Test 1 Ch 42

Question 1

The patient who had a nephrectomy yesterday has not used the patient-controlled analgesia (PCA) delivery system but admits to being in pain but fearful of addiction. Which is the nurse’s response?
a. “Modern analgesic drugs do not cause addiction.”
b. “Pain relief is worth a short period of addiction.”
c. “Addiction rarely occurs in the brief time postsurgical analgesia is required.”
d. “Addiction could be a real concern.”

Answer 1

ANS: C
Addiction rarely occurs in the short time that it is required after surgery. Modern, or older drugs, can cause addiction, but not generally in the brief post- operative time frame. Postsurgical analgesia, because of its brief application, does not usually produce a physical or a psychological dependence. The patient should be taught that addiction is not usually a concern after surgery.

Question 2

A 73-year-old patient with diabetes was admitted for below the knee amputation of his right leg. Removal of his right leg is an example of which type of surgery?
a. Palliative
b. Diagnostic
c. Reconstructive
d. Ablative

Answer 2

ANS: D
Ablative is a type of surgery where an amputation, excision of any part of the body, or removal of a growth and harmful substance is performed.

Question 3

. A patient is in need of appendix removal surgery. In which situation might surgery be delayed?
a. The patient has taken antiseizure medication today.
b. An illegible signature is on the consent form.
c. The patient is still taking anticoagulants.
d. The admission office is unable to confirm insurance coverage.

Answer 3

ANS: C

Question 4

Which circumstance could prevent the patient from signing an informed consent form for a cholecystectomy?
a. The patient complains of pain radiating to the scapula.
b. The patient received an injection of antianxiety medication 1 hour ago.
c. The patient is 85 years of age.
d. The patient is concerned over his lack of insurance coverage.

Answer 4

ANS: B
Informed consent should not be obtained if the patient is disoriented and under the influence of sedatives. Age, illegibility, and lack of insurance coverage do not prevent signing the consent. Pain into the scapula is a symptom of colitis.

Question 5

The nurse anticipates that the patient will be given which type of anesthesia because of the extensive tissue manipulation involved in a hysterectomy?
a. general
b. regional
c. specific
d. preoperative

Answer 5

ANS: A
An anesthesiologist gives general anesthetics by IV and inhalation routes through four stages of anesthesia when the procedure requires extensive tissue manipulation. Regional anesthesia would not be sufficient in this case. The terms “specific” and “preoperative” are not terms associated with types of anesthesia.

Question 6

The nurse caring for a patient who had spinal anesthesia for a vaginal repair should be alert for which sign of a serious complication?
a. a flushing of the face and torso.
b. numbness of the perineum.
c. complaint of thirst.
d. a sudden drop in blood pressure.

Answer 6

ANS: D

Question 7

Why might the older adult patient not respond to surgical treatment as well as a younger adult patient?
a. Poor skin turgor
b. Fear of the unknown
c. Response to physiologic changes
d. Decreased peristalsis related to anesthesia

Answer 7

ANS: C
Of specific concern in older adults is the body’s response to temperature changes, cardiovascular shifts, respiratory needs, and renal function. Poor skin turgor is not a reason an older adult does not respond well to surgical treatment. Fear of the unknown and decreased peristalsis are common to all ages.

Question 8

Which postoperative nursing intervention is contraindicated for a 45-year-old patient who has had a repair of a cerebral aneurysm?
a. coughing every 2 hours.
b. turning every 2 hours.
c. monitoring intravenous therapy at 50 mL/hr.
d. assessing vital signs every 2 hours.

Answer 8

ANS: A
After brain, head, neck, spinal or eye surgery, coughing is not performed. Coughing can increase intracranial pressure. The patient is still able to turn every 2 hours. Intravenous therapy is administered at the rate prescribed. Vital sign measurement is not contraindicated, and should be obtained as prescribed.

Question 9

The nurse acting as a circulating nurse has a responsibility for which activity?
a. Observing for breaks in sterile technique.
b. Performing surgical hand scrub
c. assisting with surgical draping of the patient.
d. maintaining count of sponges, needles, and instruments during surgery.

Answer 9

ANS: A

Question 10

Which statement made by a patient during a preoperative assessment would be significant to report to the charge nurse and surgeon?
a. “I have been taking an herbal product of feverfew for my migraines.”
b. “I exercise for 3 hours a day.”
c. “I drink 2 cups of coffee a day.”
d. “I use eye drops for redness every day.”

