TEST 14: The Client Having Surgery

Question 1

The Client Who Is Preparing for Surgery
1. A client tells the nurse on admission that she is uneasy about having to leave her children with
a relative while being in the hospital for surgery. The most appropriate action by the nurse is to do
which of the following?
1. Reassure the client that her children will be fine and she should stop worrying.
2. Contact the relative to determine his/her capacity to be an adequate care provider.
3. Encourage the client to call the children to make sure they are doing well.
4. Gather more information about the client’s feelings about the childcare arrangements.

Answer 1

1. 4. The health history is conducted to ascertain a client’s state of wellness or illness. A personal
      dialogue between a client and a nurse is conducted to obtain information. To achieve a relationship of
      mutual trust and respect, the nurse must have the ability to communicate a sincere interest in the client.
      The therapeutic communication must be adapted to the responses, problems, and needs of the client.
      Reassurance and the remaining options do not demonstrate that the nurse is genuinely interested in the
      client’s needs.
      CN: Psychosocial integrity; CL: Synthesize

Question 2

2. The client has a latex allergy. What should the nurse teach the client to do before having
   surgery at a free-standing surgery center? Select all that apply.
3. Determine that there will be a latex-safe environment for surgery.
4. Report symptoms experienced with the latex allergy (eg, rhinitis, conjunctivitis, flushing).
5. Notify the health care providers at the surgery center.
6. Wear a stainless steel medical alert bracelet into the surgical suite.
7. Ask to have the surgery at a hospital.

Answer 2

2. 1, 2, 3. Treatment and diagnostic evaluation must be done in a latex-safe environment.
   Signs/symptoms may be mild to anaphylaxis. Clients with latex allergy are advised to notify their
   health care providers and to wear a medical ID; however, all metal and jewelry must be removed
   prior to surgery as they could conduct an electrical current. The surgery can be safely performed at a
   free-standing surgery center as long as latex precautions are observed.
   CN: Safety and infection control; CL: Create

Question 3

3. When the nurse asks the client who is to have abdominal surgery today if the client understands
   the procedure, the client replies, “No, not really; I talked about several different things with my
   surgeon, and I am just not sure.” The nurse should:
4. Teach the client all the details of the planned procedure.
5. Utilize a second witness when the client signs for consent.
6. Notify the surgeon of the client’s expressed lack of understanding.
7. Administer the prescribed preoperative narcotics and/or sedatives.

Answer 3

3. 3. It is the surgeon’s responsibility to discuss the planned procedure and review the risks,
      benefits, and alternatives to the planned procedure. If the client verbalizes that they do not understand
      the procedure that is planned for them, it is the nurse’s responsibility to notify the surgeon of this lack
      of understanding right away, prior to any other/additional nursing actions. In this case, when the client
      verbalizes a lack of understanding, the nurse should not teach about the procedure; the surgeon needs
      to do this. The nurse cannot assist the client to sign for consent and should not administer narcotics or
      sedatives until the client understands and agrees to the procedure.
      CN: Management of care; CL: Synthesize

Question 4

4. During preadmission testing for same-day surgery, a client states that she has added two cloves
   of garlic each day to her diet to help control her blood pressure. The nurse should further inquire
   about which of the following?
5. The type of surgery the client is having.
6. What her blood pressure has been running.
7. The amount of garlic she is eating.
8. Her preference for the type of anesthesia.

Answer 4

4. 3. Garlic has anticoagulant properties and may pose a problem with bleeding if enough has
      been taken too close to surgery. Therefore, the nurse must obtain more quantifiable details about the
      client’s statement. The nurse should check the surgical procedure, anesthesia preference, and blood
      pressure status with the client. However, the part of the client’s statement that needs further
      investigation concerns intake of an herb with anticoagulant properties before a surgical procedure.
      CN: Pharmacological and parenteral therapies; CL: Synthesize

Question 5

5. What action should this nurse (see figure) take to avoid spreading nosocomial infections?
6. Remove the face mask.
7. Remove the hair covering.
8. Wash her hands before tying the strings on the mask.
9. Tie the dangling strings of the mask around her neck.

Answer 5

5. 1. The nurse should remove the face mask. The face mask contains nasal and oral droplets,
      which are easily transmitted to the hands as the mask dangles when left hanging around the neck.
      When a face mask is not worn over the mouth and nose, it should be completely removed.
      CN: Safety and infection control; CL: Synthesize

Question 6

6. The client is to have surgery on the fourth metatarsal. Identify the place on the illustration
   below where the client should mark the operative site

Answer 6

6. This is the correct surgical site.

4th toe (ring toe)

CN: Physiological adaptation; CL: Apply

Question 7

7. The nurse is reviewing the chart of a 55-year-old male client who is scheduled for a lumbar
   laminectomy. The nurse should report which of the following to the surgeon?
8. Pimple on the lower back.
9. Abnormal electrocardiogram (ECG).
10. Hearing aid.
11. Allergy to iodine.

Answer 7

7. 1. A pimple close to the incision site may be reason for the surgeon to cancel the surgical
      procedure because it increases the risk of infection. If the client had an abnormal ECG, the nurse
      would notify the anesthesiologist who will be administering the anesthesia. The anesthesiologist is
      the decision maker regarding the implications of the anesthesia on the cardiac system. The surgical
      team should be notified of the client’s hearing disability, but the surgeon, who has already met the
      client, does not need to be notified. The surgical team should be notified of the client’s allergy to
      iodine and it should be documented in all the appropriate places, but the surgeon would not need to
      be notified in advance of the surgical procedure.
      CN: Safety and infection control; CL: Synthesize

Question 8

8. Prior to going to surgery, the client tells the nurse that she cannot hear without her hearing aid
   and asks to wear it to surgery and recovery. What is the nurse’s best response?
9. Explain to the client that it is policy not to take personal items to surgery because they may be
   lost or broken.
10. Tell the client that a nurse will bring the hearing aid to the postanesthesia care unit so that she
    can have it as soon as she wakes up.
11. Explain to the client that she will have a premedication that will make her sleepy before she
    goes to surgery and she won’t need to hear.
12. Call the surgery unit to explain the client’s concern and ask if she can wear her hearing aid tosurgery.

Answer 8

8. 4. When a client has a concern, it is important to decrease her stress as much as possible. The
      nurse should call the operating room and inform the intraoperative nurse. A special container with
      correct identification can be prepared so that when the client is anesthetized and her hearing aid is
      removed, it will not be lost or broken. It is usual policy not to send personal belongings to surgery
      because they are easily broken or lost in the transfer of an anesthetized client with higher priority
      needs, but special needs do exist. In some instances, the nurse does bring a client’s personal
      belongings to the postanesthesia care unit, but in this case the item involves the client’s ability to
      communicate. Because the trend is to use little premedication, clients are more alert and may want to
      talk with their surgical team before going to sleep. Decreasing the client’s anxieties preoperatively
      affects the amount of medication used to induce the client and her overall psychological and
      physiologic status. Telling the client that she won’t need to hear is insensitive.
      CN: Basic care and comfort; CL: Synthesize

Question 9

9. The adult daughters of an elderly male client inform the nurse that they fully expect their father
   to be combative after surgery. Preoperatively, they request that the nurse put all four side rails up and
   use restraints to keep him safe. The nurse should tell the daughters:
10. “Certainly; we will want to be sure to keep your father safe too.”
11. “We will call the physician to get a prescription right away.”
12. “We will first try to keep him safe without restraint.”
13. “Restraint use is prohibited at our hospital at all times.”

Answer 9

9. 3. A restraint-free environment should always be provided as much as possible. Nursing staff
      are required to attempt lesser restrictive alternatives (eg, use of family or sitter, reorientation,
      distraction, or a toileting schedule) prior to notifying the provider of the need for restraints. Nursing
      staff are also required to document clinical conditions requiring restraint, lesser restrictivealternatives attempted, and client/family education provided regarding restraint use. Provider
      prescriptions for restraints must be time limited and specific regarding the type of restraint.
      Additionally, if restraints are implemented, nursing staff must monitor clients for safety (including
      skin checks and range of motion) and provide frequent food/fluids/toileting.
      CN: Safety and infection control; CL: Synthesize

Question 10

10. The client is to take nothing by mouth after 4:00 AM . The nurse recognizes that the client has
    deficient knowledge when he states that he:
11. Ate a gelatin dessert at 3:30 AM .
12. Brushed his teeth at 4:00 AM but did not swallow.
13. Held a cold washcloth against his lips.
14. Smoked a cigarette at 6:00 AM .

Answer 10

10. 4. The client has deficient knowledge if he smoked a cigarette after 4:00 AM because, even
       though he did not have anything to eat or drink, smoking has increased the production of gastric
       hydrochloric acid, which can increase the risk of aspiration in an anesthetized client. A gelatin
       dessert is a clear liquid and is acceptable. Comfort measures, such as brushing the teeth without
       swallowing or holding a cold washcloth against the lips, are acceptable for a client who is to have
       nothing by mouth.
       CN: Reduction of risk potential; CL: Evaluate

Question 11

11. The client tells the nurse that he is allergic to shellfish. The nurse should ask the client if he is
also allergic to:
1. All other seafood.
2. Iodine skin preparations.
3. Caffeine.
4. Alcohol-based skin preparations.

Answer 11

11. 2. Clients who are allergic to shellfish are allergic to iodine skin preparations (Iodophor and
       Betadine) or any other products containing iodine, such as dyes. Clients who are allergic to shellfish
       do not necessarily have an allergy to any other substances or seafood.
       CN: Reduction of risk potential; CL: Analyze

Question 12

12. The surgeon prescribes cefazolin (Ancef) 1 g to be given IV at 7:30 AM when the client’s
    surgery is scheduled at 8:00 AM . What is the primary reason to start the antibiotic exactly at 7:30 AM ?
13. Legally the medication has to be given at the prescribed time.
14. The antibiotic is most effective in preventing infection if it is given 30 to 60 minutes before the
    operative incision is made.
15. The postoperative dose of Ancef needs to be started exactly 8 hours after the preoperative
    dose of Ancef.
16. The peak and titer levels are needed for antibiotic therapy.

Answer 12

12. 2. The antibiotic is most effective in preventing infection, according to research, if it is given
       30 to 60 minutes before the operative incision is made. When the surgeon prescribes the antibiotic to
       be given at a specific time related to the scheduled time of the surgical procedure, it is imperative that
       the antibiotic is given on time. Legally, the nurse considers 30 minutes on either side of the scheduled
       time to be acceptable for administering medications; however, in this situation, giving the antibiotic
       30 minutes too soon can make the prophylactic antibiotic ineffective. The postoperative dose of
       antibiotic is not timed according to the preoperative dose. Peak and titer levels are measured for
       some antibiotics, but in this case the primary reason is to have the antibiotic infused before the time of
       the incision.
       CN: Reduction of risk potential; CL: Apply

Question 13

13. Which of the following is the best way for the nurse to begin the preoperative interview?
14. Walk in the client’s room and ask, “Are you Mrs. Smith?”
15. Walk in the client’s room, sit down, and take the client’s blood pressure.
16. Walk in the client’s room, sit down, maintain eye contact, and make an introduction.
17. Walk in the client’s room and ask the client’s name.

Answer 13

13. 3. Nurses should provide the preoperative client individual and sincere attention by meeting
       the client at eye level and introducing themselves by name and role. The nurse should ask the client to
       tell her full name rather than asking if she is Mrs. Smith because there might be another client by that
       name on the schedule. Nurses should not start the physical assessment or ask the client’s name without
       first identifying themselves and their role out of courtesy and to relieve the client’s anxiety in the new
       environment of the surgical experience.
       CN: Psychosocial integrity; CL: Apply

Question 14

14. A client who is to receive general anesthesia has a serum potassium level of 5.8 mEq/L (5.8
    mmol/L). What should be the nurse’s first response?
15. Call the surgeon.
16. Send the client to surgery.
17. Make a note on the front of the chart.
18. Notify the anesthesiologist.

Answer 14

14. 4. The nurse should notify the anesthesiologist because a serum potassium level of 5.8 mEq/L
       (5.8 mmol/L) places the client at risk for arrhythmias when under general anesthesia. The surgeon
       may be notified; however, the anesthesiologist will make the decision about whether to proceed with
       surgery. The nurse should not automatically send a client with abnormal laboratory findings to surgery
       because the procedure may be canceled. Once the client is inside the operating room and sterile
       supplies have opened up for the procedure, the client is usually charged. The nurse should call ahead
       of time to communicate the abnormal laboratory result instead of placing a note on the front of the
       chart. A note would not be seen until after the client has been transported to the operating room and
       the supplies have been opened.CN: Reduction of risk potential; CL: Synthesize

Question 15

15. Prior to being transported to the surgery suite, the nurse asks the client whether he has any
    allergies. The client responds, “Doesn’t anyone communicate with anyone? I have been asked that
    question over and over!” What is the nurse’s best response?1. “I’m sorry! I just have to ask that question for the record.”
16. “It’s an important question and we just have to check.”
17. “You will hear it again and again as you go through surgery.”
18. “This question is asked for verification and safety with each new phase of treatment.”

