Perioperative Care

Question 1

Which procedures are done for curative purposes (select all that apply)?

a. Gastroscopy
b. Rhinoplasty
c. Tracheotomy
d. Hysterectomy
e. Herniorrhaphy

Answer 1

d, e (hysterectomy, herniorrhaphy)

Gastroscopy is for the purpose of diagnosis. Rhinoplasty is done for a cosmetic improvement. A tracheotomy is palliative.

Question 2

A patient is scheduled for a hemorrhoidectomy at an ambulatory day-surgery center. An advantage of performing surgery at an ambulatory center is a decreased need for

a. laboratory tests and perioperative medications.
b. preoperative and postoperative teaching by the nurse.
c. psychologic support to alleviate fears of pain and discomfort.
d. preoperative nursing assessment related to possible risks and complications.

Answer 2

a. laboratory tests and perioperative medications

Ambulatory surgery is usually less expensive and more convenient, generally involving fewer laboratory tests, fewer preoperative and postoperative medications, less psychologic stress, and less susceptibility to hospital-acquired infections. However, the nurse is still responsible for assessing, supporting, and teaching the patient who is undergoing surgery, regardless of where the surgery is performed.

Question 3

A patient who is being admitted to the surgical unit for a hysterectomy paces the floor, repeatedly saying, “I just want this over.” What should the nurse do to promote a positive surgical outcome for the patient?

a. Ask the patient what her specific concerns are about the surgery.
b. Reassure the patient that the surgery will be over soon and she will be fine.
c. Redirect the patient’s attention to the necessary preoperative preparations.
d. Tell the patient she should not be so anxious because she is having a common, safe surgery.

Answer 3

a. Ask the patient what her specific concerns are about the surgery.

Excessive anxiety and stress can affect surgical recovery and the nurse’s role in psychologically preparing the patient for surgery is to assess for potential stressors that could negatively affect surgery. Specific fears should be identified and addressed by the nurse by listening and by explaining planned postoperative care. Falsely reassuring the patient, ignoring her behavior, and telling her not to be anxious are not therapeutic.

Question 4

Many herbal products that are commonly taken cause surgical problems. Which herbs listed below should the nurse teach the patient to avoid before surgery to prevent an increase in bleeding for the surgical patient (select all that apply)?

a. Garlic
b. Fish oil
c. Valerian
d. Vitamin E
e. Astragalus
f. Ginkgo biloba

Answer 4

a, b, d, f (garlic, fish oil, vitamin E, ginkgo biloba)

Valerian may cause excess sedation. Astragalus may increase blood pressure before and during surgery.

Question 5

When the nurse asks a preoperative patient about allergies, the patient reports a history of seasonal environmental allergies and allergies to a variety of fruits. What should the nurse do next?

a. Note this information in the patient’s record as hay fever and food allergies.
b. Place an allergy alert wristband that identifies the specific allergies on the patient.
c. Ask the patient to describe the nature and severity of any allergic responses experienced from these agents.
d. Notify the anesthesia care provider (ACP) because the patient may have an increased risk for allergies to anesthetics.

Answer 5

c. Ask the patient to describe the nature and severity of any allergic responses experienced from these agents.

Risk factors for latex allergies include a history of hay fever and allergies to foods such as avocados, kiwi, bananas, potatoes, peaches, and apricots. When a patient identifies such allergies, the patient should be further questioned about exposure to latex and specific reactions to allergens. A history of any allergic responsiveness increases the risk for hypersensitivity reactions to drugs used during anesthesia but the hay fever and fruit allergies are specifically related to latex allergy. After identifying the allergic reaction, the anesthesia care provider (ACP) should be notified, the allergy alert wristband should be applied, and the note in the record will include the allergies and reactions as well as the nursing actions related to the allergies.

Question 6

During a preoperative review of systems, the patient reveals a history of renal disease. This finding suggests the need for which preoperative diagnostic tests?

a. ECG and chest x-ray
b. Serum glucose and CBC
c. ABGs and coagulation tests
d. BUN, serum creatinine, and electrolytes

Answer 6

d. BUN, serum creatinine, and electrolytes

BUN, serum creatinine, and electrolytes are used to assess renal function and should be evaluated before surgery. Other tests are often evaluated in the presence of diabetes, bleeding tendencies, and respiratory or heart disease.

Question 7

During a preoperative physical examination, the nurse is alerted to the possibility of compromised respiratory function during or after surgery in a patient with which problem?

a. Obesity
b. Dehydration
c. Enlarged liver
d. Decreased peripheral pulses

Answer 7

a. Obesity

Obesity, as well as spinal, chest, and airway deformities, may compromise respiratory function during and after surgery. Dehydration may require preoperative fluid therapy and an enlarged liver may indicate hepatic dysfunction that will increase perioperative risk related to glucose control, coagulation, and drug interactions. Weak peripheral pulses may reflect circulatory problems that could affect healing.

Question 8

What type of procedural information should be given to a patient in preparation for ambulatory surgery (select all that apply)?

a. How pain will be controlled
b. Any fluid and food restrictions
c. Characteristics of monitoring equipment
d. What odors and sensations may be experienced
e. Technique and practice of coughing and deep breathing, if appropriate

Answer 8

a, b, e (how pain will be controlled, any fluid and food restrictions, technique and practice of coughing and deep breathing if appropriate)

Procedural information includes what will or should be done for surgical preparation, including what to bring and what to wear to the surgery center, length and type of food and fluid restrictions, physical preparation required, pain control, need for coughing and deep breathing (if appropriate), and procedures done before and during surgery (such as vital signs, IV lines, and how anesthesia is administered). The other options are sensory and process information.

Question 9

The nurse asks a preoperative patient to sign a surgical consent form as specified by the surgeon and then signs the form after the patient does so. By this action, what is the nurse doing?

a. Witnessing the patient’s signature
b. Obtaining informed consent from the patient for the surgery
c. Verifying that the consent for surgery is truly voluntary and informed
d. Ensuring that the patient is mentally competent to sign the consent form

Answer 9

a. Witnessing the patient’s signature

The health care provider is ultimately responsible for obtaining informed consent. However, the nurse may be responsible for obtaining and witnessing the patient’s signature on the consent form. The nurse may be a patient advocate during the signing of the consent form, verifying that consent is voluntary and that the patient understands the implications of consent, but the primary legal action by the nurse is witnessing the patient’s signature.

Question 10

When the nurse prepares to administer a preoperative medication to a patient, the patient tells the nurse that she does not really understand what the surgeon plans to do.
a. What action should be taken by the nurse?

b. What criterion of informed consent has not been met in this situation?

Answer 10

a. The nurse should notify the health care provider because the patient needs further explanation of the planned surgery.
b. Sufficient comprehension

Question 11

A patient scheduled for hip replacement surgery in the early afternoon is NPO but receives and ingests a breakfast tray with clear liquids on the morning of the surgery. What response does the nurse expect when the anesthesia care provider is notified?

a. Surgery will be done as scheduled.
b. Surgery will be rescheduled for the following day.
c. Surgery will be postponed for 8 hours after the fluid intake.
d. A nasogastric tube will be inserted to remove the fluids from the stomach.

Answer 11

a. Surgery will be done as scheduled.

The preoperative fasting recommendations of the American Society of Anesthesiology indicate that clear liquids may be taken up to 2 hours before surgery for healthy patients undergoing elective procedures. There is evidence that longer fasting is not necessary.

Question 12

What is the rationale for using preoperative checklists on the day of surgery?

a. The patient is correctly identified.
b. All preoperative orders and procedures have been carried out and records are complete.
c. Patients’ families have been informed as to where they can accompany and wait for patients.
d. Preoperative medications are the last procedure before the patient is transported to the operating room.

Answer 12

b. All preoperative orders and procedures have been carried out and records are complete.

Preoperative checklists are a tool to ensure that many preparations and precautions performed before surgery have been completed and documented. Patient identification, instructions to the family, and administration of preoperative medications are often documented on the checklist, which ensures that no details are omitted.

Question 13

A common reason that a nurse may need extra time when preparing older adults for surgery is their

a. ineffective coping.
b. limited adaptation to stress.
c. diminished vision and hearing.
d. need to include caregivers in activities.

Answer 13

c. diminished vision and hearing

One of the major reasons that older adults need increased time preoperatively is the presence of impaired vision and hearing that slows understanding of preoperative instructions and preparation for surgery. Thought processes and cognitive abilities may also be impaired in some older adults. The older adult’s decreased adaptation to stress because of physiologic changes may increase surgical risks and overwhelming surgery-related losses may result in ineffective coping that is not directly related to time needed for preoperative preparation. The involvement of caregivers in preoperative preparation. The involvement of caregivers in preoperative activities may be appropriate for patients of all ages.

Question 14

The nurse is reviewing laboratory results for a preoperative patient. Which test result should be brought to the attention of the surgeon immediately?

a. Serum K+ of 3.8 mEq/L
b. Hemoglobin of 15 g/dL
c. Blood glucose of 100 mg/dL
d. White blood cell (WBC) count of 18,000/uL

Answer 14

d. White blood cell (WBC) count of 18,000/uL

This finding may indicate an infection. The surgeon will probably postpone the surgery until the cause of the elevated WBC count has been found.

Question 15

The nurse is preparing a patient for transport to the operating room. The patient is scheduled for a right knee arthroscopy. What actions should the nurse take at this time (select all that apply)?

a. Ensure that the patient has voided.
b. Verify that the informed consent is signed.
c. Complete preoperative nursing documentation.
d. Verify that the right knee is marked with indelible marker.
e. Ensure that the H&P, diagnostic reports, and vital signs are on the chart.

Answer 15

a, b, c, d, e, (all options)

All of these are actions that are needed to ensure the patient is ready for surgery. In addition, the nurse should verify that the identification band and allergy band (if applicable) are on; the patient is not wearing any cosmetics; nail polish has been removed; valuables have been removed and secured; and prosthetics, such as eyeglasses, have been removed and secured.