Answer 10

ANS: A
The herbal remedy of feverfew acts as an anticoagulant and increases the possibility of hemorrhage. The drug should be stopped before surgery, and bleeding and clotting times should be evaluated. Exercising does not need to be reported. Two cups of coffee every day or eye drops for redness would not need to be reported.

Question 11

A patient is on postoperative day 2 after a nephrectomy. Which intervention is an effective way to increase peristalsis?
a. Ambulation
b. An enema
c. Encouraging hot liquids
d. Administering a laxative

Answer 11

ANS: A
Encouraging activity (turning every 2 hours, early ambulation) assists GI activity. An enema or a laxative would be used only if ambulation did not increase the peristalsis. Hot liquids could cause a burn injury; warm liquids are encouraged.

Question 12

A patient is transferred from the operating room to the recovery room after undergoing an open reduction and internal fixation (ORIF) of his left ankle. Which is the first assessment to make?
a. Check ankle dressings for hemorrhage.
b. Check airway for patency.
c. Check intravenous site.
d. Check pedal pulse.

Answer 12

ANS: B

Question 13

Frequent assessment of a postoperative patient is essential. Which are the first signs and symptoms of hemorrhage?
a. Increasing blood pressure
b. Decreasing pulse
c. Restlessness
d. Weakness, apathy

Answer 13

ANS: C
Restlessness is the first sign of hemorrhage, due to lack of oxygen flow to the brain. A pulse that increases and becomes thready combined with a declining blood pressure, cool and clammy skin, and reduced urine output may signal hypovolemic shock.

Question 14

The nurse instructing a postsurgical patient in the use of thrombolytic deterrent stockings will include which instruction?
a. Disregard appearance of edema above the stocking.
b. Massage legs to smooth wrinkles out of stockings.
c. Wring stockings thoroughly before hanging to dry.
d. Hand wash stockings in warm water and mild soap.

Answer 14

ANS: D
Stockings should be hand washed gently in warm water and mild soap and laid over a surface to dry. They should not be wrung out or hung. Massaging legs may dislodge a clot The appearance of edema indicates the stockings are too restrictive.

Question 15

The patient is brought into PACU still unconscious. Which action will the nurse take FIRST when the nurse assesses a temperature of 94°F?
a. Notify the charge nurse immediately.
b. Offer warm fluids through a straw.
c. Do nothing, this is a normal reaction to anesthesia.
d. Cover with a warm blanket.

Answer 15

ANS: D

Question 16

In which location are guidelines for ensuring that all nursing interventions on the day of surgery completed and documented?
a. In the nurse’s notes
b. In the anesthesia record
c. In the preoperative checklist
d. In the progress notes

Answer 16

ANS: C
When the nurse signs the preoperative checklist, that nurse assumes responsibility for all areas of care included on the list. The nurse’s notes are not the correct location for all of the pre-operative interventions. The anesthesia provider documents on the anesthesia record. The health care provider documents in the progress notes.

Question 17

While turning a patient who had a bowel resection yesterday, the wound eviscerated. Which is the initial nursing intervention?
a. Place the patient in the high Fowler’s position.
b. Give the patient fluids to prevent shock.
c. Replace the dressing with sterile fluffy pads.
d. Apply a warm, moist normal saline sterile dressing.

Answer 17

ANS: D
Cover the wound with a sterile towel moistened with sterile physiologic saline (warm). The patient is placed in the semi-Fowler’s position with the knees slightly flexed to reduce tension on the incision. The patient will need emergency surgery to repair the evisceration and should not be given oral fluids. Fluffy pads are not used, due to the threads coming loose and entering the incision.

Question 18

When will the nurse offer prescribed analgesics to a patient who is 24 hours postoperative?
a. Only when the patient asks.
b. When the onset of pain is assessed.
c. Sparingly to avoid drug dependence.
d. Only when severe pain is assessed.

Answer 18

ANS: B

Question 19

Which action will the nurse take to minimize the potential for venous stasis?
a. Place pillows under the knee in a position of comfort.
b. Assist patient to sit with feet flat on the floor.
c. Assist with early ambulation.
d. Perform gentle leg massage.

Answer 19

ANS: C
Early ambulation has been a significant factor in hastening postoperative recovery and preventing postoperative complications. Placing a pillow under the patient is contraindicated, as it will increase the risk for venous stasis. The patient may sit in a chair, but walking is the best intervention to reduce the risk of venous stasis. Massaging the legs is contraindicated, as the massage could cause a blood clot to travel toward the heart.