Answer 15

15. 4. Clients should be made aware that some questions are asked for verification and safety
       with each new phase of treatment.
       CN: Psychosocial integrity; CL: Synthesize

Question 16

16. For which of the following preoperative clients should the nurse assess the glucose level?
    Select all that apply.
17. A client with diabetes mellitus controlled by diet.
18. A client with a high stress response to surgery.
19. A client receiving corticosteroids for the past 3 months.
20. A client with a family history of diabetes receiving dextrose 5% in lactated Ringer’s solution
    (D 5 LR) IV fluids.
21. A client who consumes a high carbohydrate diet.

Answer 16

16. 1, 2, 3. Clients who have diabetes mellitus controlled by diet, those with a high stress
    response to surgery, or those who have been on steroid treatment for the last 3 months should have
    their serum glucose level assessed. A client with a family history of diabetes receiving D 5 LR IV
    fluids does not need to have the serum glucose level checked unless other clinical manifestations are
    present. The client who has a high carbohydrate diet should be able to metabolize the glucose unless
    there are other health problems.
    CN: Reduction of risk potential; CL: Analyze

Question 17

17. On the day of surgery, a client with diabetes who takes insulin on a sliding scale is to have
    nothing by mouth and all medications withheld. The client’s 6 AM glucose level is 300 mg/dL (16.7
    mmol/L). The nurse should:
18. Withhold all medications.
19. Administer the insulin dose dictated by the sliding scale.
20. Call the physician for specific prescriptions based on the glucose level.
21. Notify the surgery department.

Answer 17

17. 3. The nurse should notify the physician directly for specific prescriptions based on the
       client’s glucose level. The nurse cannot ignore the elevated glucose level. The surgical experience is
       stressful, and the client needs specific insulin coverage during the perioperative period. The nurse
       should not administer the insulin without checking with the surgeon because there are specific
       prescriptions to withhold all medications. It is not necessary to notify the surgery department unless
       the physician cancels the surgery.
       CN: Pharmacological and parenteral therapies; CL: Synthesize

Question 18

18. The nurse is preparing a preoperative teaching plan for a client who is undergoing a bilateral
    breast reduction. Which aspect of the plan is the priority?
19. Reduction of risk potential.
20. Physiologic adaptation.
21. Psychosocial integrity.
22. Health promotion and maintenance.

Answer 18

18. 3. Psychosocial integrity issues, including coping mechanisms, situational role changes, and
       body image changes, are more common in a client who undergoes elective cosmetic surgical
       procedures. Reduction of risk potential, physiologic adaptation, and health promotion and
       maintenance are greater needs for clients who are undergoing surgical correction of functional,
       anatomic, or physiologic defects in nonelective surgical procedures.
       CN: Psychosocial integrity; CL: Analyze

Question 19

19. A client is scheduled to have an elective mandibular osteotomy to correct a mandibular
    fracture sustained in an accident 6 months earlier. Which statement by the client indicates to the nurse
    the client is having difficulty coping?
20. “I will be glad to have my jaw fixed because my wife thinks I do not look like myself.”
21. “I am somewhat afraid to have the surgery but feel OK about it.”
22. “My wife will help me, but I don’t think I will need that much help.”
23. “I am ready to get this over with.”

Answer 19

19. 1. A client should not elect surgery to meet someone else’s needs. The nurse should encourage
       the client to share his feelings and his perception of the deformity and to clarify his reasons for
       electing to have the surgery. It is normal to be somewhat afraid, and it is good if a client says he feels
       “OK” about the surgery. The fact that a client believes that his wife will help him after surgery and
       that he will also be relatively independent reflects appropriate adaptation. It is a common feeling
       among preoperative clients that they are ready to “get this over with,” indicating that the waiting
       period is stressful.
       CN: Psychosocial integrity; CL: Evaluate

Question 20

20. The nurse is assessing a client’s nutritional status before surgery. Which of the following
    observations would indicate poor nutrition in a 5-foot 7-inch female (170.2 cm) client who is 21
    years of age?
21. Poor posture.
22. Brittle nails.
23. Dull expression.
24. Weight of 128 lb (58.1 kg).

Answer 20

20. 2. Brittle nails indicate poor nutrition. Poor posture indicates that the client does not stand up
       straight and use her muscles to support herself. A dull expression reflects the client’s affect and
       emotional status. The client’s weight of 128 lb (58.1 kg) is within normal range.
       CN: Health promotion and maintenance; CL: Analyze

Question 21

21. A 92-year-old who is independent and lives alone has an inguinal hernia repair. Which
    teaching method is the best approach to use for the postoperative and discharge teaching plans?
22. Explaining all the instructions to the client.2. Demonstrating the instructions for the client.
23. Explaining all the instructions to a family member.
24. Writing the instructions down for the client.

Answer 21

21. 4. The Joint Commission and Health Canada require that discharge instructions be written for
       the postoperative client. The nurse will review all instructions orally and will demonstrate any skill.
       Clients need to be given discharge instructions orally and in written form because of stress,
       medications, and the volume of material to be learned. Explaining all the instructions to a familymember is important but does not replace the need for written instructions.
       CN: Health promotion and maintenance; CL: Synthesize

Question 22

22. A client is admitted for an arthroscopy of the right shoulder through same-day surgery. Which
    nurse is responsible for starting the client’s discharge planning?
23. Preadmission nurse.
24. Preoperative nurse.
25. Intraoperative nurse.
26. Postoperative nurse.

Answer 22

22. 1. The preadmission nurse, the first person in contact with the client, starts the discharge
       planning for the client undergoing surgery. All nurses involved with the client, from preadmission
       through postoperative recovery, should continue to reinforce the discharge plan.
       CN: Health promotion and maintenance; CL: Apply

Question 23

23. The nurse is preparing to administer a preoperative medication. Which of the following
    actions should the nurse take first?
24. Have the family present.
25. Ensure that the preoperative shave is completed.
26. Have the client empty the bladder.
27. Make sure the client is covered with a warm blanket.

Answer 23

23. 3. The nurse should have the client empty the bladder before the premedication is
       administered. This will be more comfortable and safe for the client. The purpose of the
       premedication is to decrease anxiety and promote a relaxed state. The client must have an empty
       bladder before being transferred to the operating room, where the client will be immobilized and
       receive IV fluids. The family does not have to be present, but it is usually desired. Shaving the
       operative area is not generally recommended because it can cause small nicks that harbor bacteria. If
       the client must be shaved, it is usually done in the operating room holding area. The client should be
       comfortable at all times and offered a warm blanket before or after the premedication.
       CN: Basic care and comfort; CL: Synthesize

Question 24

24. Before surgery, a client states that she is afraid of surgery because her cousin died in surgery
    when having her tonsils removed. What is the nurse’s best response?
25. Reassure the client that technology has changed over the last 10 years.
26. Encourage the client to further express her concerns.
27. Explain to the client that it is normal to be afraid.
28. Ask the client if anyone else in her family has had trouble when they had surgery.

Answer 24

24. 4. The nurse should immediately think of the congenital metabolic tendency for malignant
       hyperthermia, which occurs in the presence of certain kinds of anesthetics. Whenever a preoperative
       client states that a family member has had problems with anesthesia or surgery, the nurse should
       inquire about the nature of the problems and whether other family members have had similar
       problems. Reassuring the client that technology has changed will do little to affect her fears and
       misses the opportunity to evaluate the risk for malignant hyperthermia. Encouraging the client to
       further express her concerns and reassuring her that her feelings are normal are important, but missing
       a familial tendency of malignant hyperthermia could be fatal.
       CN: Reduction of risk potential; CL: Synthesize

Question 25

25. Which of the following clients has a greater risk for latex allergies?
26. A woman who is admitted for her seventh surgery.
27. A man who works as a sales clerk.
28. A man with well-controlled type 2 diabetes.
29. A woman who is having laser surgery.

Answer 25

25. 1. Clients who have had long-term multiple exposures to latex products, such as would occur
       with six previous surgeries and recoveries, are at increased risk for latex allergies. The nurse should
       explore what types of surgeries these were, how involved the client’s recoveries were, and whether
       signs of latex allergies have occurred in the past. Working as a sales clerk, having type 2 diabetes,
       and undergoing laser surgery do not expose a client to latex or increase the risk of latex allergy.
       CN: Health promotion and maintenance; CL: Analyze

Question 26

26. The nurse is preparing to start an intravenous infusion and has raised the head of the client’s
    bed. After the nurse applies gloves to insert an IV catheter, the client begins to rub her eyes and wipe
    away nasal drainage. Which of the following should the nurse do first?
27. Distract the client’s attention.
28. Assess the client for pain.
29. Remove the IV catheter and assess the client’s vital signs.
30. Lower the head of the client’s bed.

Answer 26

26. 3. The nurse should assess the vital signs of the client who exhibits urticaria, rhinitis, and
       conjunctivitis a few seconds after coming in contact with rubber gloves, a plastic catheter, plastic IV
       tubing, and a plastic IV solution bag. The nurse should recognize that these symptoms indicate that a
       type I allergic reaction is occurring, that the client is responding to the latex, and that the reaction can
       proceed into anaphylactic shock. The client does not need to be distracted or assessed for pain. It is
       not necessary to lower the head of the bed.
       CN: Physiological adaptation; CL: Synthesize

Question 27

27. When evaluating a client’s preoperative cognitive-perceptual pattern, which of the following
    questions should the nurse ask the client?
28. “Do you have difficulty swallowing?”
29. “Do you need special equipment to walk?”
30. “Do you smoke?”
31. “Do you wear glasses?”

Answer 27

27. 4. The nurse would ask the client whether he wears glasses to evaluate his preoperative
       cognitive-perceptual pattern. Asking about the client’s swallowing pattern would evaluate his
       nutritional-metabolic pattern. Asking about his need for special equipment to walk would evaluate his
       activity-exercise pattern. Asking the client about his history of smoking would evaluate his healthperception–health management pattern.
       CN: Physiological adaptation; CL: Analyze

Question 28

28. When attempting to check the pupils of a client scheduled to receive general anesthesia, the
    nurse notices that the client has trouble tilting the head back. Which of the following is the primary
    concern related to this finding?1. The client has limited movement of his neck.
29. The client is at risk for postoperative neck pain.
30. The client is at risk for difficult intubation.
31. The ability to assess the client’s pupils is limited.

Answer 28

28. 3. The client is at risk for a difficult intubation because the neck must be hyperextended to
       pass the endotracheal tube. Assessment of the pupils should not be limited. If the client is positioned
       appropriately during surgery, there is no risk of postoperative neck pain or limited neck movement.
       CN: Reduction of risk potential; CL: Analyze

Question 29

29. A client is to have a below-the-knee amputation. Prior to the surgery, the circulating nurse in
    the operating room should:
30. Insert a Foley catheter.
31. Start an intravenous infusion.
32. Initiate a time-out.
33. Verify that the surgeon possesses the degree of expertise needed.

Answer 29

29. 3. The Universal Protocol is used to prevent wrong site, wrong procedure, and wrong person
       surgery. Actions included in the protocol are as follows: conduct a preprocedure verification
       process, mark the procedure site, and perform a time-out. Exceptions to the Universal Protocol are
       routine or “minor” procedures, such as venipuncture, peripheral IV line placement, insertion of
       oral/nasal drainage or feeding tubes, or Foley catheter insertion. Prior to closure, the physician or
       circulating nurse will initiate a time-out to verbally confirm a review of consent and procedures
       completed; all specimens are identified, accounted for, and accurately labeled; and all foreign bodies
       have been removed. The Chief of Surgery and Medical Director are the ones who will verify the
       surgeons’ levels of expertise.
       CN: Safety and infection control; CL: Apply

Question 30

30. The nurse is developing a plan to teach a client deep-breathing exercises to expand collapsed
    alveoli and prevent postoperative atelectasis and pneumonia. Which of the following steps should be
    included? Select all that apply.
31. Splint or support the incision to promote maximal comfort.
32. Inhale slowly through the nostrils; exhale through pursed lips.
33. Hold the breath for about 5 seconds to expand the alveoli.
34. Repeat this breathing method 5 to 10 times hourly.
35. Close one nostril while inhaling.