Question 16

An overweight patient (BMI 28.1 kg/m2) is scheduled for a laparoscopic cholecystectomy at an outpatient surgery setting. The nurse knows that

a. surgery will involve multiple small incisions.
b. this setting is not appropriate for this procedure.
c. surgery will involve removing a portion of the liver.
d. the patient will need special preparations because of obesity.

Answer 16

a. surgery will involve multiple small incisions.

Rationale: Many operative procedures are performed as ambulatory surgery (i.e., same-day or outpatient surgery). Obesity is not a contraindication to surgery in the outpatient setting. This patient is not classified as obese on the basis of the BMI. The case implied that a laparoscopic technique will be used that involves several small incisions and meets the requirement of a minimally invasive technique.

Question 17

The patient tells the nurse in the preoperative setting that she has noticed she has a reaction when wearing rubber gloves. What is the most appropriate intervention?

a. Notify the surgeon so the case can be cancelled.
b. Ask additional questions to assess for a possible latex allergy.
c. Notify the OR staff immediately so that latex-free supplies can be used.
d. No intervention is needed because the patient’s rubber sensitivity has no bearing on surgery.

Answer 17

b. Ask additional questions to assess for a possible latex allergy

Rationale: The nurse should ask additional screening questions to determine the patient’s risk for a latex allergy. Latex precaution protocols should be used for patients identified as having a positive latex allergy test result or a history of signs and symptoms related to latex exposure. Many health care facilities have created latex-free product carts that can be used for patients with latex allergies.

Question 18

A 59-year-old man is scheduled for a herniorrhaphy in 2 days. During the preoperative evaluation he reports that he takes ginkgo daily. What is the priority intervention?

a. Inform the surgeon, since the procedure may need to be rescheduled.
b. Notify the anesthesia care provider, since this herb interferes with anesthetics.
c. Ask the patient if he has noticed any side effects from taking this herbal supplement.
d. Tell the patient to continue to take the herbal supplement up to the day before surgery.

Answer 18

a. Inform the surgeon, since the procedure may need to be rescheduled

Rationale: Ginkgo can increase bleeding during and after surgery. The surgeon should determine how long it should be discontinued before surgery.

Question 19

A 17-year-old patient with a leg fracture is scheduled for surgery. She reports that she is living with a friend and is an emancipated minor. She has a statement from the court for verification. Which intervention is most appropriate?

a. Witness the permit after consent is obtained by the surgeon.
b. Call a parent or legal guardian to sign the permit, since the patient is under 18.
c. Obtain verbal consent, since written consent is not necessary for emancipated minors.
d. Investigate your state’s nurse practice act related to emancipated minors and informed consent.

Answer 19

a. Witness the permit after consent is obtained by the surgeon.

Rationale: An emancipated minor may sign his or her own permit. The nurse should be available to witness the signature, but no further action is required.

Question 20

-ectomy

Answer 20

Excision or removal of

E.g., appendectomy

Question 21

-lysis

Answer 21

Destruction of

E.g., electrolysis

Question 22

-orrhaphy

Answer 22

Repair or suture of

E.g., herniorraphy

Question 23

-oscopy

Answer 23

Looking into

E.g., endoscopy

Question 24

-ostomy

Answer 24

Creation of opening into

E.g., colostomy

Question 25

-otomy

Answer 25

Cutting into or incision of

E.g., tracheotomy

Question 26

-plasty

Answer 26

Repair or reconstruction of

E.g., mammoplasty

Question 27

Three purposes of the preoperative interview

Answer 27

1. Obtain the patient’s health information
2. Provide and clarify information about the planned surgery, including anesthesia
3. Assess the patient’s emotional state and readiness for surgery, including his or her expectations about surgical outcomes

Question 28

Herbal products and surgery

Answer 28

• Astragalus and ginseng - increase blood pressure before and during surgery
• Garlic, vitamin E, ginkgo, fish oils - can increase bleeding
• Kava and valerian - cause excess sedation

In general, discontinue all herbal supplements 2 to 3 weeks before any surgical procedure

HELPFUL HERBS AND VITAMINS

• Ginger - useful for preventing nausea associated with anesthesia
• Arnica - useful in soft tissue healing
• Multivitamins can be taken until day before surgery. Taking them on day of surgery on empty stomach can contribute to nausea and vomiting after surgery

Question 29

Interaction of current medications and anasthetics

Answer 29

• Certain antidepressants can potentiate effect of opioids, agents that can be used for anesthesia
• Antihypertensive drugs may predispose patient to shock from combined effect of drug and vasodilator effect of some anesthetic agents
• Insulin or oral hypoglycemic agents may require dose or agent adjustments during perioperative period because of body metabolism, decreased oral intake, stress, and anesthesia
• Antiplatelet drugs (e.g. aspirin, clopidogrel) and NSAIDs inhibit platelet aggregation and may contribute to post-op bleeding
• Long-term anticoagulation therapy have options: (1) continue therapy, (2) withhold therapy for a time before/after surgery, or (3) withhold therapy and start subQ or IV heparin therapy during perioperative period

Question 30

A break in sterile technique occurs during surgery when the scrub nurse touches

a. the mask with sterile gloved hands
b. sterile gloved hands to the gown at chest level.
c. the drape at the incision site with sterile gloved hands.
d. the lower arm to the instruments on the instrument tray.

Answer 30

a. the mask with sterile gloved hands

The mask covering the face is not considered sterile and if in contact with sterile gloved hands, it contaminates the gloves. The gown is at chest level and to 2 inches above the elbows is considered sterile, as is the drape placed at the surgical area.

Question 31

During surgery, a patient has a nursing diagnosis of risk for perioperative positioning injury. What is a common risk factor for this nursing diagnosis?

a. Skin lesions
b. Break in sterile technique
c. Musculoskeletal deformities
d. Electrical or mechanical equipment failure

Answer 31

c. Musculoskeletal deformities

Musculoskeletal deformities can be a risk factor for positioning injuries and require special padding and support on the operating table. Skin lesions and break in sterile technique are risk factors for infection and electrical or mechanical equipment failure may lead to other types of injury.

Question 32

At the end of the surgical procedure, the perioperative nurse evaluates the patient’s response to the nursing care delivered during the perioperative period. What reflects a positive outcome related to the patient’s physical status?

a. The patient’s right to privacy is maintained
b. The patient’s care is consistent with the perioperative plan of care.
c. The patient receives consistent and comparable care regardless of setting.
d. The patient’s respiratory function is consistent with or improved from baseline levels established preoperatively.

Answer 32

d. The patient’s respiratory function is consistent with or improved from baseline levels established preoperatively.

Question 33

Phases of postanesthesia care

Answer 33

Phase I:

• Care during immediate postanesthesia period
• Upon admission to PACU, ACP gives complete postanesthesia admission report
• ECG and more intense monitoring (e.g., arterial BP monitoring, mechanical ventilation)
• Goal: Prepare patient to transfer to Phase II or inpatient unit

Phase II:

• Ambulatory surgery patients
• Goal: Prepare for transfer to extended observation, home, or extended care facility

Extended Observation:

• Extended care or observation unit
• Goal: Prepare patient for self-care

Question 34

What does progression of patients through various phases of care in a postanesthesia care unit (PACU) primarily depend on?

a. Condition of patient
b. Type of anesthesia used
c. Preference of surgeon
d. Type of surgical procedure

Answer 34

a. Condition of patient

Although some surgical procedures and drug administration require more intensive postanesthesia care, how fast and through which levels of care patients are moved depend on the condition of the patient. A physiologically unstable outpatient may stay an extended time in Phase I, whereas a patient requiring hospitalization but who is stable and recovering may well be transferred quickly to an impatient unit.

Question 35

Upon admission of a patient to the PACU, the nurse’s priority assessment is

a. vital signs.
b. surgical site.
c. respiratory adequacy.
d. level of consciousness.

Answer 35

c. respiratory adequacy

Physiologic status of the patient is always prioritized with regard to airway, breathing, and circulation, and respiratory adequacy is the first assessment priority of the patient on admission to the PACU from the operating room. Following assessment of respiratory function, cardiovascular, neurologic, and renal function should be assessed as well as the surgical site.

Question 36

How is the initial information given to the PACU nurses about the surgical patient?

a. A copy of the written operative report
b. A verbal report from the circulating nurse
c. A verbal report from the anesthesia care provider (ACP)
d. An explanation of the surgical from the surgeon

Answer 36

c. A verbal report from the anesthesia care provider (ACP)

The admission of the patient to the PACU is a joint effort between the ACP, who is responsible for supervising the postanesthesia recovery of the patient, and the PACU nurse, who provides care during anesthesia recovery. The ACP gives a verbal report that presents the details of the surgical and anesthetic course, preoperative conditions influencing the surgical and anesthetic outcome, and PACU treatment plans to ensure patent safety and continuity of care.

Question 37

To prevent agitation during the patient’s recovery during anesthesia, when should the nurse begin orientation explanations?

a. When the patient is awake
b. When the patient first arrives in the PACU
c. When the patient becomes agitated or frightened
d. When the patient can be aroused and recognizes where he or she is

Answer 37

b. When the patient first arrives in the PACU

Even before patients awaken from anesthesia, their sense of hearing returns and all activities should be explained by the nurse from the time of admission to the PACU to assist in orientation and decrease confusion.

Question 38

What is included in the routine assessment of the patient’s cardiovascular function on admission to the PACU?

a. Monitoring arterial blood gases
b. Electrocardiographic (ECG) monitoring
c. Determining fluid and electrolyte status
d. Direct arterial blood pressure monitoring

Answer 38

b. Electrocardiographic (ECG) monitoring

ECG monitoring is performed on patients to assess initial cardiovascular problems during anesthesia recovery. Fluid and electrolyte status is an indication of renal function and determinations of arterial blood gases and direct arterial blood pressure monitoring are used only in special cardiovascular or respiratory problems.