Question 20

The nurse clarifies that serum potassium levels are determined before surgery for which reason?
a. Assessing kidney function.
b. Determining respiratory insufficiency.
c. Preventing arrhythmias related to anesthesia.
d. Measuring functional liver capability.

Answer 20

ANS: C
Serum electrolytes are evaluated if extensive surgery is planned or the patient has extenuating problems. One of the essential electrolytes examined is potassium; if potassium is not available in adequate amounts, arrhythmias can occur during anesthesia. Assessing the kidney function is not accomplished by assessing just the kidney function. Respiratory insufficiency and liver function cannot be assess by a serum potassium level.

Question 21

In performing the preoperative assessment, the nurse discovers that the patient is allergic to latex. What should the nurse do initially?
a. Notify the diet kitchen to omit bananas from diet tray.
b. Apply a medical alert band to patient’s wrist.
c. Tag chart with allergy alert.
d. Place patient in an isolation room.

Answer 21

ANS: B
The initial intervention would be to place a medical alert band on the patient, then tag the chart. The charge nurse and the surgeon should be notified in the event the surgeon wants to order a preoperative prophylactic treatment. The patient will need to go to the designated operating room for patients with latex allergies, or be the first case in the operating room. Even though patients allergic to latex are frequently allergic to bananas, notifying the kitchen the patient is allergic to bananas is not a necessary initial action. The patient should be fasting. It is important to tag the chart, but it is more crucial to attach a medical alert band to the patient, in case the chart is misplaced. There is no need to place the patient in an isolation room.

Question 22

Which early postoperative observation should be reported immediately?
a. “Coffee ground” emesis
b. Shivering
c. Scanty urine output
d. Evidence of pain

Answer 22

ANS: A
Any emesis that is red or coffee ground should be reported immediately as it indicates GI bleeding. Shivering, scanty urine output, and evidence of pain are within normal expectation of a postsurgical patient.

Question 23

When the postoperative patient complains of sudden chest pain combined with dyspnea, cyanosis, and tachycardia, the nurse recognizes the signs of which complication?
a. hypovolemic shock.
b. dehiscence.
c. atelectasis.
d. pulmonary embolus.

Answer 23

ANS: D
Sudden chest pain combined with dyspnea, tachycardia, cyanosis, diaphoresis, and hypotension is a sign of pulmonary embolism. Hypovolemic shock is indicated by hypotension, tachycardia, restlessness and cool, clammy skin. Dehiscence is the sudden opening of the surgical wound. Atelectasis is “collapsed lung”, characterized by fever, and reduced breath sounds in the lower lobes.

Question 24

The removal of a nondiseased appendix during a hysterectomy is classified in which way?
a. major, emergency, diagnostic.
b. major, urgent, palliative.
c. minor, elective, ablative.
d. minor, urgent, reconstructive.

Answer 24

ANS: C
Surgery is classified as elective, urgent, or emergency. Surgery is performed for various purposes, which include diagnostic studies, ablation (an amputation or excision of any part of the body or removal of a growth or harmful substance), and palliative (therapy to relieve or reduce intensity of uncomfortable symptoms without cure), reconstructive, transplant, and constructive purposes.

Question 25

Which medication would cause surgery to be delayed if it had not been discontinued several days before surgery?
a. Analgesic agent
b. Antihypertensive agent
c. Anticoagulant agent
d. Antibiotic agent

Answer 25

ANS: C
Anticoagulants alter normal clotting factors and thus increase risk of hemorrhaging. They should be discontinued for 48 hours before surgery. It is not necessary to discontinue analgesic agents unless they contain aspirin, which alters the clotting function. Antihypertensive medications lower the blood pressure and prevent heart attack and stroke. Consult with the surgeon and/or anesthesia provider regarding use of this medication. Antibiotic agents are not generally discontinued before surgery. If given orally, consult with the surgeon and/or anesthesia provider.

Question 26

Which intervention by the nurse will decrease the pain of an abdominal incision while coughing?
a. support the surgical site with a pillow.
b. position patient in a side-lying position.
c. medicate with prescribed narcotic three hours before coughing.
d. ask the patient to cross arms over the chest to increase force of cough.

