and anesthesiologist right away.

Front 80

The nurse is conducting preoperative teaching with a client who will be undergoing pelvic surgery. The nurse explains the use of antiembolism stockings and pneumatic compression devices. Which statements by the client indicate that additional teaching is needed? (Select all that apply.)
a.
“At least I will only have to wear the white stockings and SCD during surgery and not when I am recovering afterward.”
b.
“Even though I will have the stockings on after surgery, I will still have to walk and do my leg exercises.”
c.
“Since I am wearing antiembolism stockings, I won’t have to worry about putting my slippers on to go for a walk.”
d.
“I’m amazed that TED stockings can come as ‘one size fits all’ since my legs are so short.”
e.
“I can wear the TED stockings and SCD at the same time to help prevent clots.”
f.
“I’m glad that the stockings and SCD will be off during the night so I can sleep.”

Back 80

ANS: A, C, D, F
A sequential compression device (SCD) and TED hose should be worn during surgery and recovery period during the day and night. The client should never walk in TED stockings without nonskid footwear. The nurse must measure the client’s legs to make sure that the TED stockings are the correct size.

Front 81

Prior to general anesthesia, the client says to the nurse, “My brother and my father had bad reactions to anesthesia when they were put to sleep for surgery. I hope that doesn’t happen to me!” As a precaution, what equipment should the nurse have prepared for the client before anesthesia is administered? (Select all that apply.)
a.
Pacemaker
b.
Nasogastric tube
c.
Laser cautery
d.
Cooling blanket
e.
Chest tube
f.
Foley catheter
g.
Tracheostomy kit

Back 81

ANS: B, D, F
Malignant hyperthermia is a dangerous reaction to general anesthesia that is caused by a genetic disorder that is more common in males. The nurse should be prepared to insert a Foley catheter and nasogastric tube and apply a cooling blanket for the client if the reaction occurs.

Front 82

A surgical drape catches fire during a client’s surgical procedure. Which actions will be taken by the circulating nurse? (Select all that apply.)
a.
Douses the drape with water after it is removed from the client
b.
Notifies hospital security and the nursing supervisor about the fire
c.
Ensures that surgical instruments are not contaminated as the fire is put out
d.
Turns off anesthetic gases and maintain patency of the client’s airway
e.
Unplugs any electrical equipment that is located near the fire
f.
Assesses the client for injury
g.
Documents the incident per facility’s policy

Back 82

ANS: A, B, E, F, G
The circulating nurse should put out the fire once the drape has been removed from the client, and then notify hospital security and the nursing supervisor. Any electrical equipment that is located near the fire should be unplugged. The client should be assessed for injury and appropriate documentation should be completed.

Front 83

Which clients are at an increased risk for postoperative nausea and vomiting? (Select all that apply.)
a.
An older adult client with a history of hypertension
b.
A male client who was in the lateral position during surgery
c.
A middle aged client with a BMI of 46
d.
A female client who has undergone a cholecystectomy
e.
A young adult client who received 3 liters of IV fluid during surgery
f.
A male client who has a history of seasickness
g.
A male client who has a nasogastric tube to suction

Back 83

ANS: C, D, F
Obesity, motion sickness, and general anesthesia carry an increased risk for postoperative nausea and vomiting.