Question 39

With what are the postoperative respiratory complications of atelectasis and aspirations of gastric contents associated?

a. Hypoxemia
b. Hypercapnia
c. Hypoventilation
d. Airway obstruction

Answer 39

a. Hypoxemia

Hypoxemia occurs with atelectasis and aspiration as well as pulmonary edema, pulmonary embolism, and broncospasm. Hypercapnia is caused by decreased removal of CO2 from the respiratory system that could occur with airway obstruction or hypoventilation. Hypoventilation may occur with depression of central respiratory drive, poor respiratory muscle tone due to disease or anesthesia, mechanical restriction, or pain. Airway obstruction could occur with the tongue blocking the airway, restrained thick secretions, laryngospasm, or laryngeal edema.

Question 40

To prevent airway obstruction in the postoperative patient who is unconscious or semiconscious, what will the nurse do?

a. Encourage deep breathing
b. Elevate the head of the bed
c. Administer oxygen per mask
d. Position the patient in a side-lying position

Answer 40

d. Position the patient in a side-lying position

An unconscious or semiconscious patient should be placed in a lateral position to protect the airway from obstruction by the tongue. Deep breathing and elevation of the head of the bed are implemented to facilitate gas exchange when the patient is responsive. Oxygen administration is often used but the patient must first have a patent airway.

Question 41

To promote effective coughing, deep breathing, and ambulation in the postoperative patient, what is most important for the nurse to do?

a. Teach the patient controlled breathing
b. Explain the rationale for these activities
c. Provide adequate and regular pain medication
d. Use an incentive spirometer to motivate the patient

Answer 41

c. Provide adequate and regular pain medication

Incisional pain is often the greatest deterrent to patient participation in effective ventilation and ambulation and adequate and regular analgesic medications should be provide to encourage these activities. Controlled breathing may help the patient to manage pain but does not promote coughing and deep breathing. Explanations and use of an incentive spirometer help to gain patient participation but are more effective if pain is controlled.

Question 42

While assessing a patient in the PACU, the nurse finds that the patient’s blood pressure is below the preoperative baseline. The nurse determines that the patient has residual vasodilating effects of anesthesia when what is assessed?

a. A urinary output of >30 mL/hr
b. An oxygen saturation of 88%
c. A normal pulse with warm, dry, pink skin
d. A narrowing pulse pressure with normal pulse

Answer 42

c. A normal pulse with warm, dry, pink skin

Hypotension with normal pulse and skin assessment is typical of residual vasodilating effects of anesthesia and requires continued observation. An oxygen saturation of 88% indicates hypoxemia, whereas a narrowing pulse pressure accompanies hypoperfusion. A urinary output >30 mL/hr is desirable and indicates normal renal function.

Question 43

A patient in the PACU has emergence delirium manifested by agitation and thrashing. What should the nurse assess for first in the patient?

a. Hypoxemia
b. Neurologic injury
c. Distended bladder
d. Cardiac dysrhythmias

Answer 43

a. Hypoxemia

The most common cause of emergence delirium is hypoxemia and initial assessment should evaluate respiratory function. When hypoxemia is ruled out, other causes, such as a distended bladder, pain, and fluid and electrolyte disturbances, should be considered. Delayed awakening may result from neurologic injury and cardiac dysrhythmias most often result from specific respiratory, electrolyte, or cardiac problems.

Question 44

The PACU nurse applies warm blankets to a postoperative patient who is shivering and has a body temperature of 96.0F (35.6C). What treatment also may be used to treat the patient?

a. Oxygen
b. Vasodilating drugs
c. Antidysrhythmic drugs
d. Analgesics or sedatives

Answer 44

a. Oxygen

During hypothermia, oxygen demand is increased and metabolic processes slow down. Oxygen therapy is used to treat the increased demand for oxygen. Antidysrhythmics and vasodilating drugs would only be used if the hypothermia caused symptomatic cardiac dysrhythmias and vasoconstriction. Sedatives and analgesics are not indicated for hypothermia.

Question 45

Which patient is ready for discharge from Phase I PACU care to the clinical unit?

a. Arouses easily, pulse is 112 bpm, respiratory rate is 24, dressing is saturated, SaO2 is 88%
b. Difficult to arouse, pulse is 52, respiratory rate is 22, dressing is dry and intact, SaO2 is 91%
c. Awake, vital signs stable, dressing is dry and intact, no respiratory depression, SaO2 is 92%
d. Arouses, blood pressure (BP) higher than preoperative preoperatve and respiratory rate is 10, no excess bleeding, SaO2 is 90%

Answer 45

c. Awake, vital signs stable, dressing is dry and intact, no respiratory depression, SaO2 is 92%

On initial assessment in PACU, the airway, breathing, and circulation (ABC) status is assessed using a standardized tool that usually includes consciousness, respiration, oxygen saturation, circulation, and activity. Increased or decreased respiratory rate, hypertension, and an SaO2 below 90% indicate inadequate oxygenation that will be treated or managed in the PACU before discharging the patient to the next phase.

Question 46

For which nursing diagnoses or collaborative problems common in postoperative patients has ambulation found to be an appropriate intervention (select all that apply)?

a. Impaired skin integrity related to incision
b. Impaired mobility related to decreased muscle strength
c. Risk for aspiration related to decreased muscle strength
d. Ineffective airway clearance related to decreased respiratory excursion
e. Constipation related to decreased physical activity and impaired gastrointestinal (GI) motility
f. Venous thromboembolism related to dehydration, immobility, vascular manipulation, or injury

Answer 46

b, d, e, f (impaired mobility related to decreased muscle strength; ineffective airway clearance related to decreased respiratory excursion; constipation related to decreased physical activity and impaired gastrointestinal (GI) motility; venous thromboembolism related to dehydration, immobility, vascular manipulation, or injury)

These problems are improved with ambulation. Other collaborative problems could be potential complications: urinary retention, atelectasis, and pneumonia.

Question 47

A patient who had major surgery is experiencing emotional stress as well as physiologic stress from the effects of surgery. What can this stress cause?

a. Diuresis
b. Hyperkalemia
c. Fluid retention
d. Impaired blood coagulation

Answer 47

c. Fluid retention

The stress response causes fluid retention during the first 1 to 3 days postoperatively and fluid overload is possible during this time. Fluid retention results from secretion and release of antidiuretic hormone (ADH) and adrenocorticotropic hormone (ACTH) by the pituitary and activation of the renin-angiotensin-aldosterone system (RAAS). ACTH stimulates the adrenal cortex to secrete cortisol and aldosterone. The RAAS increases aldosterone release, which also increases fluid retention. Aldosterone causes renal potassium loss with possible hypokalemia and blood coagulation is enhanced by cortisol.

Question 48

In addition to ambulation, which nursing intervention could be implemented to prevent or treat the postoperative complication of syncope?

a. Monitor vital signs after ambulation
b. Do not allow the patient to eat before ambulation
c. Slowly progress to ambulation with slow changes in position
d. Have the patient deep breathe and cough before getting out of bed

Answer 48

c. Slowly progress to ambulation with slow changes in position

Slow progression to ambulation by slowly changing the patient’s position will help prevent syncope. Monitoring vital signs after walking will not prevent or treat syncope. Monitor the patient’s pulse and blood pressure (BP) before, during, and after position changes. Elevate the patient’s head, then slowly have the patient dangle, then stand by the bed to help determine if the patient is safe for walking. Eating will not have an effect on syncope. Deep breathing and coughing will not decrease syncope, although it will prevent respiratory complications.

Question 49

Which tubes drain gastric contents (select all that apply)?

a. T-tube
b. Hemovac
c. Nasogastric tube
d. Indwelling catheter
e. Gastrointestinal tube

Answer 49

c, e (nasogastric tube, gastrointestinal tube)

The nasogastric tube and gastrointestinal tube drain gastric contents. The T-tube drains bile, the Hemovac drains blood from a surgical site, and the indwelling catheter drains urine from the bladder.

Question 50

Which drainage is drained with a Hemovac?

a. Bile
b. Urine
c. Gastric contents
d. Wound drainage

Answer 50

d. Wound drainage

Bile is drained by a T-tube, urine is drained by an indwelling urinary catheter, and gastric contents are drained by a nasogastric tube or a gastrointestinal tube.

Question 51

The nurse notices drainage on the surgical dressing when the patient is transferred from the PACU to the clinical unit. In what order of priority should the nurse do the following actions? Number the options with 1 for the first action and 5 for the last action.
____ a. Reinforce the surgical dressing.
____ b. Change the dressing and assess the wound as ordered.
____ c. Notify the surgeon of excessive drainage type and amount.
____ d. Recall the report from PACU for the number and type of drains in use.
____ e. Note and record the type, amount, and color and odor of the drainage.

Answer 51

1: d. Recall the report from PACU for the number and type of drains in use.
2: a. Reinforce the surgical dressing.
3: e. Note and record the type, amount, and color and odor of the drainage.
4: c. Notify the surgeon of excessive drainage type and amount.
5: b. Change the dressing and assess the wound as ordered.

The nurse must be aware of the drains, if used, and the type of surgery to help predict the expected drainage. Dressings over surgical sites are initially removed by the surgeon unless otherwise specified and should not be changed, although reinforcing the dressing is appropriate. Some drainage is expected for most surgical wounds and the drainage should be evaluated and recorded to establish a baseline for continuing assessment. The surgeon should be notified of excessive drainage. Dressings will then be changed as ordered with assessment for infection being done as well.

Question 52

Thirty-six hours postoperatively a patient has a temperature of 100F (37.8C). What is the most likely cause of this temperature elevation?

a. Dehydration
b. Wound infection
c. Lung congestion and atelectasis
d. Normal surgical stress response

Answer 52

d. Normal surgical stress response

During the first 24 to 48 postoperative hours, temperature elevations to 100.4F (38C) are a result of the inflammatory response to surgical stress. Dehydration and lung congestion or atelectasis in the first 2 days will cause a temperature elevation above 100.4F (38C). Wound infections usually do not become evident until 3 to 5 days postoperatively and manifest with temperatures above 100F (37.8C).