Answer 30

30. 1, 2, 3, 4. Splinting the incision is important to avoid stress on the surgical site and to promote
    comfort so that the client will adhere to the plan of care. Inhaling and exhaling are important to bring
    in adequate oxygen and clear out carbon dioxide; however, closing one nostril when inhaling would
    be inappropriate and ineffective. The most important step is asking the client to hold the inhaled
    breath for about 5 seconds, which keeps the alveoli expanded. This step should be stressed the most.
    Repeating the exercise 5 to 10 times hourly is the second most important point to emphasize in this
    teaching plan.
    CN: Reduction of risk potential; CL: Create

Question 31

31. The nurse receives the preoperative blood work report for a client who is scheduled to
    undergo surgery. Which of the following laboratory findings should be reported to the surgeon?
32. Red blood cells, 4.5 million/mm 3 (4.5 × 10 12 /L).
33. Creatinine, 2.6 mg/dL (198 μmol/L).
34. Hemoglobin, 12.2 g/dL (122 g/L).
35. Blood urea nitrogen, 15 mg/dL (5.3 mmol/L).

Answer 31

31. 2. The nurse should call the surgeon for a serum creatinine level of 2.6 mg/dL (198 μmol/L),
       which is higher than the normal range of 0.5 to 1.0 mg/dL (44.2 to 88.4 μmol/L). An elevated serum
       creatinine value indicates that the kidneys are not filtering effectively and has important implications
       for the surgical client because many anesthesia and analgesia medications need to be filtered out
       through the renal system. The red blood cell count, hemoglobin level, and blood urea nitrogen level
       are within normal limits and do not need to be reported to the surgeon.
       CN: Reduction of risk potential; CL: Analyze

Question 32

32. A client will receive IV midazolam hydrochloride (Versed) during surgery. Which of the
    following should the nurse determine as a therapeutic effect?
33. Amnesia.
34. Nausea.
35. Mild agitation.
36. Blurred vision.

Answer 32

32. 1. Midazolam hydrochloride causes antegrade amnesia or decreased ability to remember
       events that occurred around the time of sedation. Nausea, mild agitation, and blurred vision are
       adverse effects of Versed.
       CN: Pharmacological and parenteral therapies; CL: Evaluate

Question 33

33. When administering IV midazolam hydrochloride (Versed) the nurse should:
34. Assess the blood pressure.
35. Monitor the pulse oximeter.
36. Encourage slow, deep breaths.
37. Explain relaxation techniques.

Answer 33

33. 3. The client should be encouraged to take slow, deep breaths because midazolam
       hydrochloride is a respiratory depressant. The nurse should assess the client’s blood pressure,
       monitor the pulse oximeter, and keep the client calm and relaxed, but the client will slip into very
       shallow, ineffective breathing if not encouraged to deep breathe.
       CN: Pharmacological and parenteral therapies; CL: Synthesize

Question 34

34. When the nurse administers IV midazolam hydrochloride (Versed), the client demonstrates
    signs of an overdose. The nurse should next collaborate with the surgical team to:
35. Ventilate with an oxygenated bag-valve mask (Ambu bag).
36. Shock the client with ECG paddles.
37. Administer 0.5 mL 1:1,000 epinephrine.
38. Titrate flumazenil (Romazicon).

Answer 34

34. 1. The nurse should have an bag-valve mask (Ambu bag) in the client’s room because
       midazolam hydrochloride can lead to respiratory arrest if it is administered too quickly. The client
       does not need to be shocked back into a normal rhythm or to receive epinephrine unless cardiac
       compromise developed after the respiratory arrest. The client would receive titrated dosing of
       flumazenil to reverse the Versed, but first the nurse should ventilate the client.
       CN: Pharmacological and parenteral therapies; CL: Synthesize

Question 35

35. Metoclopramide is prescribed as a premedication for a client about to undergo agastroduodenoscopy. Which of the following is the expected therapeutic effect?
36. Increased gastric pH.
37. Increased gastric emptying.
38. Reduced anxiety.
39. Inhibited respiratory secretions.

Answer 35

35. 2. Metoclopramide is an antiemetic given because of its gastric emptying ability, which is
       necessary in gastrointestinal procedures. It does not increase gastric pH, reduce anxiety, or inhibit
       respiratory secretions.
       CN: Pharmacological and parenteral therapies; CL: Evaluate

Question 36

36. What therapeutic outcome does the nurse expect for a client who has received a
premedication of glycopyrrolate?
1. Increased heart rate.
2. Increased respiratory rate.
3. Decreased secretions.
4. Decreased amnesia.

Answer 36

36. 3. Glycopyrrolate is an anticholinergic given for its ability to reduce oral and respiratory
       secretions before general anesthesia. Increased heart rate and respiratory rate would be adverse
       effects of the drug. Amnesia should not be an effect of the drug.
       CN: Pharmacological and parenteral therapies; CL: Apply

Question 37

37. Atropine sulfate (Atropine) is contraindicated as a preoperative medication for which of the
    following clients? Select all that apply.
38. A client with diabetes.
39. A client with glaucoma.
40. A client with urine retention.
41. A client with bowel obstruction.

Answer 37

37. 2, 3, 4. The nurse can administer atropine sulfate, an anticholinergic, to a client with diabetes.
    Atropine is contraindicated in clients with glaucoma because it increases intraocular pressure. It is
    contraindicated in clients with urine retention because it relaxes smooth muscle in the urinary tract
    and can exacerbate the problem. It is contraindicated in clients with gastrointestinal obstruction
    because it relaxes smooth muscle in the gut and may worsen the obstruction.
    CN: Pharmacological and parenteral therapies; CL: Apply

Question 38

38. After the nurse has administered droperidol, care is taken to move the client slowly based on
    the knowledge of droperidol’s effect on the:
39. Central nervous system.
40. Respiratory system.
41. Cardiovascular system.
42. Psychoneurologic system.

Answer 38

38. 3. Because droperidol causes tachycardia and orthostatic hypotension, the client should be
       moved slowly after receiving this medication. Droperidol produces a tranquilizing effect and does
       affect the central nervous, respiratory, or psychoneurologic system, but the primary reason for moving
       the client slowly is the potential cardiovascular effects of hypotension.
       CN: Pharmacological and parenteral therapies; CL: Apply

Question 39

39. A client is to receive enoxaparin (Lovenox) 6 hours before the scheduled time of
    laparoscopic vaginal assisted hysterectomy. Which of the following effects does the nurse recognize
    as an intended therapeutic action of the enoxaparin?
40. Increase in red blood cell production.
41. Reduction of postoperative thrombi.
42. Decrease in postoperative bleeding.
43. Promotion of tissue healing.

Answer 39

39. 2. Research findings have shown that enoxaparin and low-dose heparin given 6 to 12 hours
       preoperatively reduce the incidence of deep vein thrombosis and pulmonary emboli by 60% in clients
       who are at risk for deep vein thrombosis, such as those who are placed in the lithotomy position.
       Lovenox has no effect on red blood cell production, postoperative bleeding, or tissue healing.
       CN: Pharmacological and parenteral therapies; CL: Evaluate

Question 40

40. During the preoperative interview, the nurse obtains information about the client’s medication
    history. Which of the following is not necessary to record about the client?
41. Current use of medications, herbs, and vitamins.
42. Over-the-counter medication use in the last 6 weeks.
43. Steroid use in the last year.
44. All drugs taken in the last 18 months.

Answer 40

40. 4. The nurse does not need to ask about all drugs used in the last 18 months unless the client is
       still taking them. The nurse does need to know all drugs the client is currently taking, including herbs
       and vitamins, over-the-counter medications such as aspirin taken in the past 6 weeks, the amount of
       alcohol consumed, and use of illegal drugs, because these can interfere with the anesthetic and
       analgesic agents. Steroid use is of concern because it can suppress the adrenal cortex for up to 1 year,
       and supplemental steroids may need to be administered in times of stress such as surgery.
       CN: Reduction of risk potential; CL: Apply

Question 41

41. When the nurse is conducting a preoperative interview with a client who is having a vaginal
    hysterectomy, the client states that she forgot to tell her doctor that she had a total hip replacement 3
    years ago. The nurse communicates this information to the perioperative nurse because:
42. The prosthesis may cause a problem with the electrosurgical unit used to control bleeding.
43. The client should not have her hip externally rotated when she is positioned for the procedure.
44. The perioperative nurse can inform the rest of the team about the total hip replacement.4. There is not enough time to notify the surgeon and note this finding on the history and physical
    information before the procedure.

Answer 41

41. 2. The nurse should notify the surgery department and document the past surgery in the chart in
       the preoperative notes so that the client’s hip is not externally rotated and the hip dislocated while she
       is in the lithotomy position. The prosthesis should not be a problem as long as the perioperative nurseplaces the grounding pad away from the prosthesis site. The perioperative nurse will inform the rest
       of the team, but the primary reason to inform the perioperative nurse is related to safe positioning of
       the client. The surgeon can hand-write an addendum to the history and initial and date the entry. The
       history and physical information can then be retyped at a later date.
       CN: Reduction of risk potential; CL: Apply

Question 42

42. The nurse learns that a client who is scheduled for a tonsillectomy has been taking 40 mg of
    oral prednisone daily for the last week for poison ivy on the leg. What is the nurse’s best action?
43. Document the prednisone with current medications.
44. Notify the surgeon of the poison ivy.
45. Notify the anesthesiologist of the prednisone administration.
46. Send the client to surgery.

Answer 42

42. 3. The nurse should notify the anesthesiologist because supplemental prednisone suppresses
       the adrenal cortex’s natural ability to produce increased corticosteroids in times of stress such as
       surgery. The anesthesiologist may need to prescribe supplemental steroid coverage during the
       perioperative period. The nurse should document the prednisone with current medications, but it is a
       priority to inform the anesthesiologist. Because the poison ivy is not in the surgical field, the surgeon
       does not need to be called regarding the skin disruption.
       CN: Pharmacological and parenteral therapies; CL: Synthesize

Question 43

43. A client who is scheduled for an open cholecystectomy has a 20-pack-year history of
    smoking. For which postoperative complication is the client most at risk?
44. Deep vein thrombosis.
45. Atelectasis and pneumonia.
46. Delayed wound healing.
47. Prolonged immobility.

Answer 43

43. 2. The client who has a significant cigarette smoking history and an operative manipulation
       close to the diaphragm (the gallbladder is against the liver) is at increased risk for atelectasis and
       pneumonia. Postoperatively, this client will be reluctant to deep breathe because of pain, in addition
       to having residual lung damage from smoking. Therefore, the client is at greater-than-average risk for
       pulmonary complications. The client does not have an increased risk of prolonged immobility (unless
       slowed by a respiratory problem), deep vein thrombosis (as long as the client performs leg
       exercises), or delayed wound healing (as long as the client maintains appropriate nutrition).
       CN: Reduction of risk potential; CL: Analyze

Question 44

44. The family cannot go with the client past the doors that separate the public from the restricted
    area of the operating room suite. These measures are designed to:
45. Protect the privacy of clients.
46. Prevent electrical sparks that could ignite the anesthetic gases.
47. Separate the family from the surgical team while they are working on the client.
48. Provide for an aseptic environment to prevent infection.

Answer 44

44. 4. The purpose of separating the public from the restricted-attire area of the operating room is
       to provide an aseptic environment and prevent contamination of the environment by organisms. The
       client’s privacy is protected, but the main purpose is infection control.
       CN: Safety and infection control; CL: Apply

Question 45

45. Which of the following clients is most at risk for potential hazards from the surgical
experience?
1. An 80-year-old client.
2. A 50-year-old client.
3. A 30-year-old client.
4. A 5-year-old client.

Answer 45

45. 1. The 80-year-old client is at greater risk because an older adult client is more likely to have
       comorbid conditions, a less-effective immune system, and less collagen in the integumentary system.
       CN: Physiological adaptation; CL: Analyze

Question 46

46. Which pediatric surgery client should not play with a balloon?
47. A child having the 15th laser surgery for a hemangioma.
48. A child having a tonsillectomy.
49. A child having an inguinal hernia repair.
50. A child having an orchiopexy.

Answer 46

46. 1. The child having the 15th laser procedure for a hemangioma should not have a balloon
       unless it is latex free because this child has had numerous exposures to latex thus far. If the client has
       not already developed some sensitivity, the nurse should help the family be aware of latex products to
       avoid when possible. A client who is having a tonsillectomy, inguinal hernia repair, or orchiopexy is
       probably having surgery for the first time and has not been exposed to latex, although it is a good
       practice to use latex-free products whenever possible and to inquire about past exposure.
       CN: Safety and infection control; CL: Synthesize

Question 47

47. In which of the following clients is an autotransfusion possible?
48. The client who has cancer.
49. The client who is in danger of cardiac arrest.
50. The client with a contaminated wound.
51. The client with a ruptured bowel.

Answer 47

47. 2. An autotransfusion is acceptable for the client who is in danger of cardiac arrest. An
       autotransfusion cannot be collected from a client who has cancer, a contaminated wound, or
       contamination from Escherichia coli because of a ruptured bowel.
       CN: Pharmacological and parenteral therapies; CL: Apply

Question 48

48. The nurse teaches a client who had cystoscopy about the urge to void when the procedure is
    over. What other teaching should be included?
49. Ignore the urge to void.
50. Increase intake of fluids.
51. Ask for the bedpan.
52. Ring for assistance to go to the bathroom.

