EXAM 2

Question 1

List certain foods associated with latex allergy.

Answer 1

eggs, avocados, bananas, chestnuts, potatoes, peaches

Question 2

A patient who has not had any prior surgeries tells the nurse doing the preoperative assessment about allergies to avocados and bananas. Which action is most important for the nurse to take?

a. Notify the dietitian about the specific food allergies.
b. Alert the surgery center about a possible latex allergy.
c. Reassure the patient that all allergies are noted on the health record.
d. Ask whether the patient uses antihistamines to reduce allergic reactions.

Answer 2

ANS: B
Certain food allergies (e.g., eggs, avocados, bananas, chestnuts, potatoes, peaches) are related to latex allergies. When a patient is allergic to latex, special non latex materials are used during surgical procedures. The staff will need to know about the allergy in advance to obtain appropriate non latex materials and have them available during surgery.

Question 3

A patient arrives at the outpatient surgical center for a scheduled laparoscopy under general anesthesia. Which information requires the nurse’s preoperative intervention to maintain patient safety?

a. The patient has never had general anesthesia.
b. The patient is planning to drive home after surgery.
c. The patient had a sip of water 4 hours before arriving.
d. The patient’s insurance does not cover outpatient surgery

Answer 3

ANS: B
After outpatient surgery, the patient should not drive that day and will need assistance with transportation and home care. Clear liquids only require a minimum preoperative fasting period of 2 hours. The patient’s experience with anesthesia and the patient’s insurance coverage are important to establish, but these are not safety issues.

Question 4

A 38-yr-old woman is admitted for an elective surgical procedure. Which information obtained by the nurse during the preoperative assessment is most important to communicate to the anesthesiologist and surgeon before surgery?

a. The patient’s lack of knowledge about postoperative pain control
b. The patient’s history of an infection following a cholecystectomy
c. The patient’s report that her last menstrual period was 8 weeks ago
d. The patient’s concern about being able to resume lifting heavy items

Answer 4

ANS: C
This statement suggests that the patient may be pregnant and pregnancy testing is needed before administration of anesthetic agents. Although the other data may also be communicated with the surgeon and anesthesiologist, they will affect postoperative care and do not indicate a need for further assessment before surgery.

Question 5

A patient who is scheduled for a therapeutic abortion tells the nurse, “Having an abortion is wrong.” Which functional health pattern should the nurse further assess?
a. Value–belief c. Sexuality–reproductive
B. Cognitive–perceptual d. Coping–stress tolerance

Answer 5

ANS: A

The value–belief pattern includes information about conflicts between a patient’s values and proposed medical care.

Question 6

The surgical unit nurse has just received a patient with a history of smoking from the postanesthesia care unit. Which action is most important at this time? (Read Q carefully~ ABC, ASSESS!!)

a. Auscultate for adventitious breath sounds.
b. Obtain the blood pressure and temperature.
c. Remind the patient about harmful effects of smoking.
d. Ask the health care provider to prescribe a nicotine patch.

Answer 6

ANS: A
The nurse should first ensure a patent airway and check for breathing and circulation (airway, breathing, and circulation [ABCs]) in a responsive patient

Question 7

The nurse obtains a health history from a patient who is scheduled for elective hip surgery in 1 week. The patient reports use of garlic and ginkgo biloba. Which action by the nurse is most appropriate?

a. Teach the patient that these products may be continued preoperatively.
b. Advise the patient to stop the use of herbs and supplements at this time.
c. Discuss the herb and supplement use with the patient’s health care provider.
d. Reassure the patient that there will be no interactions with anesthetic agents

Answer 7

ANS: C
Both garlic and ginkgo biloba increase the risk for bleeding. The nurse should discuss the herb and supplement use with the patient’s health care provider. The nurse should not advise the patient to stop the supplements or to continue them without consulting with the health care provider and the anesthesia care provider.

Question 8

The nurse is preparing to witness the patient signing the operative consent form when the patient says, “I don’t understand what the doctor said about the surgery.” Which action should the nurse take next?

a. Provide a thorough explanation of the planned surgical procedure.
b. Notify the surgeon that the informed consent process is not complete.
c. Give the prescribed preoperative antibiotics and withhold sedative medications.
d. Notify the operating room nurse to give a more complete explanation of the procedure

Answer 8

ANS: B
The surgeon is responsible for explaining the surgery to the patient. The nurse should wait until the surgeon has clarified the surgery before having the patient sign the consent form. The nurse should communicate directly with the surgeon about the consent form rather than asking other staff to pass on the message. It is not within the nurse’s legal scope of practice to explain the surgical procedure.