Question 53

The health care provider has ordered IV morphine q2-4hr PRN for a patient following major abdominal surgery. When should the nurse plan to administer the morphine?

a. Before all planned painful activities
b. Every 2 to 4 hours during the first 48 hours
c. Every 4 hours as the patient requests the medication
d. After assessing the nature and intensity of the patient’s pain

Answer 53

d. After assessing the nature and intensity of the patient’s pain

Before administering all analgesic medications, the nurse should first assess the nature and intensity of the patient’s pain to determine if the pain is expected, prior doses of the medication have been effective, and any undesirable side effects are occurring. The administration of PRN analgesic medication is based on the nursing assessment. If possible, pain medication should be in effect during painful activities, but activities may be scheduled around medication administration.

Question 54

What should be included in the instructions given to the postoperative patient before discharge?

a. Need for follow-up care with home care nurses
b. Directions for maintaining routine postoperative diet
c. Written information about self-care during recuperation
d. Need to restrict all activity until surgical healing is complete

Answer 54

c. Written information about self-care during recuperation

All postoperative patients need discharge instructions regarding what to expect and what self-care can be assumed during recovery. Diet, activities, follow-up care, symptoms to report, and instructions about medications are individualized to the patient.

Question 55

When a patient is admitted to the PACU, what are the priority interventions the nurse performs?

a. Assess the surgical site, noting presence and character of drainage.
b. Assess the amount of urine output and presence of bladder distention.
c. Assess for airway patency and quality of respirations, and obtain vital signs.
d. Review results of intraoperative laboratory values and medications received.

Answer 55

c. Assess for airway patency and quality of respirations, and obtain vital signs

Rationale: Assessment in the postanesthesia care unit (PACU) begins with evaluation of the airway, breathing, and circulation (ABC) status of the patient. Identification of inadequate oxygenation and ventilation or respiratory compromise necessitates prompt intervention.

Question 56

A patient is admitted to the PACU after major abdominal surgery. During the initial assessment the patient tells the nurse he thinks he is going to “throw up.” A priority nursing intervention would be to

a. increase the rate of the IV fluids.
b. obtain vital signs, including O2 saturation.
c. position patient in lateral recovery position.
d. administer antiemetic medication as ordered.

Answer 56

c. position patient in lateral recovery position

If the patient is nauseated and may vomit, place the patient in a lateral recovery position to keep the airway open and reduce the risk of aspiration if vomiting occurs.

Question 57

After admission of the postoperative patient to the clinical unit, which assessment data requires the most immediate attention?

a. Oxygen saturation of 85%
b. Respiratory rate of 13/min
c. Temperature of 100.4F (38C)
d. Blood pressure of 90/60 mmHg

Answer 57

a. Oxygen saturation of 85%

During the initial assessment, identify signs of inadequate oxygenation and ventilation. Pulse oximetry monitoring is initiated because it provides a noninvasive means of assessing the adequacy of oxygenation. Pulse oximetry may indicate low oxygen saturation (

Question 58

A 70-kg postoperative patient has an average urine output of 25 mL/hr during the first 8 hours. The priority nursing intervention(s) given this assessment would be to

a. perform a straight catheterization to measure the amount of urine in the bladder.
b. notify the physician and anticipate obtaining blood work to evaluate renal function.
c. continue to monitor the patient because this is a normal finding during this time period.
d. evaluate the patient’s fluid volume status since surgery and obtain a bladder ultrasound.

Answer 58

d. evaluate the patient’s fluid volume status since surgery and obtain a bladder ultrasound

Because of the possibility of infection associated with catheterization, the nurse should first try to validate that the bladder is full. The nurse should consider fluid intake during and after surgery and should determine bladder fullness by percussion, by palpation, or by a portable bladder ultrasound study to assess the volume of urine in the bladder and avoid unnecessary catheterization.

Question 59

Discharge criteria for the Phase II patient include (select all that apply)

a. no nausea or vomiting.
b. ability to drive self home.
c. no respiratory depression.
d. written discharge instructions understood.
e. opioid pain medication given 45 minutes ago.

Answer 59

c, d, e (no respiratory depression, written discharge instructions understood, opioid pain medication given 45 minutes ago)

Phase II discharge criteria that must be met include the following: all PACU discharge criteria (Phase I) met; no intravenous opioid drugs administered for the past 30 minutes; patient’s ability to void (if appropriate with regard to surgical procedure or orders); patient’s ability to ambulate if it is not contraindicated; presence of a responsible adult to accompany or drive patient home; and written discharge instructions given and understood.

Question 60

The nurse requests the client to sign a surgical informed consent form for an emergency appendectomy. Which statement by the client indicates further teaching is required?

1. “I will be glad when this is over so I can go home today.”
2. “I will not be able to eat or drink anything prior to my surgery.”
3. “I can practice relaxing by listening to my favorite music.”
4. “I will need to get up and walk as soon as possible.”

Answer 60

1. “I will be glad when this is over so I can go home today.”
2. The client will be in the hospital for a few days. This is not a day-surgery procedure. The client needs more teaching.
3. Clients are NPO (nothing by mouth) prior to surgery to prevent aspiration during and after anesthesia. The client understands the teaching.
4. Listening to music and other relaxing techniques can be used to alleviate anxiety and pain. This statement indicates the client understands the teaching.
5. Clients are encouraged to get out of bed as soon as possible and progress until a return to daily activity is achieved. The client understands the teaching.

Question 61

The day surgery nurse is caring for the client who had a laparoscopic cholescystectomy. Which task would be most appropriate for the nurse to delegate to unlicensed assistive personnel (UAP)?

1. Empty and measure the client’s T-tube drainage
2. Discontinue the client’s intravenous fluid.
3. Assist the client who has been discharged to the car.
4. Check the client’s bandages on the abdomen.

Answer 61

3. Assist the client who has been discharged to the car.

The UAP could escort the client to the car, because the client is stable.

Question 62

The client with varicose veins is 8 hours postoperative vein ligation. Which priority intervention should the nurse implement?

1. Instruct the client to remain on strict bedrest.
2. Maintain pressure bandages on the affected leg.
3. Provide the client with a regular diet.
4. Administer the prophylactic intravenous antibiotic.

Answer 62

1. Instruct the client to remain on strict bedrest.

Because the saphenous vein is removed during vein ligation, standing and sitting are prohibited during the initial recovery period to prevent increased pressure in the lower extremities. The client is on strict bedrest for 24 hours, which is the priority intervention because standing could destroy the surgical procedure.

Question 63

Which intervention should the nurse implement for the client who has had an abdominal perineal resection for cancer of the colon?

1. Provide meticulous skin care to stoma.
2. Assess the client’s flank incision.
3. Irrigate the J-P drains every shift.
4. Position the client in high-Fowler’s position.

Answer 63

1. Provide meticulous skin care to stoma.

Colostomy stomas are portions of the large intestines pulled through the abdominal wall through which feces exits the body. Feces can be irritating to the abdominal skin, so careful and thorough skin care is needed.

Assess the client’s flank incision. – There are midline and perineal incisions, not flank incisions.

Irrigate the J-P drains every shift. – Jackson-Pratt (J-P) drains are emptied every shift, but they are not irrigated.

Question 64

The client 3 hours postoperative left above-the-knee amputation (AKA) is complaining of pain in the left foot. Which intervention should the nurse implement first?

1. Do not administer pain medication because there is no left foot.
2. Assess the client to rule out any postoperative complications.
3. Check the client’s medication administration record.
4. Medicate the client with an intravenous narcotic pain medication.

Answer 64

2. Assess the client to rule out any postoperative complications.

Phantom pain is caused by severing the peripheral nerves. The pain is real to the client, but pain could be expected or a complication so the nurse should first assess a client.

Question 65

Which problem would be highest priority for the client who had an open cholecystectomy surgery?

1. Altered elimination: diarrhea
2. Alteration in skin integrity
3. Risk for infection
4. Risk for respiratory complications

Answer 65

4. Risk for respiratory complications

The surgical incision for an open cholecystectomy is just below the diaphragm, and the client has difficulty taking deep breaths due to pain. The client is at high risk for developing pneumonia. Remember Maslow’s Hierarchy of Needs.

Question 66

The client has an eviscerated abdominal wound. Which intervention should the nurse implement first?

1. Notify the client’s surgeon immediately.
2. Assess the client’s vital signs.
3. Prepare the client for emergency surgery.
4. Apply a sterile normal saline dressing.

Answer 66

4. Apply a sterile normal saline dressing.

Evisceration is a life-threatening condition in which the abdominal contents have protruded through the abdominal incision. The nurse must protect the bowel from the environment by placing a sterile normal saline dressing on it. The saline prevents the intestines from drying out and becoming necrotic.

Question 67

The client who has undergone a craniotomy for a brain tumor has an intake of 1,400 mL and a urinary output of 3,800 mL for a 12-hour shift. Which intervention should the nurse implement first?

1. Document the findings in the chart as normal.
2. Increase the client’s intravenous rate.
3. Monitor the client’s sodium level.
4. Prepare to administer vasopressin, an antidiuretic hormone.

Answer 67

4. Prepare to administer vasopressin, an antidiuretic hormone.

Diabetes insipidus is a complication of a craniotomy and is exhibited by a large amount of dilute urine. The treatment is administering the antidiuretic hormone, vasopressin.

Question 68

The client diagnosed with L3-L4 disc degeneration has undergone an laminectomy. Which intervention should the nurse implement?

1. Position the client in the prone position.
2. Assess the client’s respiratory status.
3. Turn the client using the log-rolling method.
4. Monitor the client’s pelvic traction.

Answer 68

3. Turn the client using the log-rolling method.

The nurse should turn the client as a “log” to prevent undue strain on the surgical site. Two or three staff members should turn the client in one movement.

Question 69

Which diagnosis should the nurse identify as priority for the client who is 1 day postoperative open-heart surgery?

