What is the purpose of leg exercises prior to surgery?
Leg exercised improve circulation and prevent blood clots
What is the purpose of withholding food and fluid before surgery?
To prevent aspiration
During the admission history the client reports to the nurse of taking the usual dose of warfarin (Coumadin) the previous day. The appropriate nursing action is:
Notify the surgeon that the client took warfarin the day before surgery.
You are providing the preoperative teaching for a patient scheduled for surgery. You know to instruct the patient on the use of deep breathing, coughing, and the use of incentive spirometry. What is the rationale for these interventions?
To promote optimal lung expansion
The nurse is teaching leg exercises to the client preoperatively. The client asks why the exercises are important. The best response by the nurse is:
“Leg exercises help prevent blood clots in your legs.”
One of the things taught to a patient during preoperative teaching is to have nothing by mouth for 8 hours before surgery. The patient asks the nurse why this is important. What is the most appropriate response for the patient?
“You will need to have food and fluid restricted for 8 hours before surgery so you are not at risk for aspiration.”
A client will be undergoing an appendectomy tomorrow morning. The nurse spends significant time explaining to the client what will happen, including before and after the procedure is complete. What is the primary reason the nurse puts so much effort into preoperative teaching?
It increases the likelihood of a successful recovery.
The nurse concludes that teaching about pain management was effective when the client states:
“I will support my incision with my hands when I do my coughing and deep breathing exercises.”
You are caring for a patient in the postoperative period following an abdominal hysterectomy. Your patient states, “I don’t want to use my pain medication because it will make me dependent, and I won’t get better as fast.” Which response is most important when explaining the use of pain medication?
“Pain medication decreases your pain so you can move more easily. You will heal more quickly with decreased pain. Dependence only occurs when it is administered for an extended period of time.”
The nurse is preparing a patient for surgery. The patient is to undergo a hysterectomy without oophorectomy and the nurse is witnessing the patient’s signature on a consent form. Which comment by the patient would best indicate informed consent?
“The physician is going to remove my uterus and told me about the risk of hemorrhage.”
The nurse is reviewing the pre-admission laboratory findings of the client scheduled for surgery. Which of the following values would be of greatest concern to the nurse?
Potassium 6.2 mEq/L
When a person with a history of chronic alcoholism is admitted to the hospital for surgery, the nurse anticipates that the patient may show signs of alcohol withdrawal delirium during which time period?
Up to 72 hours after alcohol withdrawal
You are doing patient teaching for a patient who is scheduled for an appendectomy. You must teach the patient about incision splinting and leg exercises. When is the best time for you to provide teaching?
Before the surgical procedure
The nurse concludes that further teaching about diaphragmatic breathing is needed when the client:
Exhales forcefully with a short expiration
Patients who have received corticosteroids preoperatively are at risk for which type of insufficiency?
You are the nurse working in the preoperative holding area. Your patient has just received a preanesthetic medication. What should you instruct the patient to do?
Use the call light to summon the nurse for assistance.
You are doing preoperative teaching with a patient scheduled for surgery in 1 month. During the preoperative teaching, the patient gives you a list of medications she takes, the dosage, and frequency. Which of the following interventions provides the patient with the most accurate information?
Instruct the patient to stop taking St. John’s wort at least 2 weeks prior to surgery due to its interaction with anesthetic agents.
You are the clinic nurse doing a preoperative assessment on a patient who will be undergoing outpatient cataract surgery with lens implantation in 1 week. While taking the patient’s medical history, you note that this patient had a kidney transplant 8 years ago. The patient is taking immunosuppressive drugs. What is this patient at increased risk for when having surgery?
You are doing a preoperative assessment on a patient going to surgery. The patient informs you that he ingests 5 to 10 ounces of alcohol each day and has for the last 15 years. What postoperative difficulties can the nurse anticipate for this patient?
Delirium tremens within 72 hours after his last alcohol drink
A nurse is teaching a client with chronic bronchitis about breathing exercises. Which instruction should the nurse include in the teaching?
Use diaphragmatic breathing.
You are caring for a client preoperatively who is very anxious and fearful about their surgery. You know that this client’s anxiety can cause problems with the surgical experience. What type of problems can this client have because of their anxiety and fear?
Anxious clients have a poor response to surgery and are prone to complications.
An elderly client is preparing to undergo surgery. The nurse participates in preoperative care knowing that which of the following is the underlying principle that guides preoperative assessment, surgical care, and postoperative care for older adults?
Older adults have less physiologic reserve (or ability to regain physical equilibrium) than younger clients.
The nurse recognizes that which of the following clients is at least risk for perioperative complications?
A 65-year-old Caucasian man who has a history of arthritis
Which client would the nurse recognize as having the greatest risk for complications during the intraoperative or postoperative period?