Answer 48

48. 2. After a scope or catheter has been inserted into the urethra, the mucosal membrane is
       irritated and the client feels the need to void even though the bladder may not be full. The nurseshould encourage the client to force fluids to make the urine dilute. The client should not ignore the
       urge to void. The client should be encouraged to use the bathroom; there is no need to use the bedpan.
       The client does not need assistance to the bathroom because this procedure does not require any
       anesthesia except a topical anesthetic for the male client.
       CN: Basic care and comfort; CL: Synthesize

Question 49

49. Which of the following nursing interventions is most important in preventing postoperative
complications?
1. Progressive diet planning.
2. Pain management.
3. Bowel and elimination monitoring.
4. Early ambulation.

Answer 49

49. 4. Early ambulation is the most significant general nursing measure to prevent postoperative
       complications and has been advocated for more than 40 years. Walking the client increases vital
       capacity and maintains normal respiratory functioning, stimulates circulation, prevents venous stasis,
       improves gastrointestinal and genitourinary function, increases muscle tone, and increases wound
       healing. The client should maintain a healthy diet, manage pain, and have regular bowel movements.
       However, early ambulation is the most important intervention.
       CN: Reduction of risk potential; CL: Synthesize

Question 50

100/60The Client Who Is Receiving or Recovering from
Anesthesia
50. A client who had a gastrectomy has been in the postanesthesia recovery room for 30 minutes
when the vital signs suddenly change. The nurse checks the recovery room record (see chart). In
addition to notifying the physician, what other action should the nurse take immediately?

6/30/07
Time 1:45 pm 
PR 70
RR 12
BP 100/60
TEMP 98 F (36.7 C)

6/30/07
2 pm
PR 82
RR 14
BP 110/70
TEMP 99 F (37.2 C)

6/30/07
2:15 pm
PR 90
RR 20
BP 140/90
TEMP 102 F (38.9 C)

1. Administer dantrolene.
2. Elevate the head of the bed 30 degrees.
3. Administer a bolus of IV fluids.
4. Insert an indwelling urinary catheter.

Answer 50

The Client Who Is Receiving or Recovering from Anesthesia
50. 1. The client is demonstrating signs of malignant hyperthermia. Unless the body is cooled and
the influx of calcium into the muscle cells is reversed, lethal cardiac arrhythmia and hypermetabolism
occur. The client’s body temperature can rise as high as 109°F (42.8°C) as body muscles contract.
Dantrolene, an IV skeletal muscle relaxant, is used to reverse muscle rigidity. Elevating the head of
the bed will not reverse the hyperthermia. Adding fluids and inserting an indwelling urinary catheter
are not immediately beneficial steps in reversing the progression of malignant hyperthermia.
CN: Management of care; CL: Synthesize

Question 51

51. The nurse should do which of the following to decrease a female client’s anxiety about being
    placed in the lithotomy position for surgery?
52. Explain in detail what will occur in the operating room.
53. Determine what the client is concerned about.
54. Pad the stirrups for comfort.
55. Reassure the client that an all-female surgical team will be present.

Answer 51

51. 2. The nurse should first attempt to find out what the client’s concerns are and address them.
       Providing too much information with details can increase the client’s anxiety and does not address
       specific concerns. Padding the stirrups will provide comfort, but does not address concerns. Having
       an all-female team may or may not be the source of the client’s concerns.
       CN: Psychosocial integrity; CL: Synthesize

Question 52

52. A client is to receive medication by a continuous nerve block route. Prior to insertion of the
catheter by the anesthesiologist, the nurse must document which of the following? Select all that
apply.
1. Vital signs.
2. Weakness/numbness.
3. Location of pain.
4. Nausea and/or vomiting.
5. Allergies.

Answer 52

52. 1, 2, 3, 5. Prior to the catheter insertion, the nurse must document location of pain and pain
    rating, level of consciousness (LOC), vital signs, and weakness or numbness, especially in the legs,
    the nurse should also ask if the client has allergies before medication administration.
    CN: Safety and infection control; CL: Synthesize

Question 53

53. Which of the following instructions should be given to the client prior to placement of an
    epidural/intrathecal catheter? Select all that apply.
54. Take only a shower and not a tub bath while the catheter is in place, unless instructed
    otherwise by the physician.2. Report nausea, vomiting, itching, numbness, or weakness in legs.
55. Call for assistance with turning or repositioning while in bed.
56. There must be a physician prescription for out-of-bed activity and ambulating.
57. Take shallow breaths to prevent dislodging the catheter.

Answer 53

53. 2, 3, 4. Complications may develop when a client is receiving medication via epidural,
    intrathecal, or continuous nerve block routes. The following complications must be reported to the
    physician immediately: dislodged catheter, disconnected tubing or occluded line, pruritus, nausea
    and/or vomiting, pain at insertion site, loose or wet dressings. The client should call for assistance
    when getting out of bed or ambulating. The client should not bathe while the catheter is in place. The
    client does not need to take shallow breaths and should be encouraged to breathe normally and take
    deep breaths regularly.
    CN: Safety and infection control; CL: Synthesize

Question 54

54. A client has been in the position shown in the figure for surgery. The nurse should document
    that the client has been in which of the following positions?
55. Reverse Trendelenburg.
56. Low Fowler’s.
57. High lithotomy.
58. Prone.

Answer 54

54. 3. The client is in the lithotomy position. The reverse Trendelenburg position is when the
       client is lying supine with the head lower than the rest of the body. A low Fowler’s position is when
       the client is sitting up at a 30- to 45-degree angle. The prone position is when the client is lying facedown.
       CN: Management of care; CL: Apply

Question 55

55. A client arrives from surgery to the postanesthesia care unit. Which of the following
    respiratory assessments should the nurse complete first?
56. Oxygen saturation.
57. Respiratory rate.
58. Breath sounds.
59. Airway flow.

Answer 55

55. 4. Airway flow is always the first assessment. Once the nurse establishes that the client has a
       patent airway, the pulse oximeter is applied to measure the oxygen saturation, the respiratory rate is
       counted, and the breath sounds are auscultated bilaterally.
       CN: Physiological adaptation; CL: Analyze

Question 56

56. The nurse assesses vital signs on a client who has had epidural anesthesia. For which of the
following should the nurse assess next?
1. Bladder distention.
2. Headache.
3. Postoperative pain.
4. Ability to move the legs.

Answer 56

56. 1. The last area to regain sensation is the perineal area, and the nurse should check the client
       for a distended bladder. The client has received a large volume of IV fluids since the epidural was
       inserted, and the client may not feel the urge to void or may be unable to void. In that case, the nurse
       should obtain a prescription to catheterize the client before the bladder becomes so distended as to
       cause bladder spasms. The nurse should assess for a spinal headache, postoperative pain, and the
       client’s ability to move after determining whether the bladder is distended.
       CN: Reduction of risk potential; CL: Analyze

Question 57

57. When assessing a client who has had spinal anesthesia, which of the following would the
    nurse expect to find?
58. The client feels pain before moving the legs.2. The blood pressure is significantly increased.
59. Sensation returns to the toes first, then progresses to the perineal area.
60. The client has a headache while in the lying position.

Answer 57

57. 3. Spinal anesthesia is an extensive conduction nerve block that is produced when a local
       anesthetic is introduced into the subarachnoid space at the lumbar level. A few minutes after induction
       of a spinal anesthetic, anesthesia and paralysis affect the toes and perineum and then, gradually the
       legs and abdomen. When the autonomic nervous system is blocked, vasodilation occurs and
       hypotension occurs. The client will feel sensation to the toes before the perineal area. A spinal
       headache due to loss of fluid is a severe headache that occurs while in the upright position, but is
       relieved in the lying position.
       CN: Physiological adaptation; CL: Analyze

Question 58

58. The nurse in the postanesthesia care unit notes that one of the client’s pupils is larger than the
    other. The nurse should:
59. Rate the client on the Glasgow Coma Scale.
60. Administer oxygen.
61. Check the client’s baseline data.
62. Call the surgeon.

Answer 58

58. 3. The nurse should check the client’s baseline data to ascertain whether the client’s pupil has
       always been enlarged or this is a new finding. The preoperative assessment is valuable as the
       baseline for comparison of all subsequent assessments made throughout the perioperative period. The
       nurse may determine that a more involved neurologic examination is indicated or may choose to
       assess other signs using the Glasgow Coma Scale, administer oxygen, or call the surgeon, but the
       nurse still needs to know the baseline data before proceeding.
       CN: Physiological adaptation; CL: Synthesize

Question 59

59. A client is admitted to the postanesthesia care unit following a left hip replacement. The
    initial nursing assessment is: T 96.6°F (35.9°C), Pulse 90, RR 14, and BP 128/80. The client only
    responds with moaning when spoken to. The nurse should first:
60. Observe the surgical dressing.
61. Position the client on the right side.
62. Remove the oral airway remaining from surgery.
63. Administer sedation reversal agent such as flumazenil.

Answer 59

59. 2. During the immediate postanesthesia period, the unconscious client should be positioned on
       the side to maintain an open airway and promote drainage of secretions; because of the type of
       surgery, the client should be positioned on the right side. Removing the oral airway and observing the
       surgical dressing is appropriate, but other actions should be implemented before these. Respiratory
       depression can occur in a client after a procedure requiring sedation. If the client cannot be aroused,
       the sedation drugs can be reversed by administering a sedation reversal agent, but this client’s
       respiratory rate is 14, and the client is moaning, indicating expected recovery from anesthetics.
       CN: Physiological adaptation; CL: Synthesize

Question 60

60. The surgical floor receives a client from the postanesthesia care unit. Assessment reveals that
    the client has a patent airway and stable vital signs. The nurse should next:
61. Check the dressing for signs of bleeding.
62. Empty any peri-incisional drains.
63. Assess the client’s pain level.
64. Assess the client’s bladder.

Answer 60

60. 1. The nurse should check the dressing for signs of bleeding to establish a baseline for future
       assessments of the dressing and to verify that there is no obvious sign of hemorrhage. The nurse does
       not need to empty peri-incisional drains at this time. All drains should have been emptied and
       reconstituted by the postanesthesia care nurse before the client was transferred to the surgical floor.
       Assessing the client’s pain level and assessing the bladder are important; however, it is moreimportant to assess the surgical site for bleeding because hemorrhage is a life-threatening
       complication of any surgical procedure.
       CN: Physiological adaptation; CL: Synthesize

Question 61

61. When preparing a teaching plan for an adult client about general anesthesia induction, which
    explanation would be most appropriate?
62. “Your premedication will put you to sleep.”
63. “You will breathe in an inhalant anesthetic mixed with oxygen through a facial mask and
    receive intravenous medication to make you sleepy.”
64. “You will receive intravenous medication to make you sleepy.”
65. “You will breathe in medication through a facial mask to make you sleepy.”

Answer 61

61. 2. Adult clients are induced for general anesthesia by breathing in an inhalant anesthetic mixed
       with oxygen through a facial mask and receiving intravenous medication to make them sleepy. Clients
       are not induced with the premedication. Clients usually are not induced with the intravenous infusion
       or the mask alone.
       CN: Basic care and comfort; CL: Synthesize

Question 62

62. A client with impaired cardiac functioning is at risk during anesthesia induction with
    thiopental sodium (Sodium Pentothal) because this drug causes:
63. Bradycardia.
64. Complete muscle relaxation.
65. Hypotension.
66. Tachypnea.

Answer 62

62. 3. Sodium pentothal, a short-acting barbiturate, can cause hypotension, which may be
       especially problematic for the client with impaired cardiac functioning. Sodium pentothal does not
       cause bradycardia, complete muscle relaxation, hypertension, or tachypnea.
       CN: Pharmacological and parenteral therapies; CL: Apply

Question 63

63. The nurse anticipates that a client who has received propofol (Diprivan) as the induction and
    maintenance agent for general anesthesia will most likely experience:
64. Minimal nausea and vomiting.
65. Hypotension.
66. Slow induction of anesthesia.
67. Small tremors of the skeletal muscles.

Answer 63

63. 1. Propofol, a nonbarbiturate anesthetic, causes less nausea and vomiting because of a direct
       antiemetic action. It does not cause hypotension or skeletal muscle movement, and it does not act
       slowly.
       CN: Pharmacological and parenteral therapies; CL: Analyze

Question 64

64. What is the main reason desflurane (Suprane) and sevoflurane (Ultane), volatile liquidanesthesia agents, are used for surgical clients who go home the day of surgery?
65. These agents are better tolerated.
66. These agents are predictable in their cardiovascular effects.
67. These agents are nonirritating to the respiratory tract.
68. These agents are rapidly eliminated.