1. Alteration in comfort related to incisional pain.
2. Altered respiratory status related to mechanical ventilation.
3. Fluid and electrolyte imbalance related to increased blood loss.
4. High risk for complications related to knowledge deficit of postoperative care.

Answer 69

2. Altered respiratory status related to mechanical ventilation.

The client is on a mechanical ventilator which is an altered way of breathing; airway is priority according to Maslow’s Hierarchy of Needs.

Question 70

The nurse in the holding area of the surgery department is interviewing a client who requests to keep his religious medal on during surgery. Which intervention should the nurse implement?

1. Notify the surgeon about the client’s request to wear the medal.
2. Tape the medal to the client and allow the client to wear the medal.
3. Request the family member take the medal prior to surgery.
4. Explain taking the medal to surgery is against the policy.

Answer 70

2. Tape the medal to the client and allow the client to wear the medal.

Question 71

The nurse must obtain surgical consent forms for the scheduled surgery. Which client would not be able to consent legally to surgery?

1. The 65-year-old client who cannot read or write.
2. The 30-year-old client who does not understand English.
3. The 16-year-old client who has a fractured ankle.
4. The 80-year-old client who is not oriented to the day.

Answer 71

3. The 16-year-old client who has a fractured ankle.

Question 72

The nurse is preparing a client for surgery. Which intervention should the nurse implement first?

1. Check the permit for the spouse’s signature.
2. Take and document intake and output.
3. Administer the “on call” sedative.
4. Complete the preoperative checklist.

Answer 72

4. Complete the preoperative checklist.

Question 73

The nurse is interviewing a surgical client in the holding area. Which information should the nurse report to the anesthesiologist? Select all that apply.

1. The client has loose, decayed teeth.
2. The client is experiencing anxiety.
3. The client smokes two (2) packs of cigarettes a day.
4. The client has had a chest x-ray which does not show infiltrates.
5. The client reports using herbs.

Answer 73

1. The client has loose, decayed teeth.
2. The client smokes two (2) packs of cigarettes a day.
3. The client reports using herbs.

Question 74

Which task would be most appropriate for the nurse to delegate to the unlicensed assistive personnel (UAP)?

1. Complete the preoperative checklist.
2. Assess the client’s preoperative vital signs.
3. Teach the client about coughing and deep breathing.
4. Assist the client to remove clothing and jewelry.

Answer 74

4. Assist the client to remove clothing and jewelry.

The UAP can remove clothing and jewelry.

Question 75

The nurse is assessing a client in the day surgery unit who states, “I am really afraid of having this surgery. I’m afraid of what they will find.” Which statement would be the best therapeutic response by the nurse?

1. “Don’t worry about your surgery. It is safe.”
2. “Tell me why you’re worried about your surgery.”
3. “Tell me about your fears of having this surgery.”
4. “I understand how you feel. Surgery is frightening.”

Answer 75

3. “Tell me about your fears of having this surgery.”

Question 76

The 68-year-old client scheduled for intestinal surgery does not have clear fecal contents after three (3) tap water enemas. Which intervention should the nurse implement first?

1. Notify the surgeon of the client’s status.
2. Continue giving enemas until clear.
3. Increase the client’s IV fluid rate.
4. Obtain STAT serum electrolytes.

Answer 76

1. Notify the surgeon of the client’s status.

Question 77

The nurse is caring for a male client scheduled for abdominal surgery. Which interventions should the nurse include in the plan of care? Select all that apply.

1. Perform passive range-of-motion exercises.
2. Discuss how to cough and deep breathe effectively.
3. Tell the client he can have a meal in the PACU.
4. Teach ways to manage postoperative pain.
5. Discuss events which occur in the post-anesthesia care unit.

Answer 77

2. Discuss how to cough and deep breathe effectively.

Question 78

The nurse is caring for a client scheduled for total hip replacement. Which behavior indicates the need for further preoperative teaching?

1. The client uses the diaphragm and abdominal muscles to inhale through the nose and exhale through the mouth.
2. The client demonstrates dorsiflexion of the feet, flexing of the toes, and moves the feet in a circular motion.
3. The client uses the incentive spirometer and inhales slowly and deeply so the piston rises to the preset volume.
4. The client gets out of bed by lifting straight upright from the waist and then swings both legs along the side of the bed.

Answer 78

4. The client gets out of bed by lifting straight upright from the waist and then swings both legs along the side of the bed.

Question 79

The nurse is completing a preoperative assessment on a male client who states, “I am allergic to codeine.” Which intervention should the nurse implement first?

1. Apply an allergy bracelet on the client’s wrist.
2. Label the client’s allergies on the front of the chart.
3. Ask the client what happens when he takes the codeine.
4. Document the allergy on the medication administration record.

Answer 79

3. Ask the client what happens when he takes the codeine.

Question 80

Which laboratory result would require immediate intervention by the nurse for the client scheduled for surgery?

1. Calcium 9.2 mg/dL.
2. Bleeding time 2 minutes.
3. Hemoglobin 15 g/dL.
4. Potassium 2.4 mEq/L.

Answer 80

4. Potassium 2.4 mEq/L.

Question 81

Which activities are the circulating nurse’s responsibilities in the operating room?

1. Monitor the position of the client, prepare the surgical site, and ensure the client’s safety.
2. Give preoperative medication in the holding area and monitor the client’s response to anesthesia.
3. Prepare sutures; set up the sterile field; and count all needles, sponges, and instruments.
4. Prepare the medications to administered by the anesthesiologist and change the tubing for the anesthesia machine.

Answer 81

1. Monitor the position of the client, prepare the surgical site, and ensure the client’s safety.

Question 82

The circulating nurse observes the surgical scrub technician remove a sponge from the edge of the sterile field with a clamp and place the sponge and clamp in a designated area. Which action should the nurse implement?

1. Place the sponge back where it was.
2. Tell the technician not to waste supplies.
3. Do nothing because this is the correct procedure.
4. Re-count all sponges.

Answer 82

3. Do nothing because this is the correct procedure.

The technician followed the correct procedure. Sponges are counted to maintain client safety, so all sponges must be kept together to repeat the count before the incision site is sutured. The sponge must be removed, not used, and placed in the designated area to be counted later.

Question 83

Which violation of surgical asepsis would require immediate intervention by the circulating nurse?

1. Surgical supplies were cleaned and sterilized prior to the case.
2. The circulating nurse is wearing a long-sleeved sterile gown.
3. Masks covering the mouth and nose are being worn by the surgical team.
4. The scrub nurse setting up the sterile field is wearing artificial nails.

Answer 83

4. The scrub nurse setting up the sterile field is wearing artificial nails.

Question 84

The circulating nurse and the scrub technician find a discrepancy in the sponge count. Which action should the circulating nurse take first?

1. Notify the client’s surgeon.
2. Complete an occurrence report.
3. Contact the surgical manager.
4. Re-count all sponges.

Answer 84

4. Re-count all sponges.

A re-count of sponges may lead to the discovery of the cause of the presumed error. Usually it is just a miscount or a result of a sponge being placed in a location other than the sterile field, such as the floor or a lower shelf.

Question 85

What is the physical environment of a surgery suite primarily designed to promote?

a. Electrical safety
b. Medical and surgical asepsis
c. Comfort and privacy of the patient
d. Communication among the surgical team

Answer 85

b. Medical and surgical asepsis

Although all of the factors listed are important to the safety and well-being of the patient, the first consideration in the physical environment of the surgical suite is prevention of transmission of infection to the patient.

Question 86

When transporting an inpatient to the surgical department, which area is a nurse from another area of the hospital able to access?

a. Clean core
b. Holding area
c. Corridors of surgical suite
d. Unprepared operating room

Answer 86

b. Holding area

Persons in street clothes or attire other than surgical scrub clothing can interact with personnel of the surgical suite in unrestricted areas, such as the holding area, nursing station, control desk, or locker rooms. Only authorized personnel wearing surgical attire and hair covering are allowed in semirestricted areas, such as corridors, and masks must be worn in restricted areas, such as operating rooms and clean core and scrub sink areas.

Question 87

Which nursing actions are completed by the scrub nurse (select all that apply)?

a. Prepares instrument table
b. Documents intraoperative care
c. Remains in the sterile area of the OR
d. Checks mechanical and electrical equipment
e. Passes instruments to surgeon and assistants
f. Monitors blood and other fluid loss and urine output

Answer 87

a. Prepares instrument table
c. Remains in the sterile area of the OR
e. Passes instruments to surgeon and assistants

The circulating nurse documents intraoperative care, checks mechanical and electrical equipment, and monitors blood and other fluid loss and urine output.

Question 88

What is the primary goal of the circulating nurse during preparing of the operating room, transferring and positioning of the patient, and assisting the anesthesia team?

a. Avoiding any type of injury to the patient
b. Maintaining a clean environment for the patient
c. Providing for patient comfort and sense of well-being
d. Preventing breaks in aseptic technique by the sterile members of the team

Answer 88

a. Avoiding any type of injury to the patient

The protection of the patient from injury in the operating room environment is maintained by the circulating nurse by ensuring functioning equipment, preventing falls and injury during transport and transfer, monitoring asepsis, and providing supportive care for the anesthetized patient.

Question 89

What short-acting barbiturates are most commonly used for induction of general anesthesia (select all that apply)?

a. Nitrous oxide
b. Propofol (Diprivan)
c. Isoflurane (Florane)
d. Thiopental sodium (Pentothal)
e. Sodium methohexital (Brevital)

Answer 89

d. Thiopental sodium (Pentothal)
e. Sodium methohexital (Brevital)

Nitrous oxide is a weak gaseous anesthetic. Propofol (Diprivan) is a nonbarbiturate hypnotic that has a rapid onset and may be used for induction. Isoflurane (Forane) is a volatile liquid inhalation agent.