Question 9

Which topic is most important for the nurse to discuss preoperatively with a patient who is scheduled for an open cholecystectomy?

a. Care for the surgical incision
b. Deep breathing and coughing
c. Oral antibiotic therapy after discharge
d. Medications to be used during surgery

Answer 9

ANS: B
Preoperative teaching, demonstration, and re-demonstration of deep breathing and coughing are needed on patients having abdominal surgery to prevent postoperative atelectasis.

Question 10

Five minutes after receiving the ordered preoperative midazolam by IV injection, the patient asks to get up to go to the bathroom to urinate. Which action by the nurse is most appropriate?

a. Assist the patient to the bathroom.
b. Offer the patient a urinal or bedpan.
c. Ask the patient to wait until the drug has been fully metabolized.
d. Tell the patient that a bladder catheter will be placed in the operating room.

Answer 10

ANS: B
The patient will be at risk for a fall after receiving the sedative, so the best nursing action is to have the patient use a bedpan or urinal. Having the patient get up either with assistance or independently increases the risk for a fall.

Question 11

The outpatient surgery nurse reviews the complete blood cell (CBC) count results for a patient who is scheduled for surgery. The results are white blood cell (WBC) count 10.2 103/µL; hemoglobin 15 g/dL; hematocrit 45%; platelets 150 103/µL. Which action should the nurse take?

a. Notify the surgeon and anesthesiologist immediately.
b. Ask the patient about any symptoms of a recent infection.
c. Continue to prepare the patient for the surgical procedure.
d. Discuss the possibility of blood transfusion with the patient.

Answer 11

ANS: C
The CBC count results are normal. With normal results, the patient can go to the holding area when the operating room is ready for the patient. There is no need to notify the surgeon or anesthesiologist, discuss blood transfusion, or ask about recent infection.

Question 12

Which information in the preoperative patient’s medication history is most important to communicate to the health care provider?

a. The patient takes garlic capsules every day.
b. The patient quit using cocaine 10 years ago.
c. The patient took a prescribed sedative the previous night.
d. The patient uses acetaminophen (Tylenol) for aches and pains.

Answer 12

ANS: A
Chronic use of garlic may predispose to intraoperative and postoperative bleeding. The use of a sedative the previous night, occasional acetaminophen use, and a distant history of cocaine use will not usually affect the surgical outcome

Question 13

A patient who takes a diuretic and a -blocker to control blood pressure is scheduled for breast reconstruction surgery. Which patient information is most important to communicate to the health care provider before surgery?

a. Hematocrit 36%
b. Blood pressure 144/82
c. Serum potassium 3.2 mEq/L
d. Pulse rate 54-58 beats/minute

Answer 13

ANS: C
The low potassium level may increase the risk for intraoperative complications such as dysrhythmias. Slightly elevated blood pressure is common before surgery because of anxiety. The lower heart rate would be expected in a patient taking a -blocker. The hematocrit is in the low normal range but does not require any intervention before surgery.

Question 14

When caring for a preoperative patient on the day of surgery, which actions included in the plan of care can the nurse delegate to unlicensed assistive personnel (UAP) (select all that apply)?

a. Teach incentive spirometer use.
b. Explain routine preoperative care.
c. Obtain and document baseline vital signs.
d. Remove nail polish and apply pulse oximeter.
e. Transport the patient by stretcher to the operating room.

Answer 14

ANS: C, D, E
Obtaining vital signs, removing nail polish, pulse oximeter placement, and transport of the patient are routine skills that are appropriate to delegate.

Question 15

A nurse is assessing a client’s laboratory values before surgery. Which of the following results should the nurse report to the provider? (Select all that apply)

a. Potassium 3.9 mEq/L
b. Sodium 145 mEq/L
c. Creatinine 2.8 mg/dL
d. Blood glucose 235 mg/dL )
e. WBC 17,850/mm3

Answer 15

C, D, E

Question 16

An alert patient does not want to have a tracheostomy inserted because of extended endotracheal intubation, although family members state that they want it done. What is the best action for the nurse to take?

a. Advocate for the patient’s rights.
b. Try to change the patient’s mind.
c. Call surgery to cancel the procedure.
d. Tell the family they cannot interfere

Answer 16

A

The nurse must act as the patient’s advocate and assist the patient with fulfilling his wishes. However, as the patient’s advocate, the nurse must be sure he knows the risks and benefits of refusing a tracheostomy.