Answer 64

64. 4. Desflurane and sevoflurane are volatile liquid anesthesia agents that are used for outpatient
       surgeries primarily because they are rapidly eliminated. They have the added benefits of being better
       tolerated and nonirritating to the respiratory tract, and they have predictable cardiovascular effects.
       However, rapid elimination is an important consideration for outpatient procedures.
       CN: Pharmacological and parenteral therapies; CL: Apply

Question 65

65. A 250-lb (113.4-kg) male client recovering from general anesthesia has the following
    assessment findings: pulse, 150 bpm; blood pressure, 90/50 mm Hg; respiratory rate, 28 breaths/min;
    tympanic temperature, 99.8°F (37.7°C); and rigid muscles. The nurse determines that the client is:
66. Recovering as expected from the anesthesia and continues monitoring him.
67. Exhibiting the effects of excessive blood loss experienced in the operating room and increases
    the rate of his IV infusion.
68. In the early stages of malignant hyperthermia and obtains emergency medications and notifies
    the anesthesiologist.
69. In pain and offers him pain medication.

Answer 65

65. 3. A heart rate of 150 bpm or greater, hypotension, and muscle rigidity are early signs of
       malignant hyperthermia. The nurse should quickly assemble emergency supplies and personnel
       because malignant hyperthermia is potentially and rapidly fatal in more than 50% of cases. Rapid,
       extreme rise in temperature is a late sign. Another factor influencing the analysis is that the client has
       a large body frame, and having large, bulky muscles is a risk factor for malignant hyperthermia. The
       client’s vital signs are well out of the range of normal; analysis of the data and swift intervention are
       indicated. Excessive blood loss is unlikely and the data do not support this conclusion. Although
       clients do have changes in vital signs when in acute pain, the nurse would expect the client to be
       hypertensive, not hypotensive.
       CN: Physiological adaptation; CL: Analyze

Question 66

66. The nurse is assessing a client recovering from anesthesia. Which of the following is an early
indicator of hypoxemia?
1. Somnolence.
2. Restlessness.
3. Chills.
4. Urgency.

Answer 66

66. 2. One of the earliest signs of hypoxia is restlessness and agitation. Decreased level of
       consciousness and somnolence are later signs of hypoxia. Chills can be related to the anesthetic agent
       used but are not indicative of hypoxia. Urgency is not related to hypoxia.
       CN: Physiological adaptation; CL: Analyze

Question 67

67. The nurse is to administer flumazenil (Mazicon) IV for reversal of sedation. Which of the
    following interventions should be included in the care plan? Select all that apply.
68. Administer the medication as a 2-mg bolus.
69. Give the medication undiluted in incremental doses.
70. Be alert for shivering and hypotension.
71. Use only a free-flowing IV line in a large vein.
72. Monitor the client’s level of consciousness.

Answer 67

67. 2, 3, 4, 5. Flumazenil should be administered in small quantities such as 0.2 mg over 15 to 30
    seconds but never as a bolus. Flumazenil may be given undiluted in incremental doses. Adverse
    effects of flumazenil may include shivering and hypotension. The nurse should monitor the client’s
    level of consciousness while recovering from sedation. Flumazenil should be administered through a
    free-flowing IV line in a large vein because extravasation causes local irritation.CN: Pharmacological and parenteral therapies; CL: Synthesize

Question 68

68. An 80-year-old client had spinal anesthesia for a transurethral resection of the prostate and
    received 4,000 mL of room temperature isotonic bladder irrigation. He now has continuous irrigation
    through a three-way indwelling urinary catheter. Which postoperative nursing intervention is most
    important to include in his plan of care?
69. Empty the catheter drainage bag.
70. Cover the client with warm blankets.
71. Hang new bags of irrigation.
72. Turn the client.

Answer 68

68. 2. It is important for the nurse to cover this client with warm blankets because he is at high
       risk for hypothermia secondary to age, spinal anesthesia, placement in a lithotomy position in the cool
       operating room for 1.5 hours, instillation of 4,000 mL of room temperature bladder irrigation, and
       ongoing bladder irrigation. Spinal anesthesia causes vasodilation, which results in heat loss from the
       core to the periphery. The nurse will empty the catheter drainage bag and hang new bags of irrigation
       as needed, but the client’s potential for hypothermia should be addressed first. The client will not be
       turned at this time.
       CN: Reduction of risk potential; CL: Synthesize

Question 69

69. Which of the following clients is expected to retain anesthetic agents longest?
70. A client who is 6 feet 2 inch tall (188 cm) and weighs 250 lb (113.4 kg).
71. A client who is 5 feet 4 inch (162.6 cm) tall and weighs 110 lb (49.9 kg).
72. A client who is 5 feet 1 inch (155 cm) tall and weighs 200 lb (90.7 kg).
73. A client who is 5 feet 7 (170.2 cm) inch tall and weighs 145 lb (65.8 kg).

Answer 69

69. 3. The client who is 5 feet 1 inch tall (155 cm) and weighs 200 lb (90.7 kg) would be
       expected to retain the anesthetic agents longer because adipose tissue absorbs the drug before the
       desired systemic effect is reached for anesthesia maintenance. Nursing interventions are aimed at
       encouraging the obese client to turn, cough, and deep breathe despite feeling sleepy and tired. The
       sooner this client ambulates, the sooner the retained anesthesia will be worked out of the adipose
       tissue.
       CN: Reduction of risk potential; CL: Analyze

Question 70

70. An awake postoperative client received an intravenous regional nerve block (Bier block) in
    the arm that is now casted and elevated on a pillow. What action should the nurse encourage the clientto avoid until sensation returns?
71. Holding the operated arm close to the face.
72. Holding the operated arm with the unoperated arm.
73. Using the unoperated arm.
74. Using pain medication

Answer 70

70. 1. The nurse should encourage the client to avoid holding the operated arm, the arm with the
       intravenous regional nerve block (Bier block), close to the face because the client does not have
       motor control over it. With the cast in place, the client could hit the eye, nose, or mouth and cause
       soft-tissue damage. It is acceptable for the client to hold the operated arm with the unoperated arm or
       to use the unoperated arm. The nurse should administer the analgesic before the intravenous regional
       anesthetic completely wears off so that the pain does not peak before pain medication is
       administered.
       CN: Reduction of risk potential; CL: Synthesize

Question 71

71. The physician prescribed IV naloxone (Narcan) to reverse the respiratory depression from
    morphine administration. After administration of the naloxone the nurse should:
72. Check respirations in 5 minutes because naloxone is immediately effective in relieving
    respiratory depression.
73. Check respirations in 30 minutes because the effects of morphine will have worn off by then.
74. Monitor respirations frequently for 4 to 6 hours because the client may need repeated doses of
    naloxone.
75. Monitor respirations each time the client receives morphine sulfate 10 mg IM.

Answer 71

71. 3. The nurse should monitor the client’s respirations closely for 4 to 6 hours because naloxone
       has a shorter duration of action than opioids. The client may need repeated doses of naloxone to
       prevent or treat a recurrence of the respiratory depression. Naloxone is usually effective in a few
       minutes; however, its effects last only 1 to 2 hours and ongoing monitoring of the client’s respiratory
       rate will be necessary. The client’s dosage of morphine will be decreased or a new drug will be
       prescribed to prevent another instance of respiratory depression.
       CN: Pharmacological and parenteral therapies; CL: Synthesize

Question 72

72. The nurse should monitor the surgical client closely for which clinical manifestation with the
administration of naloxone (Narcan)?
1. Dizziness.
2. Biliary colic.
3. Bleeding.
4. Urine retention.

Answer 72

72. 3. Abnormal coagulation test results have been associated with naloxone (Narcan), and the
       nurse should monitor surgical clients closely for bleeding. Dizziness, biliary colic, and urine
       retention are not associated with naloxone.
       CN: Pharmacological and parenteral therapies; CL: Analyze

Question 73

73. The nurse anticipates that the client who has received epidural anesthesia is at decreased risk
for a spinal headache because:
1. A 17G needle is used.
2. A subarachnoid injection is made.
3. A noncutting needle is used.
4. A faster onset occurs.

Answer 73

73. 3. The client who receives epidural anesthesia is at decreased risk for a headache because a
       noncutting needle is used instead of a side angle-cutting needle. The epidural needle is a 25G to 27G
       needle, which is much smaller than a 17G needle. The injection made for an epidural is an extradural,
       not a subarachnoid, injection as for spinal anesthesia. The onset of spinal anesthesia is faster because
       a larger dose of medication is usually administered.
       CN: Physiological adaptation; CL: Analyze

Question 74

74. Which of the following systems is not blocked by spinal anesthesia?
75. The sympathetic nervous system.
76. The sensory system.
77. The parasympathetic nervous system.
78. The motor system.

Answer 74

74. 3. Spinal anesthesia does not cause parasympathetic blockage. The spinal anesthetic agent
       usually is injected into the L2 subarachnoid space, where it produces sympathetic, sensory, and motor
       blockade.
       CN: Pharmacological and parenteral therapies; CL: Apply

Question 75

The nurse is to administer midazolam (Versed) 2.5 mg. The medication is available in a 5 mg/mL
vial. The nurse should administer
_______________________ mL.

Answer 75

75. 0.5 mL. Multiply 2.5 mg/5 mg by the unknown X mg/1 mL. Cross-multiply to get 5X = 2.5 mL.
    Divide both sides of the equation by 5 to get X = 0.5 mL.
    CN: Pharmacological and parenteral therapies; CL: Apply

Question 76

76. A client in the postanesthesia care unit is being actively rewarmed with an external warming
    device. How often should the nurse monitor the client’s body temperature?
77. Every 5 minutes.
78. Every 10 minutes.
79. Every 15 minutes.
80. Every 20 minutes.

Answer 76

76. 3. In order to prevent burns, the nurse should assess the client’s temperature every 15 minutes
       when using an external warming device.
       CN: Safety and infection control; CL: Apply

Question 77

The Client Who Has Had Surgery
77. A client requests a narcotic analgesic shortly after the oncoming nurse receives change-of-
shift report. The nurse who is leaving reported that the client had received morphine 10 mg (IM)
within the past hour. In what order from first to last should the oncoming registered nurse (RN) do the
following actions?
1. Validate with the outgoing RN that morphine 10 mg (IM) had been administered.
2. Assess the client for manifestations of pain.
3. Check the medication documentation as to when morphine 10 mg (IM) was dispensed and to
whom.
4. Check to ascertain if any discrepancy had been documented with accompanying reason/s.

Answer 77

The Client Who Has Had Surgery
77. 2, 3, 1, 4. The oncoming nurse should first assess the client for pain. Next, the nurse should
check the documentation and then validate with the nurse who reported giving the medication that the
medication had been given. Finally, the nurse should determine if there is a discrepancy between
administration and documentation.
CN: Management of care; CL: Synthesize

Question 78

78. On the first day after surgery, a client has been breathing room air. The vital signs are normal,
    and the O 2 saturation is 89%. The nurse should first:
79. Lower the head of the bed.
80. Notify the physician.
81. Assist the client to take several deep breaths and cough.
82. Administer oxygen by nasal cannula as prescribed at 2 L/min.

Answer 78

78. 3. Deep breathing and coughing help to increase lung expansion and prevent the accumulation
       of secretions in postoperative clients. An O 2 saturation of 89% is not an unexpected or emergent
       finding immediately following surgery. Frequent coughing and deep breathing will likely quickly
       remedy an O 2 saturation of 89% but will also effectively help to prevent atelectasis and pneumonia in
       the remainder of the postoperative period. It is not necessary to notify the physician prior to
       intervening with coughing/deep breathing, and it is not appropriate to position this client with the
       head of bed lower because this would make it more difficult for the client to expectorate secretions.
       Oxygen may be necessary, but the nurse should assist the client to cough and deep breath first, in an
       attempt to improve his oxygenation and saturation.
       CN: Physiological integrity; CL: Synthesize

Question 79

79. A client has been unable to void since having abdominal surgery 7 hours ago. The nurse
    should first:
80. Encourage the client to increase oral fluid intake.
81. Insert an intermittent urinary catheter.
82. Notify the health care provider.
83. Assist the client up to the toilet to attempt to void.

Answer 79

79. 4. Urinary retention is common following surgery with anesthesia, following childbirth, or as
       a result of specific medication use, for example narcotics for pain. Clients should be assisted to an
       anatomically comfortable position to void prior to resorting to more invasive methods such as
       intermittent or indwelling catheterization to manage urinary retention. Difficulty voiding after delivery
       is expected, and it is not necessary to notify the physician. While increasing fluid intake is important,
       it will not help the client void now.
       CN: Basic care and comfort; CL: Synthesize

Question 80

80. Following abdominal surgery, a client refuses to deep breathe and cough every 2 hours as
    prescribed. The nurse should do which of the following first?
81. Ask the client’s wife to insist that the client take the deep breaths every 2 hours.
82. Respect the client’s wishes and turn the client from side-to-side more frequently.
83. Suggest that the client increase the daily fluid intake to at least 2,500 mL.
84. Explain the risks of not expanding the lungs and why the exercise is important.