Question 90

Because of the rapid elimination of volatile liquids used for general anesthesia, what should the nurse anticipate the patient will need early in the anesthesia recovery period?

a. Warm blankets
b. Analgesic medication
c. Observation for respiratory depression
d. Airway protection in anticipation of vomiting

Answer 90

b. Analgesic medication

The volatile liquid inhalation agents have very little residual analgesia and patients experience early onset of pain when the agents are discontinued. These agents are associated with a low incidence of nausea and vomiting. Prolonged respiratory depression is not common because of their rapid elimination. Hypothermia is not related to use of these agents but they may precipitate malignant hyperthermia in conjunction with neuromuscular blocking agents.

Question 91

What is the primary advantage of the use of midazolam (Versed) as an adjunct to general anesthesia?

a. Amnestic effect
b. Analgesic effect
c. Prolonged action
d. Antiemetic effect

Answer 91

a. Amnestic effect

Midazolam (Versed) is a rapid, short-acting sedative-hypnotic benzodiazepine that is used to prevent recall of events under anesthesia because of its amnestic properties.

Question 92

The patient will be placed under moderate sedation to allow realignment of a fracture in the emergency department. When the family asks about this anesthesia, what should the nurse tell them?

a. Includes inhalation agents
b. Induces high levels of sedation
c. Frequently used for traumatic injuries
d. Patient remains responsive and breathes without assistance

Answer 92

d. Patient remains responsive and breathes without assistance

Moderate sedation uses sedative, anxiolytic, and/or analgesic medications. Inhalation agents are not used. It is not expected to induce levels of sedation that would impair a patient’s ability to protect the airway.

Question 93

What condition should the nurse anticipate that might occur during epidural and spinal anesthesia?

a. Spinal headache
b. Hypotension and bradycardia
c. Loss of consciousness and seizures
d. Downward extension of nerve block

Answer 93

b. Hypotension and bradycardia

During epidural and spinal anesthesia, a sympathetic nervous system blockade may be occur that results in hypotension, bradycardia, and nausea and vomiting. A spinal headache may occur after, not during, spinal anesthesia and loss of consciousness and seizures are indicative of IV absorption overdose. Upward extension of the effect of the anesthesia results in inadequate respiratory excursion and apnea.

Question 94

Match the methods of local anesthetic administration with their descriptions.
1. Nerve block 2. IV nerve block 3. Spinal block 4. Epidural block 5. Local infiltration
____ a. Injection of agent into subarachnoid space
____ b. Injection of anesthetic agent directly into tissues
____ c. Injection of a specific nerve with an anesthetic agent
____ d. Injection of anesthetic agent into space around the vertebrae
____ e. Injection of agent into veins of extremity after limb is exsanguinated

Answer 94

3. Spinal block – Injection of agent into subarachnoid space
4. Local infiltration – Injection of anesthetic agent directly into tissues
5. Nerve block – Injection of a specific nerve with an anesthetic agent
6. Epidural block – Injection of anesthetic agent into space around the vertebrae
7. IV nerve block – Injection of agent into veins of extremity after limb is exsanguinated

Question 95

A priority nursing intervention to assist a preoperative patient in coping with fear of postoperative pain would be to

a. inform the patient that pain medication will be available.
b. teach the patient to use guided imagery to help manage pain.
c. describe the type of pain expected with the patient’s particular surgery.
d. explain the pain management plan, including the use of a pain rating scale.

Answer 95

d. explain the pain management plan, including the use of a pain rating scale.

If a patient has fear of pain and discomfort after surgery, the nurse should reassure the patient that a pain management plan will be in place. The nurse should teach the patient to ask for medications after surgery when pain is present and assure him or her that taking these medications will not contribute to an addiction. The nurse should instruct the patient on the use of some form of pain rating scale (e.g., 0 to 10, FACES) and to request pain medication before the pain becomes severe.

Question 96

A patient is scheduled for surgery requiring general anesthesia at an ambulatory surgical center. The nurse asks him when he ate last. He replies that he had a light breakfast a couple of hours before coming to the surgery center. What should the nurse do first?

a. Tell the patient to come back tomorrow, since he ate a meal.
b. Proceed with the preoperative checklist, including site identification.
c. Notify the anesthesia care provider of when and what the patient last ate.
d. Have the patient void before administering any preoperative medications.

Answer 96

c. Notify the anesthesia care provider of when and what the patient last ate.

The nothing-by-mouth (NPO) protocol of each surgical facility should be followed. Restriction of fluids and food is designed to minimize the potential risk of pulmonary aspiration and to decrease the risk of postoperative nausea and vomiting. If a patient has not followed the NPO instructions, surgery may be delayed or canceled. The nurse should notify the anesthesia care provider immediately.

Question 97

A patient who normally takes 40 units of glargine insulin (long acting) at bedtime asks the nurse what to do about her dose the night before surgery. The best response would be to have her

a. skip her insulin altogether the night before surgery.
b. take her usual dose at bedtime and eat a light breakfast in the morning.
c. eat a moderate meal before bedtime and then take half her usual insulin dose.
d. get instructions from her surgeon or health care provider on any insulin adjustments.

Answer 97

d. get instructions from her surgeon or health care provider on any insulin adjustments.

Insulin is not usually omitted completely. The patient should obtain instructions from her health care provider or surgeon about any dosage adjustments that she should make the day before and the morning of surgery (if applicable).

Question 98

Preoperative considerations for older adults include (select all that apply)

a. only using large-print educational materials.
b. speaking louder for patients with hearing aids.
c. recognizing that sensory deficits may be present.
d. providing warm blankets to prevent hypothermia.
e. teaching important information early in the morning.

Answer 98

c. recognizing that sensory deficits may be present.
d. providing warm blankets to prevent hypothermia.

Many older adults have sensory deficits. Preoperative and operating rooms are cool; warm blankets should be provided as needed.

Question 99

Five minutes after receiving a preoperative sedative medication by IV injection, a patient asks to get up to go to the bathroom to urinate. What is the most appropriate action for the nurse to take?

a. Offer the patient to use the urinal/bedpan after explaining the need to maintain safety.
b. Assist the patient to the bathroom and stay next to the door to assist patient back to bed when done.
c. Allow the patient to go to the bathroom since the onset of the medication will be more than 5 minutes.
d. Ask the patient to hold the urine for a short period since a urinary catheter will be placed in the operating room.

Answer 99

a. Offer the patient to use the urinal/bedpan after explaining the need to maintain safety.

The prime issue after administration of either sedative or opioid analgesic medications is safety. Because the medications affect the central nervous system, the patient is at risk for falls and should not be allowed out of bed, even with assistance. The other options would not be safe for the patient.

Question 100

While performing preoperative teaching, the patient asks when she needs to stop drinking water before the surgery. Based on the most recent practice guidelines established by the American Society of Anesthesiologists, the nurse tells the patient that

a. she must be NPO after breakfast.
b. she needs to be NPO after midnight.
c. she can drink clear liquids up to 2 hours before surgery.
d. she can drink clear liquids up until she is moved to the OR.

Answer 100

c. she can drink clear liquids up to 2 hours before surgery.

Practice guidelines for preoperative fasting state the minimum fasting period for clear liquids is 2 hours. Evidence-based practice no longer supports the long-standing practice of requiring patients to be NPO after midnight.

Question 101

The nurse is admitting a patient to the same-day surgery unit. The patient tells the nurse that he was so nervous he had to take kava last evening to help him sleep. Which nursing action would be most appropriate?

a. Tell the patient that using kava to help sleep is often helpful.
b. Inform the anesthesiologist of the patient’s recent use of kava.
c. Tell the patient that the kava should continue to help him relax before surgery.
d. Inform the patient about the dangers of taking herbal medicines without consulting his health care provider.

Answer 101

b. Inform the anesthesiologist of the patient’s recent use of kava.

Kava may prolong the effects of certain anesthetics. Thus the anesthesiologist needs to be informed of recent ingestion of this herbal supplement. Patients should not take anything before surgery without the health care provider’s knowledge.

Question 102

A 75-year-old patient is being prepared for surgery. What assessment data needs to be included for this patient (select all that apply)?

a. Fluid balance history
b. Attitude about surgery
c. Foods the patient dislikes
d. Current mobility problems
e. Current cognitive function
f. Patient’s opinion about the surgeon

Answer 102

a. Fluid balance history
d. Current mobility problems
e. Current cognitive function

Preoperative fluid balance history is especially critical for older adults as they have reduced adaptive capacity that puts them at greater risk for over- and under-hydration. Mobility problems must be assessed to assist with intraoperative and postoperative positioning and ambulation. Preoperative assessment of the older person’s baseline cognition function is especially crucial for intraoperative and postoperative evaluation as they are more prone to adverse outcomes during and after surgery from the stressors of the surgery, dehydration, hypothermia, and anesthesia. Attitude about surgery and opinion or faith in the surgeon is important for all patients. Foods the patient dislikes are not important unless the patient is allergic to them, but this is no more important for older patients than it is for all patients.

Question 103

When reviewing the preoperative forms, the nurse notices that the informed consent form is not present or signed. What is the best action for the nurse to take?

a. Have the patient sign the consent form.
b. Have the family sign the form for the patient.
c. Call the surgeon to obtain consent for surgery.
d. Teach the patient about the surgery and get verbal permission.

Answer 103

c. Call the surgeon to obtain consent for surgery.

The informed consent for the surgery must be obtained by the physician. The nurse can witness the signature on the consent form and verify that the patient (or caregiver if patient is a minor, unconscious, or mentally incompetent to sign) understands the informed consent. Verbal consents are not enough. The state’s nurse practice act and agency policies must be followed.

Question 104

As the nurse is preparing a patient for outpatient surgery, the patient wants to give his hearing aid to his wife so it will not be lost during surgery. Which action by the nurse should be taken in this situation?

a. Give the hearing aid to the wife as he wishes.
b. Tape the hearing aid to his ear to prevent loss.
c. Encourage the patient to wear it for the surgery.
d. Tell the surgery nurse that he has his hearing aid out.

Answer 104

c. Encourage the patient to wear it for the surgery.

