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10 Cards in this Set

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1. A patient undergoes a surgical procedure that requires the use of general anesthesia. Following general anesthesia, the patient is most at risk for:


A. atelectasis.


B. anemia.


C. dehydration.


D. peripheral edema.

Correct answer: A


Atelectasis occurs when the postoperative patient fails to move, cough, and breath deeply. With good nursing care, this is an avoidable complication. Anemia (Option B) is a rare complication that usually occurs in patients who lose a signifi cant amount of blood or continue bleeding postoperatively. Fluid shifts that occur postoperatively may result in dehydration (Option C) and peripheral edema (Option D), but the patient is most at risk for atelectasis.

2. The nurse is administering preoperative medication to a patient going to the operating room for an aortobifemoral bypass. After administering preoperative medication to the patient, the nurse should: A. allow him to walk to the bathroom unassisted.


B. place the bed in low position with the side rails up.


C. tell him that he’ll be asleep before he leaves for surgery.


D. take his vital signs.

Correct answer: B


When the preoperative medication is given, the bed should be placed in low position, with the side rails raised. The patient should void before the preoperative medication is given—not after. Option A is incorrect because the patient shouldn’t get up without assistance. The patient may not be asleep (Option C), but he may be drowsy. Vital signs (Option D) should be taken before the preoperative medication is given.

3. The nurse is caring for a patient who was given pain medication before leaving the PACU. Upon returning to her room, the patient states that she is experiencing pain and requests more pain medication. Which is the best action for the nurse to take?


A. Tell the patient that she must wait 4 hours for more pain medication.


B. Give one-half of the ordered as-needed dose.


C. Document the patient’s pain.


D. Notify the practitioner that the patient is continuing to experience pain.

Correct answer: D


The practitioner should be notifi ed of the patient’s complaint so that new medication orders can be established. A patient who’s experiencing pain after surgery shouldn’t have to wait 4 hours for pain relief (Option A). A nurse can’t alter a dose without fi rst consulting the practitioner (Option B); if she does, she could be charged with practicing medicine without a license. The patient’s pain should be documented (Option C); however, the nurse also needs to follow up with the patient about it.

4. The nurse is evaluating a patient postoperatively for infection. Which of the following would be most indicative of infection?


A. The presence of an indwelling urinary catheter


B. A rectal temperature of 100° F (37.8° C) C. Redness, warmth, and tenderness in the incision area


D. A white blood cell (WBC) count of 8,000/mL

Correct answer: C


Redness, warmth, and tenderness in the incision area would lead the nurse to suspect a postoperative infection. The presence of any invasive device (Option A) predisposes a patient to infection but alone doesn’t indicate infection. A rectal temperature of 100° F (Option B) is normal in a postoperative patient because of the infl ammatory process. Because a normal WBC count ranges from 4,000 to 10,000/mL, Option D is incorrect.

5. The nurse is caring for a patient with a postoperative wound evisceration. Which action should the nurse perform first?


A. Explain to the patient what is happening, and provide support.


B. Cover the protruding organs with sterile gauze moistened with sterile saline solution.


C. Push the protruding organs back into the abdominal cavity.


D. Ask the patient to drink as much fl uid as possible.

Correct answer: B


Immediately covering the wound with moistened gauze prevents the organs from drying. Both the gauze and the saline solution must be sterile to reduce the risk of infection. Explaining what is happening and providing support (Option A) may reduce the patient’s anxiety but aren’t the fi rst priorities. Option C is incorrect because pushing the organs back into the abdomen may tear or damage them; therefore, the nurse should avoid doing this. Option D is incorrect because evisceration requires emergency surgery, so the nurse should immediately place the patient on nothing-by-mouth status.

6. A patient in the postoperative phase of abdominal surgery is to advance his diet as tolerated. The patient has tolerated ice chips and a clear liquid diet. As the next step, the nurse would expect the patient to advance to:


A. fluid restriction.


B. a full-liquid diet.


C. a general diet.


D. a soft diet.

Correct answer: B


After a clear liquid diet, which is nutritionally inadequate but minimally irritating to the stomach, a patient advances to a full-liquid diet next, which adds bland and protein foods. A soft diet (Option D) comes after that, which omits foods that are hard to chew or digest. A regular or general diet (Option C) has no limitations. Fluid restriction (Option A) is ordered in addition to the diet order for a patient in renal or congestive heart failure.

7. The patient’s intake and output record contains the following information: milk, 180 mL; orange juice, 60 mL; one serving scrambled eggs; one slice toast; one can Ensure oral nutritional supplement, 240 mL; I.V. dextrose 5% in water at 100 mL/hour; 50 mL water after twice daily medications. Medications are given at 9:00 a.m. and 9:00 p.m. What is the patient’s total intake for the 7 a.m. to 3 p.m. shift?


A. 1,000 mL


B. 1,250 mL


C. 1,330 mL


D. 1,380 mL

Correct answer: C


The patient’s total intake is 1,330 mL, based on the following equation: 180 + 60 + 240 + 800 + 50 = 1,330.

8. Which action is included in the principles of asepsis?


A. Maintaining a sterile environment


B. Keeping the environment as clean as possible


C. Testing for microorganisms in the environment


D. Cleaning an environment until it is free from germs

Correct answer: B


Asepsis is the process of avoiding contamination from outside sources by keeping the environment clean. A clean environment has a reduced number of microorganisms, but isn’t necessarily sterile (the absence of all microorganisms) (Option A). Testing for microorganisms or culturing (Option C) isn’t indicated for asepsis. Cleaning an environment until it is free from germs (Option D) would result in a sterile environment.

9. On the first day after thoracotomy, the nurse’s assessment of the patient reveals a temperature of 100° F (37.8° C), a heart rate of 96 beats/minute, blood pressure of 136/86 mm Hg, and shallow respirations of 24 breaths/minute, with rhonchi heard at the lung bases. The patient complains of incisional pain. Which nursing action takes priority?


A. Medicating the patient for pain


B. Helping the patient out of bed


C. Administering ibuprofen (Motrin) as ordered to reduce fever


D. Encouraging the patient to cough and deep-breathe

Correct answer: A


Although all the interventions are incorporated in this patient’s care plan, relieving pain and making the patient comfortable take priority. Doing so gives the patient the energy and stamina to achieve the other objectives.

10. Which intervention is most important to include in a nursing care plan for a patient with atelectasis?


A. Give oxygen continuously at 3 L/minute. B. Have the patient cough and deep-breathe every 4 hours.


C. Have the patient use an incentive spirometer every hour.


D. Get the patient out of bed to a chair every day.

Correct answer: C


Incentive spirometry is used to prevent or treat atelectasis. Performed every hour, it produces deep inhalations that help open the collapsed alveoli. Giving oxygen (Option A) doesn’t encourage deep inhalation. Coughing and deep breathing (Option B) is a good intervention but rarely results in as deep an inspiratory effort as incentive spirometry; it should also be performed more frequently than every 4 hours. Getting the patient out of bed to a chair (Option D) also helps expand the lungs and stimulate deep breathing, but it’s not as important as incentive spirometry.