Answer 80

80. 4. Following surgery, clients are at risk for respiratory complications and should take the
       necessary actions to prevent these. The nurse should first be sure that the client understands how to do
       the exercises and the potential complications if they are not done. It is not the wife’s responsibility to
       make the client do the exercise, but she can help. Increasing fluid intake and frequent turning are
       appropriate, but not sufficient for aerating the lungs.
       CN: Health promotion and maintenance; CL: Synthesize

Question 81

81. Eight hours after surgery, a client has a distended bladder and is unable to void. Which of the
    following interventions is contraindicated?
82. Facilitate voiding by normal position.
83. Pour running water over perineum.
84. Insert an indwelling urinary catheter.
85. Insert a straight catheter every 4 hours.

Answer 81

81. 3. An indwelling urinary catheter increases the risk of urinary tract infection because
       microbes ascend the catheter and travel to the bladder. The nurse should try to facilitate the client’s
       ability to void by using the sitting position for a woman or the standing position for a man and by
       running warm water over the perineum. If such conservative methods fail, the nurse should obtain a
       prescription to catheterize the client every 4 hours using a small French straight catheter until the
       client can void on his or her own.
       CN: Reduction of risk potential; CL: Synthesize

Question 82

82. A client who had open heart surgery is being transported to the intensive care unit (ICU) for
    postoperative recovery from anesthesia. The nurse in the ICU is assessing the client’s level of
    consciousness. When asked, the client can give his name but is not sure about where he is or the time
    of day. What should the nurse do?
83. Notify the surgeon.
84. Rub the client’s sternum to arouse the client.3. Encourage the client’s wife to orient the client.
85. Tell the client where he is and the time of day

Answer 82

82. 4. The first cognitive response that returns after anesthesia is orientation to person. The nurse
       assesses this by asking the client his name. Orientation to place and time usually occurs after
       orientation by the nurse because of confusion from anesthesia and waking in an unfamiliar place. The
       nurse can then continue to assess and document the client’s cognitive ability to remember information.
       The nurse does not need to notify the surgeon. The client’s cognitive response is normal. It is not
       necessary to ask the wife to reorient the client; however, she can continue to talk to him and help him
       regain consciousness.
       CN: Physiological adaptation; CL: Synthesize

Question 83

83. Following surgery, a client is receiving 1,000 mL normal saline (IV) with 40 mEq (40
    mmol/L) KCl, which has been prescribed to be infused at 125 mL/h. The client states, “My IV hurts.”
    What should the nurse do first?
84. Contact the client’s physician for a different IV prescription.
85. Slow down the infusion to a keep-open rate (20 to 50 mL/h).
86. Assess the IV site for signs of phlebitis, extravasation, or IV-related infection.
87. Check the hanging parenteral fluid and administration set for documentation as to when they
    were last changed.

Answer 83

83. 3. Potassium in an IV solution may be irritating to a vein. The nurse should assess the IV site
       before taking any of the other actions listed. The infusion may have to be slowed and/or stopped, and
       the physician contacted. An outdated parenteral fluid setup does not cause pain, but may be a source
       of infection.
       CN: Pharmacological and parenteral therapies; CL: Synthesize

Question 84

84. A nurse is assessing a client when she returns from same-day surgery for a dilatation and
    curettage. The nurse checks preoperative vital signs at 8:30 AM to compare them with the current vital
    signs at 10:30 PM (see chart). What should the nurse do first?

8:30 AM
PR 80
RR 16
BP 90/60
TEMP 99.5 F (37.5 c)

10:30 PM
PR 90
RR 20 
BP 100/80
TEMP 97 F (36.1 C)

1. Call the physician for pain medication.
2. Cover the client with warmed blankets.
3. Administer oxygen at 4 L/min.
4. Increase the IV fluid rate.

Answer 84

84. 2. The client’s body temperature dropped 2.5°F (1.4°C) from the preoperative to
       postoperative phase. The client lost heat during the preoperative period. The client has not had time
       to regain the heat she has lost and should not be discharged postoperatively until her postoperative
       vital signs, which include body temperature, are closer to her preoperative vital signs. The client’s
       pulse rate, respiratory rate, and blood pressure have compensated according to the client’s
       hypothermic state and will reflect changes as the client warms up. There are no indications that the
       client needs more pain medication, oxygen, or IV fluids.
       CN: Physiological adaptation; CL: Synthesize

Question 85

85. A client returns to the medical-surgical floor from the postanesthesia recovery room after a
    colon resection for adenocarcinoma. The client has comorbidities of stage 2 hypertension and a
    previous myocardial infarction. The first set of postoperative vital signs recorded are pulse rate of
    110 bpm, respiration rate of 20/min, blood pressure of 130/86 mm Hg, and temperature of 98°F
    (36.7°C). The surgeon calls to ask if the client needs a unit of packed red blood cells. The nurse’s
    response should be based on which data? Select all that apply.
86. Cyanotic mucous membrane.
87. Warm, dry skin.
88. Vital sign changes.
89. Oxygen saturation.
90. Intake and output.

Answer 85

85. 1, 3, 4, 5. When assessing a postoperative client for perfusion and the manifestation of shock,
    nursing assessment should include an inspection for cyanotic mucous membranes; cold, moist, pale
    skin; and the level of oxygen saturation in relation to hemoglobin. The nurse should also compare the
    client’s postoperative vital signs with his preoperative vital signs to determine how much physiologic
    stress has occurred during the intraoperative period. A client who is perfusing well would have
    warm, dry skin. A client well hydrated would have good skin turgor. The nurse would also assess
    fluid status using the intake and output record. If hemoglobin and hematocrit were available, the
    values would be included in the assessment.
    CN: Management of care; CL: Analyze

Question 86

86. The nurse is caring for a client receiving a continuous infusion of narcotics for relief of
    postoperative pain. On assessment, the client’s vital signs are as follows: HR 84, RR 8, BP 104/56,
    and oxygen saturation of 88% on room air. Which of the following is the nurse’s first action?1. Administer Narcan as prescribed.
87. Stop the continuous infusion of narcotics.
88. Assist the client to sit and stimulate coughing/deep breathing.
89. Call the rapid response team.

Answer 86

86. 3. The client still has a respiratory rate of 8; it would be important to assist the client to sit
       and stimulate the client to take some deep breaths and cough. This action will also help the nurse to
       determine what the client’s level of sedation is; if the client is too sedated to cooperate with
       coughing/deep breathing, it will be important to slow or stop the continuous infusion of narcotics and
       to consider administration of Narcan. The client still has a respiratory rate, so it is not necessary tocall the rapid response team.
       CN: Physiologic adaptation; CL: Synthesize

Question 87

87. A client had a colectomy 81⁄2 hours ago and has received 1,500 mL of dextrose 5% in water
    with normal saline solution. The client has just used a patient-controlled analgesia pump to
    administer morphine for pain, has been repositioned for comfort, and has stable pulse rate,
    respirations, and blood pressure. What should the nurse do next?
88. Check that the family is comfortable.
89. Assess vital signs following the use of morphine.
90. Dim the lights in the room.
91. Increase nasal oxygen from 2 to 3 L.

Answer 87

87. 3. The nurse is helping the client manage pain and comfort level. The nurse has completed the
       assessment of the client and should now dim the lights and create a quiet environment. Such
       nonpharmacologic measures as adjusting the light level in the room facilitate pain management.
       Decreasing stimulation from the environment, such as brightness to the optic nerve, promotes the
       client’s ability to relax skeletal muscles and fall asleep. It is too soon to reassess vital signs.
       Checking that the family is comfortable is important but is not the next thing to do for this client.
       Increasing the oxygen flow rate is not indicated, and, if needed, should have been done before
       repositioning the client.
       CN: Management of care; CL: Synthesize

Question 88

88. A client who had an esophageal hernia repair 4 hours ago has a pulse rate of 90 bpm,
    respiration rate of 16/min, blood pressure of 130/80 mm Hg, pulse oximeter of 91, and a temperature
    of 100.4°F (38°C). What should the nurse do first?
89. Obtain a culture of the incision.
90. Notify the surgeon to obtain an antibiotic prescription.
91. Offer pain medication.
92. Assist the client to a sitting position to take deep breaths.

Answer 88

88. 4. When a postoperative client has a temperature elevation to greater than 100°F (37.8°C) in
       the first 24 hours after surgery, the temperature elevation is usually related to atelectasis. Because this
       client had upper abdominal surgery with manipulation around the diaphragm, the client is more prone
       to guarding the operative site and shallow breathing. Encouraging the client to take deep breaths and
       use incentive spirometry are appropriate measures to prevent atelectasis and pulmonary infection.
       The nurse must assist the client in filling the alveoli in the lower posterior lobes of the lungs. An
       incentive spirometer is a good visual biofeedback instrument that the client had practiced with
       preoperatively. Changing the client’s position from lying to sitting for deep breathing will expand
       alveoli in the lower posterior lobes. There is no indication that a surgical wound infection is
       occurring. An antibiotic is not indicated at this time. Pain medication will decrease respirations and
       the client is not indicating pain at the moment.
       CN: Physiological adaptation; CL: Synthesize

Question 89

89. After completing client teaching on the use of patient-controlled analgesia (PCA), the nurse
    determines that the client understands the use of the PCA when the client states:
90. “It is OK for my family to press the button for me if I’m too tired to do it myself.”
91. “I should wait until the pain is really bad before I push the button to get more pain medicine.”
92. “The machine will only give me the prescribed amount of pain medication even if I push the
    button too soon.”
93. “I have to be careful about pushing the button too many times or I will overdose myself.”

Answer 89

89. 3. The client must be able to verbalize understanding about receiving no more pain medication
       than is prescribed no matter how many times the button is pushed. Only the client should press the
       button for the PCA. The client should administer the pain medication when the pain is first noticed,
       well before the pain is out of control. One of the advantages of the PCA is that the amount of pain
       medication is controlled; therefore overdosing is not a client concern when using a PCA.
       CN: Pharmacological and parenteral therapies; CL: Evaluate

Question 90

90. A client had a total abdominal hysterectomy and bilateral oophorectomy for ovarian
    carcinoma yesterday. She received 2 mg of morphine sulfate IV by patient-controlled analgesia
    (PCA) 10 minutes ago. The nurse was assisting her from the bed to a chair when the client felt dizzy
    and fell into the chair. The nurse should:
91. Discontinue the PCA pump.
92. Administer oxygen.
93. Take the client’s blood pressure.
94. Assist the client back to bed.

Answer 90

90. 3. The nurse should take the client’s blood pressure. She is likely experiencing orthostatic
       hypotension. The PCA pump does not need to be discontinued because, as soon as the blood pressure
       stabilizes, the pain medication can be resumed. Administering oxygen is not necessary unless the
       oxygen saturation also drops. The client should sit in the chair until the blood pressure stabilizes.
       CN: Pharmacological and parenteral therapies; CL: Synthesize

Question 91

91. Immediately following pelvic surgery, a client has an indwelling urinary catheter. Which of
    the following would be helpful to prevent catheter-related urinary tract infection?
92. Provide catheter and perineal care twice daily.
93. Monitor the color, clarity, and amount of urine output.
94. Advocate for limited use of and duration of indwelling urinary catheters.
95. Palpate for lower abdominal distension once per shift.

Answer 91

91. 3. Urinary catheters should be limited in use and duration only as needed for client care. The
       guideline also specifies that if used, the catheter should be inserted using aseptic technique, secured
       to provide unobstructed flow and drainage, and maintained in a way that protects sterility of the
       catheter and the drainage system.
       CN: Safety and infection control; CL: Synthesize

Question 92

92. A nurse is instructing a client who had abdominal surgery that day to do deep-breathing
    exercises. In which order should the nurse teach the client to perform diaphragmatic breathing andcoughing?
93. Inhale through the nose.
94. Cough deeply from the lungs.
95. Exhale through pursed lips.
96. Splint the incisional site.

Answer 92

92.4. Splint the incisional site.
1. Inhale through the nose.
3. Exhale through pursed lips.
2. Cough deeply from the lungs.
The client must first splint the incision to avoid increased intolerable pain or he or she may not
cooperate with the pulmonary ventilation. The next step is to inhale oxygen to expand the alveoli for a
few seconds and then exhale carbon dioxide in successive steps 5 to 10 times. The client should try to
cough on the end of the exhalation to remove retained secretions from the larger airways.
CN: Reduction of risk potential; CL: Synthesize

Question 93

93. The postoperative nursing assessment of a client’s ability to swallow fluids before providing
    oral fluids is based on the type of anesthesia given. Which of the following clients would not have
    delayed fluid restrictions?
94. The client who has undergone a bronchoscopy under local anesthesia.
95. The client who has undergone a transurethral resection of a bladder tumor under general
    anesthesia.
96. The client who has undergone a repair of carpal tunnel syndrome under local anesthesia.
97. The client who has undergone an inguinal herniorrhaphy with spinal and intravenous conscious
    sedation.