The 35-year-old client with non-insulin dependent diabetes.
How should a nurse teach a patient to perform deep breathing and coughing to use postoperatively?
The patient should take a deep breath in through the mouth and exhale all the air out through the mouth, take a short breath, and cough from deep in the lungs.
The nurse should determine that a client is coughing effectively after surgery if the nurse observes which of the following activities?
The client takes a deep abdominal breath and then “huff” or “hack” coughs three or four times.
Which of the following medications may increases the hypotensive action of anesthesia?
The nurse is preparing a client for surgery. The nurse would notify the surgeon if the client made which of the following statements?
“I took my Coumadin as usual last evening.”
“I took two aspirins for joint pain this morning.”
During an intraoperative procedure, a client starts gagging and retching. The nurse immediately sits the client up and turns the client’s head to one side? Why?
To avoid aspiration
You are the circulating nurse in an operating room that has several surgeries scheduled. You would know to monitor which patient during the intraoperative period because he or she is at increased risk for hypothermia?
A 72-year-old woman
The client asks the nurse how the spinal anesthesia will be administered. The best response by the nurse is:
“The anesthesiologist will inject the anesthetic into the space around your lower spinal cord.”
You are the circulating nurse caring for a 78-year-old patient who is scheduled for a total hip replacement. Which of the factors should you consider during the preparation of the patient in the operating room?
Pressure points should be assessed and well padded.
The nurse recognizes older adults require lower doses of anesthetic agents due to:
decreased lean tissue mass.
A patient is to undergo surgery on his kidney. The patient would be placed in which position for the surgery?
on their side with the head and the feet down
A nurse is monitoring a client recovering from moderate sedation that was administered during a colonoscopy. Which finding requires the nurse’s immediate attention?
Oxygen saturation (SaO2) of 85%
Which statement by the client indicates further teaching about epidural anesthesia is necessary?
“I will become unconscious.”
The nurse recognizes that the older adult is at risk for surgical complications due to:
decreased renal function
A nurse is caring for a patient following surgery under a spinal anesthetic. What interventions can the nurse implement to prevent a spinal headache?
Keep the patient lying flat
What is the most important postoperative instruction a nurse must give to a client who has just returned from the operating room after receiving a subarachnoid block?
“Remain supine for the time specified by the physician.”
You are caring for a male patient who has had spinal anesthesia. The patient is under a physician’s order to lie flat postoperatively. When the patient asks to go to the bathroom, you encourage him to comply with the physician’s order. What is the rationale for complying with this order?
Which nursing diagnosis is most important for the client who is undergoing a surgical procedure expected to last several hours?
Risk for perioperative positioning injury related to positioning in the OR
Which of the following clinical manifestations is often the earliest sign of malignant hyperthermia?
Tachycardia (heart rate above 150 beats per minute)
The nursing student is preparing an elderly patient for surgery. The patient is scheduled for a general anesthetic. Which side effect should the nurse monitor the patient for?
A patient who has undergone surgery and received spinal anesthesia is reporting a headache. Which of the following would be most appropriate?
Encourage increased fluid intake.
You note a colleague making an inappropriate remark about the patient’s weight. The patient is unconscious at the time. What should you do?
Discourage the comments.
The nursing instructor is talking with her class about spinal anesthesia. What would be the nursing care intervention required when caring for a client recovering from spinal anesthesia?
Instruct the client to remain flat for 6 to 12 hours.
The nurse knows that elderly patients are at higher risk for complications and adverse outcomes during the intraoperative period. What is the best rationale for this phenomenon?
The elderly patient has reduced ability to adjust rapidly to emotional and physical stress.
A nurse is reviewing the medical record of a patient who is to receive general anesthesia and notes a nursing diagnosis of anxiety related to surgical concerns. The nurse implements measures to reduce the patient’s anxiety based on the understanding of which of the following?
Increased anxiety can increase the patient’s postoperative pain level.
A patient begins to vomit during surgery. Place the actions below in the order in which they would be performed.
Turn the patient to the side.
Lower the head of the surgical table.
Provide a basin for collection.
Suction to remove saliva.
As a nurse, you know that one of the risks for a surgical patient is vomiting. What can aspirated vomitus lead to?
The client complains of weakness and dizziness as the nurse assists the client to sit on the side of the bed. The nurse recognizes the client is experiencing:
You are the recovery room nurse who is admitting a patient from the OR. What is the first assessment you would make on a newly admitted patient?
patency of the airway
The nurse is admitting a patient to the medical-surgical unit from the PACU. A concern for this patient is pneumonia. What would the nurse do to help the patient clear secretions and help prevent pneumonia?
Encourage the patient to use the incentive spirometer every 2 hours
Which of the following actions should the nurse perform to prevent deep vein thrombosis in a client recovering from abdominal surgery?