Answer 26

ANS: A
To ease the pressure on the incision, the nurse helps the patient support the surgical site with a pillow or rolled bath blanket. The heel of the hand can be used as well, but it is not the ideal method. Positioning the patient in a side-lying position would not reduce the pain while coughing. Medicating the patient with a narcotic three hours before coughing would not be effective, due to the fact that the medication level would be greatly reduced. Asking the patient to cross arms over the chest would not reduce the pain level.

Question 27

Which patient statement indicates the patient needs further education regarding tomorrow’s scheduled bowel resection surgery?
a. “I am going to have adequate pain medication after surgery.”
b. “I know you all are going to make me cough and walk soon after surgery.”
c. “I am glad I will get to go home tomorrow evening.”
d. “I will have to put up with dressing changes.”

Answer 27

ANS: C
The patient’s lack of understanding about the length of time in the hospital following such a serious surgery indicates a knowledge deficit that needs to be addressed. The patient should expect adequate pain control, coughing and early ambulation and dressing changes to occur after surgery.

Question 28

Which instruction will the nurse give when teaching the patient to cough effectively after surgery?
a. Breathe through the nose, hold breath, and exhale slowly.
b. Take three deep breaths and cough from the chest.
c. Inhale while contracting the abdominal muscles and exhale while contracting the
diaphragm.
d. Take short, frequent panting breaths and cough from the throat to clear
accumulated mucus.

Answer 28

ANS: B
Because lung ventilation is vital, the nurse assists the patient to turn, cough, and breathe deeply every 1 to 2 hours until the chest is clear. Having practiced this combination preoperatively, the patient is usually adequately able to remove trapped mucus and surgical gases. The patient should first take three deep breaths, and cough deeply from the chest. Breathing through the nose, holding the breath and exhaling slowly describes deep breathing, not coughing. Diaphragmatic breathing is not the same as coughing. The patient should breathe deeply and cough from the lungs, not take short, panting breathings or cough from the throat.

Question 29

Which is the responsibility of the nurse as a witness to informed consent?
a. Explain the surgical options.
b. Explain the operative risks.
c. Verify/obtain the patient’s signature.
d. Verify the patient’s understanding of the procedure.

Answer 29

ANS: C

Question 30

On the patient’s return to the medical-surgical unit, the nurse performing an abdominal assessment can affirm an absence of bowel sounds after listening in each quadrant for which length of time?
a. 30 seconds.
b. 1 minute.
c. 2 minutes.
d. 3 minutes.

Answer 30

ANS: D

Question 31

When the patient asks the nurse ”please make sure no one sees me with my dentures out”, the nurse recognizes which common preoperative fear?
a. anesthesia.
b. loss of control.
c. fear of separation from family.
d. mutilation.

Answer 31

ANS: B
Fear of loss of control may be partially related to concerns about anesthesia, but this patient’s concern is about self-image. Preoperative anxiety from any cause may affect the amount of anesthesia and postoperative analgesia needed. Asking to not be seen without dentures does not reflect separation fear or fear of mutilation.

Question 32

Which is the ideal time for preoperative teaching?
a. Immediately before surgery to eliminate fear
b. 2 months in advance so the patient can prepare
c. 1 to 2 days before the surgery when anxiety is not as high
d. In the surgical holding area

Answer 32

ANS: C

Question 33

In preparation for the return of the patient following surgery, the patient’s bed and equipment should be in which position?
a. Lowest position with side rails elevated with oxygen and suction equipment
available
b. Highest position with side rails elevated with IV pole and pump at bedside
c. Lowest position with side rails down on the receiving side
d. Highest position with the side rails down on receiving side and up on opposite side

Answer 33

ANS: D
In preparation for the return of the patient following surgery, the patient’s bed should be in the highest position to be level with the surgical gurney and should have the side rail down on the receiving side, with the opposite side rail up to prevent the patient from falling out of bed during transfer.

Question 34

A patient is transferred from the operating room to the recovery room after undergoing an amputation of his left foot. Which intervention is the last step for immediate assessment once the patient enters the PACU?
a. System review
b. Breathing
c. Circulation
d. Airway
e. Level of consciousness

Answer 34

ANS: A
The assessment of an adequate airway is primary in the postanesthesia assessment, followed by breathing assessment, level of consciousness, circulation, and finally system review.

Question 35

Which is the first step a patient should take to control coughing?
a. Inhale deeply and hold breath for a count of three.
b. Document exercise and patient reaction.
c. Cough two or three times without inhaling then relax.
d. Take several deep breaths, inhaling through the nose.

Answer 35

ANS: D