Answer 93

93. 3. The client who has not had the gag reflex anesthetized is the client who had a repair of the
       carpal tunnel syndrome under local anesthesia because the area being anesthetized was the tissue in
       the wrist. The client who had a bronchoscopy received a local anesthetic on the vocal cords, and the
       nurse should check the gag reflex or ability to swallow before administering fluids. Clients who had
       general anesthesia or intravenous conscious sedation received medication for central nervous system
       sedation, and the nurse should assess the level of consciousness and ability to swallow before
       administering fluids.
       CN: Reduction of risk potential; CL: Analyze

Question 94

94. The client has just returned to bed following the first ambulation since abdominal surgery.
    The client’s heart rate and blood pressure are slightly elevated; oxygen saturation is 91% on room air,
    but the client reports being “a little short of breath,” but does not have dizziness or pain. The nurse
    should first:
95. Obtain a 12-lead EKG.
96. Administer pain medication.
97. Allow the client to rest for a few minutes, then reassess.
98. Request new activity prescriptions from the health care provider.

Answer 94

94. 3. The client is experiencing activity intolerance which is common following the first
       ambulation following surgery. The nurse should allow the client to rest and continue to monitor vital
       signs. Since the client is not dizzy or in pain, the nurse should wait to see if the client recovers from
       ambulating and reports having pain prior to administering pain medication. There is no need to
       request different activity prescriptions; it will still be important for the client to ambulate. The client
       is not having chest pain; it is not necessary to obtain a 12-lead EKG.
       CN: Basic care and comfort; CL: Synthesize

Question 95

95. Eight hours following bowel surgery, the nurse observes that the client’s urine output has
    decreased from 50 to 20 mL/h. The nurse should assess the client further for which of the following?
96. Bowel obstruction.
97. Adverse effect of opioid analgesics.
98. Hemorrhage.
99. Hypertension.

Answer 95

95. 3. When the urine output is less than 30 mL/h, the nurse should assess for potential causes
       such as hypovolemia or hemorrhage. The nurse should assess and evaluate the client’s vital signs,
       intake and output, dressing, and available laboratory values and notify the physician. Bowel
       obstruction, although possible after surgery, is characterized most notably by abdominal distention
       and absent bowel sounds, not decreased urine output. The nurse would not expect the client to have
       hypertension, but rather hypotension.
       CN: Physiological adaptation; CL: Synthesize

Question 96

96. A client who had a left thoracoscopy sustained an injury secondary to the surgery position.The nurse should assess the client for:
97. Footdrop.
98. Knee swelling and pain.
99. Tingling in the arm.
100. Absence of the Achilles reflex.

Answer 96

96. 3. A client who had a left thoracoscopy is placed in the lateral position, in which the most
       common injury is an injury to the brachial plexus. Numbness and tingling in the arm suggests a
       brachial plexus injury. There is no undue pressure on the ankles or knees during thoracic surgery.
       CN: Physiological adaptation; CL: Analyze

Question 97

97. Which of the following types of surgery is most likely to cause the client to experience
postoperative nausea and vomiting?
1. Total hip replacement.
2. Mitral valve repair.
3. Abdominal hysterectomy.
4. Mastectomy of the left breast.

Answer 97

97. 3. Although any client may experience nausea and vomiting secondary to anesthetics or
       postoperative analgesics, the client who has had manipulation of the abdominal organs is more prone
       to postoperative nausea and vomiting than the client who has had a procedure such as a total joint
       replacement, open heart surgery, or a mastectomy.
       CN: Physiological adaptation; CL: Analyze

Question 98

98. The nurse is evaluating a client who is using a flow incentive spirometer (see figure)
    following abdominal surgery 1 day ago. The client is performing the procedure correctly when the
    client does which of the following? Select all that apply.
99. Inhales before using the spirometer.
100. Inhales for 3 seconds following fully expanding the lungs.
101. Coughs after using the spirometer.
102. Uses the spirometer once every 8 hours.
103. Exhales passively before using the spirometer again.
104. Is sitting upright.

Answer 98

98. 2, 3, 5, 6. The client should be in an upright position when using the spirometer. The client
    should exhale fully prior to using the spirometer and then inhale to expand the lungs and then continue
    inhaling for 3 more seconds. The client should relax and exhale before inhaling for the next use of the
    spirometer. The client should cough and clear retained secretions following the use of the spirometer.
    The client should use the spirometer every 2 hours during the immediate postoperative period.
    CN: Physiological adaptation; CL: Evaluate

Question 99

99. The nurse is planning to teach incisional care to a client before discharge. Which of the
    following instructions should be included?
100. “Do not touch your incision before your next appointment.”
101. “Clean your incision three times a day with hydrogen peroxide and water.”
102. “Do not be concerned about uneven lumps under the suture lines.”
103. “If the staples don’t come out by themselves before your next appointment, the surgeon will
     remove them.”

Answer 99

99. 3. The nurse should inform the client that as the incision heals uneven lumps might appear
       under the incision line because the collagen is growing new tissue at different rates. Eventually, the
       lumps will even out and the tissue will be smooth. The client can touch the incision with clean hands
       as needed to perform incisional care. The client should not clean the incision with hydrogen peroxide
       because it may dry out the natural skin oils. The surgeon will remove the staples for the client.
       CN: Reduction of risk potential; CL: Synthesize

Question 100

100. The nurse is removing the client’s staples from an abdominal incision when the clientsneezes and the incision splits open, exposing the intestines. Which of the following actions should
     the nurse take next?
101. Press the emergency alarm to call the resuscitation team.
102. Cover the abdominal organs with sterile dressings moistened with sterile normal saline.
103. Have all visitors and family leave the room.
104. Call the surgeon to come to the client’s room immediately.

Answer 100

100. 2. When a wound eviscerates (abdominal organs protruding through the opened incision), the
        nurse should cover the open area with a sterile dressing moistened with sterile normal saline and then
        cover it with a dry dressing. The surgeon should then be notified to take the client back to the
        operating room to close the incision under general anesthesia. The nurse should not press the
        emergency alarm because this is not a cardiac or respiratory arrest. The nurse should have the
        visitors and family leave the room to decrease the chance of airborne contamination, but the primary
        focus should be on covering the wound with a moist, sterile covering.
        CN: Safety and infection control; CL: Synthesize

Question 101

101. On the fourth day after surgery, a client has a postoperative wound infection. Which of the
     following should the nurse assess? Select all that apply.
102. Total white blood count (WBC) 10,000/mm 3 (10 × 10 9 /L).
103. Redness and swelling beyond the incision line.
104. Temperature of 102°F (38.9°C).
105. 89% segmented neutrophils.
106. Incisional pain greater than on day 2.

Answer 101

101. 2, 3, 4. WBC count should be above normal (4,500 to 11,000/mm 3 [4.5 to 11 × 10 9 /L]) with
     an acute infection or inflammatory response such as a postoperative wound infection. Redness and
     swelling beyond the incision line is expected with a wound infection. An elevated temperature such
     as 102°F (38.9°C) on the third to fourth postoperative day indicates an infection process rather than
     an inflammatory process. Elevated segmented neutrophils demonstrate that the most mature WBCs
     have responded to the invading bacteria at the incision site, which is an expected response. Typically,
     postoperative pain begins to lessen by the fourth day.
     CN: Physiological adaptation; CL: Analyze

Question 102

102. The nurse is making rounds and observes the client receiving oxygen (see figure). The nurse
     should do which of the following?
103. Position the mask lower on the client’s nose.
104. Verify that the reservoir bag remains deflated.
105. Confirm that the flow rate is set to deliver oxygen at 6 to 10 L/min.
106. Loosen the elastic band on the client’s face.

Answer 102

102. 3. The client is receiving oxygen using a partial rebreathing mask which is positioned
        correctly. The correct flow rate for this type of oxygen mask is 6 to 10 L of oxygen per minute. To be
        effective, the mask must cover the client’s face. The elastic band must be tight enough to secure the
        mask. When used correctly, the reservoir bag should inflate during the inspiratory phase.
        CN: Physiological adaptation; CL: Synthesize

Question 103

103. Which of the following should be included in the plan of care for a client with a surgical
     wound that requires a wet-to-dry dressing?
104. Place a dry dressing in the wound.
105. Use Burow’s solution to wet the dressing.
106. Pack the wet dressing tightly into the wound.
107. Cover the wet packing with a dry sterile dressing.

Answer 103

103. 4. A wet-to-dry dressing should be able to dry out between dressing changes. Thus, the
        dressing should be moist, not dry, when applied. As the moist dressing dries, the wound will be
        debrided of necrotic tissue, exudate, and so forth. Normal saline is most commonly used to moistenthe sponge; Burow’s solution will irritate the wound. The sponge should not be packed into the wound
        tightly because the circulation to the site could be impaired. The moist sponge should be placed so
        that all surfaces of the wound are in contact with the dressing. Then the sponge is covered and
        protected by a dry sterile dressing to prevent contamination from the external environment.
        CN: Safety and infection control; CL: Synthesize

Question 104

104. Two days following abdominal surgery, a client is refusing to take a narcotic pain
     medication, even though the pain rating is an 8 on a 0–10 scale. The client tells the nurse, “I don’t
     want to get dependent on that stuff.” Which of the following is the most appropriate response from the
     nurse?
105. “You will recover more quickly and more effectively if you take pain medication now.”
106. “Newer pain medications do not cause dependence or addiction.”3. “It is your right to not take pain medication.”
107. “You do not need to worry about becoming addicted so soon.”

Answer 104

104. 1. Common client misconceptions regarding pain and pain medication administration include
        a concern that taking pain medication regularly will lead to addiction. However, this misconception
        overstates the risk of addiction and greatly understates the risk of immobility due to poor pain control,
        including atelectasis, decubitus formation, and delayed healing. The nurse should assist the client to
        understand the importance of adequate pain medication to support and promote client mobilization
        following surgery and client/family satisfaction with care. There is a potential for dependence and
        addiction with all narcotic drugs, although not likely during the postoperative periods.
        CN: Basic care and comfort; CL: Synthesize

Question 105

105. The nurse empties a Jackson-Pratt drainage bulb. Which of the following nursing actions
     ensures correct functioning of the drain?
106. Irrigating it with normal saline.
107. Connecting it to low intermittent suction.
108. Compressing it and then plugging it to establish suction.
109. Connecting it to a drainage bag and clamping it off.

Answer 105

105. 3. After emptying a Jackson-Pratt drainage bulb, the nurse should compress the bulb, plug it
        to establish suction, and then document the amount and type of drainage emptied. Irrigating a Jackson-
        Pratt drain is inappropriate because it could contaminate the wound. The Jackson-Pratt drain is not
        usually connected to wall suction. The purpose of the Jackson-Pratt drain is to remove bloody
        drainage from the deep tissues of the incision; clamping the drain would be counterproductive.
        CN: Reduction of risk potential; CL: Synthesize

Question 106

106. Which of the following interventions should the nurse implement for pulmonary emboli
     prophylaxis?
107. Have the client perform leg exercises every hour while awake.
108. Encourage the client to cough and deep breathe.
109. Massage the client’s calves.
110. Have the client wear antiembolism stockings when out of bed.

Answer 106

106. 1. Performing leg exercises, including ankle pumping, ankle rotation, and quadriceps setting
        exercises, will help prevent stasis of blood in the lower extremities, which can lead to blood clot
        formation. Encouraging the client to cough and deep breathe is an important postoperative
        intervention; however, it is directed at preventing pneumonia, not pulmonary emboli. The nurse
        should not massage the calves because a deep vein thrombus could dislodge and travel to the
        pulmonary vasculature. Antiembolism stockings should be worn continuously during the
        postoperative period.
        CN: Physiological adaptation; CL: Synthesize

Question 107

107. The nurse assesses a client who has just received morphine sulfate. The client’s blood
     pressure is 90/50 mm Hg; pulse rate, 58 bpm; respiration rate, 4 breaths/min. The nurse should check
     the client’s chart for a prescription to administer:
108. Flumazenil (Romazicon).
109. Naloxone hydrochloride (Narcan).
110. Doxacurium (Nuromax).
111. Remifentanil (Ultiva).

Answer 107

107. 2. Naloxone hydrochloride is the antidote for morphine sulfate. The signs of overdose on
        morphine sulfate are a respiration rate of 2 to 4 breaths/min, bradycardia, and hypotension.
        Flumazenil is the antidote for midazolam. Doxacurium is a nondepolarizing muscle relaxant.
        Remifentanil is an opioid used as an anesthetic adjunct.
        CN: Pharmacological and parenteral therapies; CL: Synthesize

Question 108

108. The nurse observes the client with an intermittent compression device in place after
     abdominal surgery (see the figure below). The nurse should:
109. Elevate the client’s legs.
110. Apply stockings to be worn under the device.
111. Instruct the client not to move while the device is inflated.
112. Make sure the client is comfortable.