Reinforce the need for the client to perform leg exercises every hour when awake.
A client who had abdominal surgery 4 days ago reports that “something gave way” when he sneezed. The nurse observes a wound evisceration. Which nursing action is the first priority?
Applying a sterile, moist dressing
The nursing instructor is discussing postoperative care with the junior nursing students. A student nurse asks, “Why does the patient go to the PACU prior to the medical-surgical unit?” What is the nursing instructor’s best response?
“The PACU allows the patient to recover from the effects of anesthesia, and the patient stays in PACU until he or she is oriented, has stable vital signs, and is without complications.”
A nurse is caring for a client with a postoperative wound evisceration. Which action should the nurse perform first?
Cover the protruding internal organs with sterile gauze moistened with sterile saline solution.
Which of the following sets of clinical data would allow the nurse to conclude that the nursing actions taken to prevent postoperative pneumonia have been effective?
Vital signs within normal limits; absence of chills and cough
In the immediate postoperative period, vital signs are taken at least every:
You are caring for a client postoperatively. What nursing interventions help prevent venous stasis and other circulatory complications in a client who has undergone surgery?
Encourage the client to move legs frequently and do leg exercises
You are caring for a 79-year-old man who has returned to the medical-surgical unit following abdominal surgery. Your patient is unable to ambulate and is now refusing to wear an external pneumatic compression stocking. You explain that refusing to wear external pneumatic compression stockings places him at significant risk for what?
Following admission of the postoperative client to the clinical unit, which of the following assessment data requires the most immediate attention?
Oxygen saturation of 82%
You are the nurse caring for a patient after abdominal surgery in the postanesthesia care unit. The patient’s blood pressure has increased and the patient is restless. The patient’s oxygen saturation is 97%. You know that the change in your patient is most likely caused by what?
The patient is in pain.
The nurse is caring for a postoperative client with a hemovac. The hemovac is expanded and contains approximately 25 cc of serosanguineous drainage. The best nursing action would be to:
Empty and measure the drainage and compress the hemovac.
You are the nurse caring for a patient who just had surgery. What is your highest priority?
Maintaining a patent airway
The nurse is changing the dressing of a client who is 4 days postoperative with an abdominal wound. The nurse has changed this dressing daily since surgery. Today, the nurse notes increased serosanguinous drainage, wound edges not approximated, and a ¼-inch gap at the lower end of the incision. The nurse concludes which of the following conditions exists?
Nursing assessment findings reveal a temperature of 96.2°F, pulse oximetry 90%, shivering, and client complains of chilling. The findings are indicative of which nursing diagnosis?
A 38-year-old patient has just been admitted to the PACU following abdominal surgery. As the patient begins to awaken, he is restless and asking for “a drink of water.” The nurse checks his skin and it is cold, moist, and pale. What is the nurse concerned the patient may be at risk for?
Hemorrhage and shock
The PACU nurse is caring for an older adult who presents with clinical manifestations of delirium. Which short-term outcome would be most important for this client? The client:
maintains adequate oxygenation status.
The nurse is preparing the client with an abdominal incision for discharge. Which statement by the client indicates teaching has been ineffective?
“I can resume my usual activities as soon as I get home.”
Nursing assessment findings reveal a temperature of 103.2°F, tachycardia, and client complaints of increased incisional pain. The nurse recognizes the client is experiencing:
The client is experiencing nausea and vomiting following surgery. The nurse expects the surgeon to order:
The nursing assessment of the postoperative client reveals an incision that is well-approximated with sutures intact, minimal redness and edema, and absence of drainage. The nurse recognizes the wound is healing by:
A physician calls the nurse for an update on his client who underwent abdominal surgery 5 hours ago. The physician asks the nurse for the total amount of drainage collected in the Hemovac since surgery. The nurse reports that according to documentation, no drainage has been recorded. When the nurse finishes on the telephone, she goes to assess the client. Which assessment finding explains the absence of drainage?
The Hemovac drain isn’t compressed; instead it’s fully expanded.
A nurse asks a client who had abdominal surgery 3 days ago if he has moved his bowels since surgery. The client states, “I haven’t moved my bowels, but I am passing gas.” How should the nurse intervene?
Encourage the client to ambulate at least three times per day.
A client had a nephrectomy 2 days ago and is now complaining of abdominal pressure and nausea. The first nursing action should be to:
auscultate bowel sounds.
Your patient is 2 hours postoperative with a Foley catheter in situ. The last hourly urine output you recorded for this patient was 10 mL. The tubing of the Foley is patent. What should you do?
Notify the physician, and continue to closely monitor the hourly urine output
You admit a patient to the postanesthesia care unit with a blood pressure of 130/90 and a pulse of 68 beats per minute. After 30 minutes, the patient’s blood pressure is 120/65, and the pulse is 100. You document the patient’s skin as cold, moist, and pale. What is the patient showing signs of?