Question 17

An experienced nurse orients a new nurse to the postanesthesia care unit (PACU). Which action by the new nurse, if observed by the experienced nurse, indicates that the orientation was successful?

a. The new nurse assists a nauseated patient to a supine position.
b. The new nurse positions an unconscious patient supine with the head elevated.
c. The new nurse positions an unconscious patient on the side upon arrival in the PACU.
d. The new nurse places a patient in the Trendelenburg position for a low blood pressure

Answer 17

ANS: C
The patient should initially be positioned in the lateral “recovery” position to keep the airway open and avoid aspiration. The Trendelenburg position is avoided because it increases the work of breathing. The patient is placed supine with the head elevated after regaining consciousness.

Question 18

A patient’s T-tube is draining dark green fluid after gallbladder surgery. What action by the nurse is the most appropriate?

a. Notify the patient’s surgeon.
b. Place the patient on bed rest.
c. Document the color and amount of drainage.
d. Irrigate the T-tube with sterile normal saline.

Answer 18

A T-tube normally drains dark green to bright yellow drainage so no action other than to document the amount and color of the drainage is needed. The other actions are not necessary.

Question 19

A postoperative patient has a nursing diagnosis of ineffective airway clearance. The nurse determines that interventions for this nursing diagnosis have been successful if which is observed?

a. Patient drinks 2 to 3 L of fluid in 24 hours.
b. Patient uses the spirometer 10 times every hour.
c. Patient’s breath sounds are clear to auscultation.
d. Patient’s temperature is less than 100.2°F orally.

Answer 19

ANS: C
One characteristic of ineffective airway clearance is the presence of adventitious breath sounds such as crackles, so clear breath sounds are an indication of resolution of the problem

Question 20

A patient who has begun to awaken after 30 minutes in the postanesthesia care unit (PACU) is restless and shouting at the nurse. The patient’s oxygen saturation is 96%, and recent laboratory results are all normal. Which action by the nurse is most appropriate?

a. Increase the IV fluid rate.
b. Assess for bladder distention.
c. Notify the anesthesia care provider (ACP).
d. Demonstrate the use of the nurse call bell button

Answer 20

ANS: B
Because the patient’s assessment indicates physiologic stability, the most likely cause of the patient’s agitation is emergence delirium, which will resolve as the patient wakes up more fully

Question 21

Which action could the postanesthesia care unit (PACU) nurse delegate to unlicensed assistive personnel (UAP) who help to transport a patient to the clinical unit?

a. Clarify the postoperative orders with the surgeon.
b. Help with the transfer of the patient onto a stretcher.
c. Document the appearance of the patient’s incision in the chart.
d. Provide hand off communication to the surgical unit charge nurse.

Answer 21

ANS: B

The scope of practice of UAP includes repositioning and moving patients under the supervision of a nurse

Question 22

A patient is transferred from the post anesthesia care unit (PACU) to the clinical unit. Which action by the nurse on the clinical unit should be performed first?

a. Assess the patient’s pain.
b. Orient the patient to the unit.
c. Take the patient’s vital signs.
d. Read the postoperative orders.

Answer 22

ANS: C
Because the priority concerns after surgery are airway, breathing, and circulation, the vital signs are assessed first. The other actions should take place after the vital signs are obtained and compared with the vital signs before transfer.

Question 23

When caring for a patient the second postoperative day after abdominal surgery for removal of a large pancreatic cyst, the nurse obtains an oral temperature of 100.8° F (38.2° C). Which action should the nurse take next?

a. Place ice packs in the patient’s axillae.
b. Have the patient use the incentive spirometer.
c. Request an order for acetaminophen (Tylenol).
d. Ask the health care provider to prescribe a different antibiotic.

Answer 23

ANS: B
A temperature of 100.8° F (38.2° C) in the first 48 hours is usually caused by atelectasis, and the nurse should have the patient deep breathe, cough, and use the incentive spirometer.

Question 24

The nurse assesses a patient on the second postoperative day after abdominal surgery to repair a perforated duodenal ulcer. Which finding is most important for the nurse to report to the surgeon?

a. Tympanic temperature 99.2° F (37.3° C)
b. Fine crackles audible at both lung bases
c. Redness and swelling along the suture line
d. 200 mL sanguineous fluid in the wound drain

Answer 24

ANS: D

Wound drainage should decrease and change in color from sanguineous to serosanguineous by the second postoperative day.