Although jewelry is removed before surgery, hearing aids should be left in place to allow the patient to better follow instructions given in the surgical suite and the postanesthesia care unit (PACU), as well as the dismissal instructions that will be given before he returns home for recovery.

Question 105

The nurse is doing a preoperative assessment on a male patient who has type 2 diabetes mellitus, weighs 146 kg, and is 5 feet 8 inches tall. Which patient assessment is a priority related to anesthesia?

a. Has hemoglobin A1C of 8.5%
b. Has several seasonal allergies
c. Has body mass index of 48.8 kg/m2
d. Has history of postoperative vomiting

Answer 105

c. Has body mass index of 48.8 kg/m2

The patient’s body mass index is the priority because it indicates the patient is severely obese. The patient’s size may impair the anesthesiologist’s ability to ventilate and medicate the patient properly, as well as the surgery room staff’s ability to position the patient safely. The other factors are not the priority.

Question 106

Proper attire for the semirestricted area of the surgery department is

a. street clothing.
b. surgical attire and head cover.
c. surgical attire, head cover, and mask.
d. street clothing with the addition of shoe covers.

Answer 106

b. surgical attire and head cover.

The semirestricted area includes the surrounding support areas and corridors. Only authorized staff members are allowed access to the semirestricted areas. All staff in the semirestricted area must wear surgical attire and cover all head and facial hair.

Question 107

Activities that the nurse might perform in the role of a scrub nurse during surgical include (select all that apply)

a. checking electrical equipment.
b. preparing the instrument table.
c. passing instruments to the surgeon and assistants.
d. coordinating activities occurring in the operating system.
e. maintaining accurate counts of sponges, needles, and instruments.

Answer 107

b. preparing the instrument table.
c. passing instruments to the surgeon and assistants.
e. maintaining accurate counts of sponges, needles, and instruments.

Maintaining accurate counts of sponges, needles, and instruments is a shared responsibility of the scrub nurse and circulating nurse. (Note: It is listed as an activity for both in Table 19-1.)

Question 108

The nurse is caring for a patient undergoing surgery for a knee replacement. What is critical to the patient’s safety during the procedure (select all that apply)?

a. Universal protocol is followed.
b. The ACP is an anesthesiologist.
c. The patient has adequate health insurance.
d. The circulating nurse is a registered nurse.
e. The patient’s allergies are conveyed to the surgical team.

Answer 108

a. Universal protocol is followed.
e. The patient’s allergies are conveyed to the surgical team.

Intraoperative nursing care includes determining the patient’s allergy status in response to food, drugs, and latex. Preventing use of the wrong site, wrong procedure, and wrong surgery has become known as the Universal Protocol. The Universal Protocol is part of a global patient safety initiative.

Question 109

The nurse’s primary responsibility for the care of the patient undergoing surgery is

a. developing an individualized plan of nursing care for the patient.
b. carrying out specific tasks related to surgical policies and procedures.
c. ensuring that the patient has been assessed for safe administration of anesthesia.
d. performing a preoperative history and physical assessment to identify patient needs.

Answer 109

a. developing an individualized plan of nursing care for the patient.

A primary role of the nurse is to assess the patient to develop an individual plan of care.

Question 110

When scrubbing at the scrub sink, the nurse should

a. scrub from elbows to hands.
b. scrub without mechanical friction.
c. scrub for a minimum of 10 minutes.
d. hold the hands higher than the elbows.

Answer 110

d. hold the hands higher than the elbows.

To perform a surgical scrub, the fingers and hands should be scrubbed first, progressing to the forearms and elbows. The hands should be held away from surgical attire and higher than the elbows at all times to prevent contamination from clothing or from detergent suds and water draining from the unclean area above the elbows to the clean and previously scrubbed areas of the hands and fingers.

Question 111

When positioning a patient in preparation for surgery, the nurse understands that injury to the patient is most likely to occur as a result of

a. incorrect musculoskeletal alignment.
b. loss of perception of pain or pressure.
c. pooling of blood in peripheral vessels.
d. disregarding the patient’s need for modesty.

Answer 111

a. incorrect musculoskeletal alignment.

Whatever position is required for the procedure, great care is taken to prevent injury to the patient. Because anesthesia blocks the sensory nerve impulses, the patient does not feel pain or discomfort or sense stress placed on the nerves, muscles, bones, and skin. Improper positioning can result in muscle strain, joint damage, pressure ulcers, nerve damage, and other untoward effects.

Question 112

Intravenous induction for general anesthesia is the method of choice for most patients because

a. the patient is not intubated.
b. the agents are nonexplosive.
c. induction is rapid and pleasant.
d. emergence is longer but with fewer complications.

Answer 112

c. induction is rapid and pleasant.

Routine general anesthesia is usually established with an intravenous (IV) induction agent, which may be a hypnotic, anxiolytic, or dissociative agent. When used during the initial period of anesthesia, these agents induce a pleasant sleep with a rapid onset of action that patients find desirable.

Question 113

The nurse would be alerted to the occurrence of malignant hyperthermia when the patient demonstrates what manifestation?

a. Hypocapnia
b. Muscle rigidity
c. Decreased body temperature
d. Confusion upon arousal from anesthesia

Answer 113

b. Muscle rigidity

Malignant hyperthermia is a metabolic disease characterized by hyperthermia with rigidity of skeletal muscles from altered control of intracellular calcium occurring as a result of exposure to certain anesthetic agents in susceptible patients. Hypoxemia, hypercapnia, and ventricular dysrhythmias may also be seen with this disorder.

Question 114

Before admitting a patient to the operating room, which forms or results must the nurse make sure are in the chart of all patients (select all that apply)?

a. Electrocardiogram
b. Signed consent form
c. Functional status evaluation
d. Renal and liver function tests
e. A history and physical report

Answer 114

b. Signed consent form
e. A history and physical report

The National Patient Safety Goals (NPSG) require documentation of a history and physical, signed consent form, and nursing and preanesthesia assessment in the chart of a patient going for surgery. The physical examination explains in detail the overall status of the patient before surgery for the surgeon and other members of the surgical team.

Question 115

Which intraoperative nursing responsibilities should be performed by the scrub nurse (select all that apply)?

a. Documenting intraoperative care
b. Keeping track of irrigation solutions for monitoring of blood loss
c. Passing instruments and supplies to the surgeon by anticipating his or her needs
d. Coordinating the flow and activities of members of the surgical team in the surgical suite
e. Performing the count of sponges, needles, and instruments used during the surgical procedure

Answer 115

b. Keeping track of irrigation solutions for monitoring of blood loss
c. Passing instruments and supplies to the surgeon by anticipating his or her needs
e. Performing the count of sponges, needles, and instruments used during the surgical procedure

Both the scrub nurse and circulating nurse will participate in the counting of surgical sponges, needles, and instruments, whereas passing instruments to the surgeon and other sterile activities are the exclusive responsibility of the scrub nurse. The circulating nurse takes primary responsibility for the coordination of the surgical suite and documentation.

Question 116

What event in the surgical suite represents a violation of aseptic technique?

a. A glove contacts the leg of the table that supports the sterile field.
b. The cuff of the scrub nurse’s sterile gown contacts the sterile field.
c. The sterile field was established at 0650, and the current time is 0900.
d. Bacteria are present in the nares and upper respiratory passages of the nurse.

Answer 116

a. A glove contacts the leg of the table that supports the sterile field.

Tables are sterile only at tabletop level. Areas below this are considered contaminated. The sterile gown below the point 2 inches above the elbow is considered sterile. The passage of time in and of itself does not necessarily render a field contaminated. Bacteria are inevitable in the respiratory passages of team members, but they present a threat to sterility only if they are not confined by attire.

Question 117

A surgical patient’s premedication regimen includes midazolam (Versed). What are the most likely desired effects of this medication?

a. Monitored anesthesia care and amnesia
b. Potentiates volatile agents to speed induction
c. Analgesia and prevention of intraoperative vomiting
d. Relaxation of skeletal muscles and facilitation of endotracheal intubation

Answer 117

a. Monitored anesthesia care and amnesia

Midazolam is a benzodiazepine that is widely used for its ability to induce amnesia and provide moderate sedation (conscious sedation). Nitrous oxide is a gaseous agent that potentiates volatile agents to speed induction and reduce total dosage and side effects. Antiemetics prevent intraoperative vomiting. Neuromuscular blocking agents facilitate endotracheal intubation.

Question 118

A 71-year-old male patient who is currently undergoing coronary artery bypass graft (CABG) surgery has just experienced intraoperative vomiting. The nurse should consequently anticipate the use of which drug?

a. Midazolam (Versed)
b. Fentanyl (Sublimaze)
c. Meperidine (Demerol)
d. Ondansetron (Zofran)

Answer 118

a. Midazolam (Versed)

Ondansetron (Zofran) is an antiemetic, whereas midazolam (Versed) is a benzodiazepine, and fentanyl (Sublimaze) and meperidine (Demerol) are opioid analgesics.

Question 119

The perioperative nurse would recognize the need to monitor the patient for hallucinations and agitation when which anesthetic agent is administered?

a. Nitrous oxide
b. Ketamine (Ketalar)
c. Thiopental (Pentothal)
d. Halothane (Fluothane)

Answer 119

b. Ketamine (Ketalar)

A disadvantage of ketamine (Ketalar) is the associated risk of agitation, hallucinations, and nightmares. These unwanted effects are not associated with the use of thiopental (Pentothal), halothane (Fluothane), or nitrous oxide.

Question 120

The new nursing student is confused about where the patient’s family (who are wearing street clothes) can be with the patient in the surgical suite. Which explanation should the perioperative nurse give to the student nurse?

a. The family is not allowed to talk to the nurse at the nursing station.
b. The family can be with the patient in the preoperative holding area.
c. The family cannot be with the patient until the postanesthesia care unit.
d. The family is only allowed in the conference room for preoperative teaching.

Answer 120

b. The family can be with the patient in the preoperative holding area.