You are caring for an 88-year-old patient who is recovering from an ileac-femoral bypass graft. The patient is 2 days post-op and has been mentally intact. When you assess the patient, you find he is confused and has disturbed sleep patterns and impaired psychomotor skills. What would you suspect is the problem with the patient?
You have just received a postoperative patient from the PACU to the medical-surgical unit. Your patient is an 84-year-old female who had surgery for a left hip replacement. What is a primary concern for this patient in the first few hours on the unit?
You admit a patient to the PACU who has undergone a surgical procedure that required the use of general anesthesia. What is the patient most at risk for following general anesthesia?
You are caring for a postoperative patient on the medical-surgical unit. During each patient assessment, you evaluate your patient for infection. Which sign or symptom would be most indicative of infection?
Red, warm, tender incision
You are a nurse in the PACU caring for a 56-year-old male patient who had a hernia repair. The patient’s blood pressure is now 164/92, he has no history of hypertension prior to surgery, and his preoperative blood pressure was 112/68. You know that hypertension following surgery is often related to what?
Pain, hypoxia, or bladder distention, which all cause sympathetic stimulation
Which method of wound healing is one in which wound edges are not surgically approximated and integumentary continuity is restored by granulation?
Your patient is in the recovery room following chest surgery. The patient complains of severe nausea. What would you do next?
Turn the patient completely to one side
Corticosteroids have which effect on wound healing?
Mask presence of infection
Nursing assessment findings reveal urinary output < 30 ml/hr, tachycardia, tachypnea, decreased hemoglobin, and acute confusion. The findings are indicative of which nursing diagnosis?
Decreased cardiac output
Following a splenectomy, a client has a hemoglobin (Hb) level of 7.5 g/dl and has vertigo when getting out of bed. The nurse suspects abnormal orthostatic changes. The vital sign values that most support the nurse’s analysis are:
blood pressure of 80/40 mm Hg and pulse of 130 beats/minute.
Which of the following clinical manifestations increase the risk for evisceration in the postoperative client?
Explanation: The Valsalva maneuver produces tension on abdominal wounds, which increases the risk for evisceration.
The nurse is assessing the client for wound complications following surgery. For which clinical manifestation should the nurse assess? Select all that apply.
In portable wound suction, the use of gentle, constant suction enhances drainage of these fluids and collapses the skin flaps against the underlying tissue, thus removing “dead space.” Which of the following is a portable suction device?
A client who is receiving the maximum levels of medication for postoperative recovery asks the nurse if there are other measures that the nurse can employ to ease pain. Which of the following strategies might the nurse employ? Select all that apply.
• Changing the client’s position
• Putting on soothing music
• Performing guided imagery
The nurse suspects the client is developing postoperative pneumonia. Which clinical manifestation would support the nurse’s conclusion? Select all that apply.
Which findings would be indicative of a nursing diagnosis of decreased cardiac output?
tachycardia; hemoglobin 10.9 gm/dL; BP 88/56
You are performing your shift assessment of your patient. You find his mental status, level of consciousness, speech, and orientation are intact and at baseline. Your patient tells you he is very anxious. What would you do next?
Assess oxygen levels
You are the nurse in the emergency department (ED). You are caring for a man who has returned to the ED after receiving ten stitches for a knife wound while cleaning fish. The wound is now infected, the stitches were removed, and the wound is cleaned and packed with gauze. The ED doctor plans to have the man return tomorrow to remove the packing and resuture the wound. You are aware that the wound will now heal by what?
A nurse is reviewing with a client the use of a patient-controlled anesthesia device and is explaining the benefits. Which of the following would the nurse correctly emphasize? Select all that apply.
• Fosters client participation in care
• Facilitates reduction of postoperative pulmonary complications
To prevent thromboembolism in the postoperative client, the nurse should include which of the following in the plan of care?
Assist with oral fluid intake.
Which of the following factors may contribute to rapid and shallow respirations in a postoperative client? Select all that apply.
• Constricting dressings
• Abdominal distention
Which intervention is appropriate for a nurse caring for a client in severe pain receiving a continuous I.V. infusion of morphine?
Obtaining baseline vital signs before administering the first dose
The nurse caring for a 74-year-old man who has just returned to the medical-surgical unit following surgery for a total knee replacement received report from the PACU. Part of the report had been passed on from the pre-operative assessment where the patient stated that he has “been confused in the past when he takes pain medications.” What does the nurse realize that the elderly may do?
The elderly may require lower doses of medication and are easily confused with new medications.
On the second postoperative day, nursing assessment reveals that the client has a temperature of 103°F (39.5°C). The nurse recognizes that the client is most likely exhibiting a sign of:
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