Question 25

After receiving a change-of-shift report about these postoperative patients, which patient should the nurse assess first?

a. Obese patient who had abdominal surgery 3 days ago and whose wound edges are separating
b. Patient who has 30 mL of sanguineous drainage in the wound drain 10 hours after hip replacement surgery
c. Patient who has bibasilar crackles and a temperature of 100° F (37.8 °C) on the first postoperative day after chest surgery
d. Patient who continues to have incisional pain 15 minutes after hydrocodone and acetaminophen (Vicodin) was given

Answer 25

ANS: A
The patient’s history and assessment suggests possible wound dehiscence, which should be reported immediately to the surgeon

Question 26

While ambulating in the room, a patient complains of feeling dizzy. In what order will the nurse accomplish the following activities? (Put a comma and a space between each answer choice [A, B, C, D].)

a. Have the patient sit down in a chair.
b. Give the patient something to drink.
c. Take the patient’s blood pressure (BP).
d. Inform the patient’s health care provider.

Answer 26

ANS:

A, C, B, D

Question 27

A nurse is caring for a client who arrived in the PACU following a total hip arthroplasty. The client is not responding to verbal stimuli. Which of the following actions should the nurse perform first?

a. Compare and contrast the peripheral pulses
b. Apply a warm blanket.
c. Assess dressing
d. Place the client in a lateral position.

Answer 27

D

Question 28

A nurse is planning care for a client to prevent postoperative atelectasis. Which of the following interventions of care. (select all that apply)

a. Encourage use of the incentive spirometer every 2 hr.
b. Instruct the client to splint the incision when coughing and deep breathing.
c. Reposition the client every 2 hr.
d. Administer antibiotic therapy
e. Assist with early ambulation

Answer 28

A, B, C, E

Question 29

The nurse is positioning a patient after a surgical procedure. What is the best position unless contraindicated, for this patient to be placed in to prevent respiratory complications?
 Supine
 Lateral
 Semi-Fowler’s
 High-Fowler’s

Answer 29

Lateral

Question 30

The nurse is working on a surgical floor and is preparing to receive a postoperative patient from the postanesthesia care unit (PACU). What should the nurse’s initial action be upon the patient’s arrival?
Assess the patient’s pain.
Assess the patient’s vital signs.
Check the rate of the IV infusion.
Check the physician’s postoperative orders

Answer 30

Take the patient’s vital signs

Highest priority action by the nurse is to assess the physiologic stability of the patient. This is accomplished in part by taking the patient’s vital signs

Question 31

In planning postoperative interventions to promote repositioning, ambulation, coughing, and deep breathing, which action should the nurse recognize will best enable the patient to achieve the desired outcomes?

a. Administering adequate analgesics to promote relief or control of pain
b. Asking the patient to demonstrate the postoperative exercises every 1 hour
c. Giving the patient positive feedback when the activities are performed correctly
d. Warning the patient about possible complications if the activities are not performed

Answer 31

ANS: A

Question 32

A postoperative patient has a bronchial obstruction resulting from retained secretions and an oxygen saturation of 87%. What condition does the nurse suspect is occurring?
 Atelectasis 
 Bronchospasm
 Hypoventilation
 Pulmonary embolism

Answer 32

Atelectasis

most common cause of postoperative hypoxemia is atelectasis, which may be the result of bronchial obstruction caused by retained secretions or decreased respiratory excursion

Question 33

A patient is having elective cosmetic surgery performed on the face and will be staying in the facility for 24 hours after surgery. What is the nurse’s postoperative priority for this patient?
 Manage patient pain.
 Control the bleeding.
 Maintain fluid balance.
 Manage oxygenation status.

Answer 33

Manage oxygenation status

Question 34

A nurse is caring for an unconscious patient who has just been admitted to the post anesthesia care unit after abdominal hysterectomy. How should the nurse position the patient?

Left lateral position with head supported on a pillow

Prone position with a pillow supporting the abdomen

Supine position with head of bed elevated 30 degrees

Semi-Fowler’s position with the head turned to the right

Answer 34

An unconscious patient should be placed in the lateral “recovery” position to keep the airway open and reduce the risk of aspiration