The perioperative nurse should explain to the student nurse that the family can be in the preoperative holding area before the patient goes to surgery, but this includes talking to the nurse at the nursing station. They are also taken to the conference room for preoperative and postoperative meetings with staff, including teaching.

Question 121

A patient having an open reduction internal fixation (ORIF) of a left lower leg fracture will receive regional anesthesia during the procedure. As the patient is prepared in the operating room, what should the nurse implement to maintain patient safety during surgery that is directly related to the type of anesthesia being used?

a. Apply grounding pad to unaffected leg.
b. Assess peripheral pulses and skin color.
c. Verify the last oral intake before surgery.
d. Ensure a smooth surface under the patient.

Answer 121

d. Ensure a smooth surface under the patient.

Regional anesthesia decreases sensation to the anesthetized area without impairing level of consciousness, which means the affected leg will be without sensation while the anesthetic is effective. A double tourniquet on the affected leg is used to restrict blood flow. This increases the patient’s risk of impaired skin integrity because the patient does not have sensation and cannot identify discomfort or foreign objects and will not be moving during surgery. The nurse’s role includes positioning the patient for correct alignment, exposure of the surgical site, and preventing injury. The other options will be occurring but are not directly related to the regional anesthesia.

Question 122

A 78-year-old patient is having surgery. What risk areas will the nurse need to be especially aware of for this patient during surgery?

a. Sterility
b. Paralysis
c. Urine output
d. Skin integrity

Answer 122

d. Skin integrity

Skin of older adults has lost elasticity and is at increased risk for injury from tape, electrodes, warming or cooling blankets, and dressings. Pooling cleansing solution may create skin burns or abrasions. The nurse is responsible for monitoring patient safety and adjusting patient position as necessary to prevent pressure or misalignment. Sterility and urine output would be monitored for all patients. Paralysis would not be unusual during some types of surgery but would have an impact on any patient’s skin integrity.

Question 123

The patient is going to have a colonoscopy. Which type of anesthesia should the nurse expect to be used?

a. Local anesthesia
b. Moderate sedation
c. General anesthesia
d. Monitored anesthesia care (MAC)

Answer 123

d. Monitored anesthesia care (MAC)

The nurse should expect monitored anesthesia care (MAC) to be used for the patient having a colonoscopy because it can match the sedation level to the patient needs and procedural requirements. Local anesthesia would not be used because the area affected by a colonoscopy is larger than loss of sensation could be provided for with topical, intracutaneous, or subcutaneous application. Moderate sedation is used for procedures performed outside the OR, and the patient remains responsive. General anesthesia is not needed for a colonoscopy, and it requires advanced airway management.

Question 124

In which surgical area will the patient’s skin be prepped for surgery, and what clothing will the person doing the prepping be wearing?

a. Surgical suite wearing a lab coat
b. Preoperative holding area wearing street clothes
c. Postanesthesia care unit (PACU) wearing scrubs
d. Operating room wearing surgical attire and masks

Answer 124

d. Operating room wearing surgical attire and masks

Surgical attire includes pants and shirts (or scrubs), a cap or hood, masks, and protective eyewear. All surgical attire is worn when the patient’s skin is being prepped in the operating room to avoid contamination of the site. The surgical suite includes all unrestricted, semirestricted, and restricted areas of the controlled surgical environment. A lab coat is usually worn by the staff over their scrubs when they leave the surgical area. The staff will not wear street clothes in the preoperative holding area, although the family may. The holding area and PACU will not include prepping the patient for surgery.

Question 125

Unless contraindicated by the surgical procedure, which position is preferred for the unconscious patient immediately postoperative?

a. Supine
b. Lateral
c. Semi-Fowler’s
d. High-Fowler’s

Answer 125

b. Lateral

Unless contraindicated by the surgical procedure, the unconscious patient is positioned in a lateral “recovery” position. This recovery position keeps the airway open and reduces the risk of aspiration if the patient vomits. Once conscious, the patient is usually returned to a supine position with the head of the bed elevated.

Question 126

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?

a. Assess the patient’s pain.
b. Assess the patient’s vital signs.
c. Check the rate of the IV infusion.
d. Check the physician’s postoperative orders.

Answer 126

b. Assess the patient’s vital signs.

The 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. The other actions can then take place in rapid sequence.

Question 127

When assessing a patient’s surgical dressing on the first postoperative day, the nurse notes new, bright-red drainage about 5 cm in diameter. In response to this finding, what should the nurse do first?

a. Recheck in 1 hour for increased drainage.
b. Notify the surgeon of a potential hemorrhage.
c. Assess the patient’s blood pressure and heart rate.
d. Remove the dressing and assess the surgical incision.

Answer 127

c. Assess the patient’s blood pressure and heart rate.

The first action by the nurse is to gather additional assessment data to form a more complete clinical picture. The nurse can then report all of the findings. Continued reassessment will be done. Agency policy determines whether the nurse may change the dressing for the first time or simply reinforce it.

Question 128

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 128

a. Administering adequate analgesics to promote relief or control of pain

Even when a patient understands the importance of postoperative activities and demonstrates them correctly, it is unlikely that the best outcome will occur unless the patient has sufficient pain relief to cooperate with the activities.

Question 129

Bronchial obstruction by retained secretions has contributed to a postoperative patient’s recent pulse oximetry reading of 87%. Which health problem is the patient probably experiencing?

a. Atelectasis
b. Bronchospasm
c. Hypoventilation
d. Pulmonary embolism

Answer 129

a. Atelectasis

The most common cause of postoperative hypoxemia is atelectasis, which may be the result of bronchial obstruction caused by retained secretions or decreased respiratory excursion. Bronchospasm involves the closure of small airways by increased muscle tone, whereas hypoventilation is marked by an inadequate respiratory rate or depth. Pulmonary emboli do not involve blockage by retained secretions.

Question 130

In caring for the postoperative patient on the clinical unit after transfer from the PACU, which care can be delegated to the unlicensed assistive personnel (UAP)?

a. Monitor the patient’s pain.
b. Do the admission vital signs.
c. Assist the patient to take deep breaths and cough.
d. Change the dressing when there is excess drainage.

Answer 130

c. Assist the patient to take deep breaths and cough.

The UAP can encourage and assist the patient to do deep breathing and coughing exercises and report complaints of pain to the nurse caring for the patient. The RN should do the admission vital signs for the patient transferring to the clinical unit from the PACU. The LPN or RN will monitor and treat the patient’s pain and change the dressings.

Question 131

The patient had abdominal surgery. The estimated blood loss was 400 mL. The patient received 300 mL of 0.9% saline during surgery. Postoperatively, the patient is hypotensive. What should the nurse anticipate for this patient?

a. Blood administration
b. Restoring circulating volume
c. An ECG to check circulatory status
d. Return to surgery to check for internal bleeding

Answer 131

b. Restoring circulating volume

The nurse should anticipate restoring circulating volume with IV infusion. Although blood could be used to restore circulating volume, there are no manifestations in this patient indicating a need for blood administration. An ECG may be done if there is no response to the fluid administration, or there is a past history of cardiac disease, or cardiac problems were noted during surgery. Returning to surgery to check for internal bleeding would only be done if patient’s level of consciousness changes or the abdomen becomes firm and distended.

Question 132

The patient donated a kidney, and early ambulation is included in her plan of care. But the patient refuses to get up and walk. What rationale should the nurse explain to the patient for early ambulation?

a. “Early walking keeps your legs limber and strong.”
b. “Early ambulation will help you be ready to go home.”
c. “Early ambulation will help you get rid of your syncope and pain.”
d. “Early walking is the best way to prevent postoperative complications.”

Answer 132

d. “Early walking is the best way to prevent postoperative complications.”

The best rationale is that early ambulation will prevent postoperative complications that can then be discussed. Ambulating increases muscle tone, stimulates circulation that prevents venous stasis and VTE, speeds wound healing, and increases vital capacity and maintains normal respiratory function. These things help the patient be ready for discharge, but early ambulation does not eliminate syncope and pain. Pain management should always occur before walking.

Question 133

An older patient who had surgery is displaying manifestations of delirium. What should the nurse do first to provide the best care for this new patient?

a. Check his chart for intraoperative complications.
b. Check which medications were used for anesthesia.
c. Check the effectiveness of the analgesics he has received.
d. Check his preoperative assessment for previous delirium or dementia.

Answer 133

d. Check his preoperative assessment for previous delirium or dementia.

If the patient’s ABCs are okay, it is important to first know if the patient was mentally alert without cognitive impairments before surgery. Then intraoperative complications, anesthesia medications, and pain will be assessed as these can all contribute to delirium.

Question 134

The patient had surgery at an ambulatory surgery center. Which criteria support that this patient is ready for discharge (select all that apply)?

a. Vital signs baseline or stable
b. Minimal nausea and vomiting
c. Wants to go to the bathroom at home
d. Responsible adult taking patient home
e. Comfortable after IV opioid 15 minutes ago

Answer 134

a. Vital signs baseline or stable
b. Minimal nausea and vomiting
d. Responsible adult taking patient home

Ambulatory surgery discharge criteria includes meeting Phase I PACU discharge criteria that includes vital signs baseline or stable and minimal nausea and vomiting. Phase II criteria includes a responsible adult driving patient, no IV opioid drugs for last 30 minutes, able to void, able to ambulate if not contraindicated, and received written discharge instruction with patient understanding confirmed.

Question 135

A patient is having elective cosmetic surgery performed on her face. The surgeon will keep her at the surgery center for 24 hours after surgery. What is the nurse’s postoperative priority for this patient?

a. Manage patient pain.
b. Control the bleeding.
c. Maintain fluid balance.
d. Manage oxygenation status.

Answer 135

d. Manage oxygenation status.

The nurse’s priority is to manage the patient’s oxygenation status by maintaining an airway and ventilation. With surgery on the face, there may be swelling that could compromise her ability to breathe. Pain, bleeding, and fluid imbalance from the surgery may increase her risk for upper airway edema causing airway obstruction and respiratory suppression, which also indicate managing oxygenation status as the priority.