Answer 108

108. The device is applied correctly and the nurse should ensure the client’s comfort. The client’s
     legs should remain extended as shown while using the device; legs may be elevated but it is not
     necessary to elevate the client’s legs. The device should be placed directly on the client’s legs; it is
     incorrect to apply stockings under them. The client may move in bed as needed; active and isometric
     movement is encouraged to promote blood flow.
     CN: Health promotion and maintenance; CL: Synthesize

Question 109

109. A client is being discharged from same-day surgery. Which of the following statements
     indicates that the client has deficient knowledge?
110. “My husband is taking the day off from work to drive me home.”
111. “I can drive myself home after surgery.”
112. “I am taking a taxi home, and my daughter will meet me at home.”
113. “My son will be here at noon to take me home.”

Answer 109

109. 2. The client admitted for same-day surgery should not drive home after the surgical
        procedure because it is unsafe. Even without an anesthetic, the surgical event can be more stressful
        than anticipated. It is acceptable to have someone arrive after the surgery has started to take the clienthome. A taxi is permissible but not desirable.
        CN: Reduction of risk potential; CL: Evaluate

Question 110

110. The nurse is teaching a client who has had a laparoscopic cholecystectomy about
     postoperative pain management. Which of the following statements indicates that the client has
     deficient knowledge?
111. “My pain is related to the gas used to distend my abdominal cavity.”
112. “My diet should include eating bland foods until the gas clears up.”
113. “My pain is related to the large incision and manipulation.”
114. “My pain should be relieved by walking to eliminate the gas.”

Answer 110

10. 3. The client has deficient knowledge when stating that pain from a laparoscopic
       cholecystectomy is related to a large incision and manipulation of tissue. The nurse should explain
       that there are four puncture sites for the incision and that gas is used to distend the abdominal cavity
       to keep the abdominal organs away from the operative site. There is no real manipulation of tissue to
       produce pain. The pain that clients do experience from this procedure is related to the gas, which
       irritates the diaphragm. The client should start on clear liquids and advance to bland foods until the
       gas is gone. Walking helps to eliminate the gas from the abdominal cavity within 12 to 24 hours after
       surgery.
       CN: Reduction of risk potential; CL: Evaluate

Question 111

111. The initial postoperative assessment is completed on a client who had an arthroscopy of the
     knee. Assessment of which of the following parameters is not necessary every 15 minutes during the
     first postoperative hour?
112. Vital signs including pulse oximeter.
113. Pain rating of the operative site.
114. Urine output.
115. Neurovascular check distal to the operative site.

Answer 111

111. 3. The urine output does not have to be checked every 15 minutes for a client who has had an
        arthroscopy because this client probably does not have a catheter in place. If the client voids, the
        output would be recorded. Assessments every 15 minutes during the first hour would include vital
        signs, pulse oximeter values, and pain to monitor the client’s comfort level and check for compartment
        syndrome. Neurovascular checks distal to the operative site are especially vital because a tourniquet
        was used proximal to the operative site during the surgical procedure and because edema may
        develop during the postoperative period.
        CN: Reduction of risk potential; CL: Analyze

Question 112

112. After surgery, a client was treated for postoperative nausea and vomiting and now is
     experiencing hypotension and tachycardia. The nurse should review the medication record to
     determine if the client has received which of the following medications?
113. Ondansetron hydrochloride.
114. Droperidol.
115. Prochlorperazine.
116. Promethazine.

Answer 112

112. 2. Hypotension and tachycardia are common adverse effects of droperidol and should be
        monitored closely by the nurse. Hypotension and tachycardia are not common adverse effects of
        ondansetron hydrochloride, prochlorperazine, or promethazine.
        CN: Pharmacological and parenteral therapies; CL: Analyze

Question 113

113. When an epidural catheter is used for postoperative pain management, the nurse should:
114. Assess but not disturb the epidural dressing.
115. Change the epidural dressing daily.
116. Change the epidural dressing daily only if it is wet.
117. Use strict aseptic technique when handling the epidural catheter.

Answer 113

113. 1. The nurse should assess but not disturb the epidural dressing because the catheter can be
        easily dislodged and organisms can easily be transmitted into the central nervous system. The nurse
        should not have to change the dressing at all if a waterproof dressing is applied over the epidural site.
        Even with strict aseptic technique, a drain into a sterile cavity is a direct route for transmission of
        organisms and places a client at increased risk of infection.
        CN: Pharmacological and parenteral therapies; CL: Apply

Question 114

114. The nurse understands that the client who has epidural pain management postoperatively can
     ambulate because:
115. The analgesia is periodically administered through the epidural catheter.
116. A low concentration of analgesia is used with the catheter.
117. The analgesia from the epidural catheter bathes the spinal fluid.
118. The epidural medication affects the sympathetic and motor function.

Answer 114

114. 2. The client who has epidural pain management postoperatively can ambulate because a low
        concentration of local analgesia causes sensory blockage only. The catheter is placed so that constant
        pain management plus patient-controlled administration of an analgesic dose can block sensory
        innervation. Motor function should not be affected since the catheter is placed above the dura lining
        the spinal fluid. If the catheter would move through the dura sac, spinal analgesia would occur,
        affecting motor function as well as sympathetic nervous system function.
        CN: Pharmacological and parenteral therapies; CL: Apply

Question 115

115. The nurse is caring for a client who is using a portable wound suction unit (see figure). Six
     hours following surgery, the drainage unit is full. The nurse should do which of the following?
116. Remove the drain from the incision.
117. Notify the surgeon.3. Empty drainage.
118. Record the amount in the unit as output on the client’s chart.

Answer 115

115. 3. Portable wound suction units can be emptied and drained. The nurse should compress the
        unit after emptying to create suction before reinserting the plug. It is normal for the suction unit to be
        full 6 hours after surgery, and the nurse does not need to notify the surgeon. The drainage unit should
        be emptied when full or every 8 hours. The drain in the incision should remain in place until the
        surgeon removes it. While all drainage should be noted as output on the chart, recording the amountwithout emptying the drainage unit is not accurate nor is it safe practice.
        CN: Safety and infection control; CL: Synthesize

Question 116

116. Two days after surgery, a client continues to take hydrocodone 7.5 mg and acetaminophen
     500 mg (Lortab 7.5/500). What should the nurse ask the client before administering the pain
     medication?
117. “Where is your pain located?”
118. “Have you emptied your bladder?”
119. “How long has it been since your last dose?”
120. “Is your pain better than before you had surgery?”

Answer 116

116. 1. The nurse should ask the location of the client’s pain because Lortab is an opioid, which
        can be constipating. By the third day, many clients become constipated and are feeling distended, with
        sharp, cramping pain due to gas, which is treated with ambulation, not more opioids. The client’s
        emptying the bladder should not affect the pain level. The nurse should look at the client’s chart to
        determine when the client’s last dose of pain medication was administered, rather than asking the
        client. The client’s statement regarding the pain level before the surgery is not relevant to whether the
        nurse should administer the Lortab.
        CN: Physiological adaptation; CL: Synthesize

Question 117

117. A client wakes up in the postanesthesia care unit and sees a drain with bright red fluid in it
     exiting from the total hip incision, and asks the nurse, “Is this the way it is supposed to be?” Which of
     the following represents the nurse’s best response?
118. “The drainage is blood and fluid that must be drained out for healing.”
119. “Don’t worry about it. I will explain it when you are more awake.”
120. “This blood is being kept sterile and will be given back to you.”
121. “I will give you something to make you sleep so you will not worry.”

Answer 117

117. 1. Blood and serous fluid is drained from the operative site to prevent hematoma formation
        or a collection of fluid that could become a site for infection. This also minimizes postoperative
        swelling, which can be painful. A simple explanation such as this is appropriate because the client is
        just waking up from surgery. Blood from the operative site can be collected through an
        autotransfusion system so that it can be transfused to the client during or immediately after surgery.
        However, strict guidelines about volume of blood lost, how quickly the device fills, and how long the
        blood has been out of the client’s body govern whether the blood can be transfused. Therefore,
        although it is possible that the drainage system to which the client refers is an autotransfusion system,
        it is more likely that the client has a simple Hemovac drain. It is incorrect to tell a client not to worry
        about something even if she is in the drowsy state of awakening from anesthesia. It is inappropriate to
        ignore the client and give her something to make her drowsy instead of addressing his concerns.
        CN: Psychosocial integrity; CL: Synthesize

Question 118

118. A client has a Jackson-Pratt drainage tube in place the first day after surgical repair of a
     ruptured diverticulum. The client asks the nurse the purpose of the drain. What is the nurse’s best
     response?
119. “The drainage tube is used to prevent infection in the peritoneal cavity.”
120. “The drainage tube is used to prevent bleeding into the peritoneal cavity.”
121. “The drainage tube is used to prevent pressure on the bladder.”
122. “The drainage tube is used to prevent pressure on the gallbladder.”

Answer 118

118. 1. The purpose of the Jackson-Pratt drainage tube is to drain off the purulent drainage from
        the sterile peritoneal cavity and prevent peritonitis. A Jackson-Pratt drain cannot prevent bleeding.
        The Jackson-Pratt drain has no effect on pressure on the bladder. There is no reason to be concerned
        about pressure on the gallbladder.
        CN: Reduction of risk potential; CL: Apply

Question 119

119. A client who had a cholecystectomy has a biliary drainage tube in place. Which of the
     following colors of the drainage is expected?
120. Pinkish red.
121. Dark yellow-orange.
122. Clear.
123. Green.

Answer 119

119. 2. Biliary drainage tubes (T tubes) are placed in the common bile duct and drain bile, which
        is dark yellow-orange. Serosanguineous drainage is thin and pinkish red. Bile is not clear and is not
        green unless it comes in contact with gastric fluid.
        CN: Reduction of risk potential; CL: Analyze

Question 120

120. A client is to be discharged from same-day surgery 7 hours after his inguinal hernia repair.
     Which of the following indicates this client is ready to be discharged?
121. The client voids 500 mL of urine.2. The client tolerates eating a hamburger.
122. The client is pain free.
123. The client walks in the hallway unassisted.

Answer 120

120. 1. Urinary elimination in the first 8 hours postoperatively is a requirement before the client
        who has had an inguinal hernia repair can be discharged from same-day surgery. Ingestion of fluids
        without nausea and vomiting is important, but eating solid foods is not a requirement for discharge
        from same-day surgery. Being completely pain free is an unrealistic expectation for the time frame
        and is not a requirement for leaving same-day surgery. However, the client should be comfortable and
        his pain should be controlled. It is not a requirement for the client to ambulate in the hallway, but the
        client should be able to sit up and go to the bathroom without assistance.
        CN: Reduction of risk potential; CL: Analyze

Question 121

121. A client is eligible for patient-controlled analgesia (PCA) when:
122. A family member is able to assist with self-dosing.
123. There is a court-appointed advocate to assist with self-dosing.
124. The client has the ability to self-dose.
125. There is a nurse to assist with self-dosing.

Answer 121

121. 3. The ability to self-dose is a requirement for the client to use PCA. Having a family
        member or court-appointed advocate present is not a requirement for initiating PCA. The nurseteaches the client about how to use PCA and monitors effectiveness of the pain medication; however,
        it is not necessary for the nurse to assist with the dosing.
        CN: Pharmacological and parenteral therapies; CL: Evaluate

Question 122

122. How often should the client's temperature be assessed during the first 24 hours after
surgery?
1. Every 2 hours.
2. Every 4 hours.
3. Every 6 hours.
4. Every 8 hours.

Answer 122

122. 2. The client’s body temperature should be assessed every 4 hours during the first 24 hours
        because the client is still at risk for hypothermia or malignant hyperthermia. The client does not need
        to be checked every 2 hours unless indicated by an abnormal finding.
        CN: Reduction of risk potential; CL: Apply

Question 123

123. A nurse is assessing a client’s blood pressure 8 hours after surgery. The client’s blood
     pressure before surgery was 120/80 mm Hg, and on admission to the postsurgical nursing unit, it was
     110/80 mm Hg. The client’s blood pressure is now 90/70 mm Hg. What should the nurse do first?
124. Notify the health care provider.
125. Elevate the head of the bed.
126. Administer pain medication.
127. Check the intake and output record.

Answer 123

123. 1. The client’s systolic blood pressure is dropping and the pulse pressure is narrowing,
        indicating impending shock. The nurse should notify the surgeon. Elevating the head of the bed will
        not increase the blood pressure. Administering pain medication could cause the blood pressure to
        drop further. The intake and output record may indicate decreased urine output related to shock, but
        the nurse should first contact the health care provider.
        CN: Reduction of risk potential; CL: Synthesize

Question 124

124. A client has been positioned in the lithotomy position under general anesthesia for a pelvic
     procedure. In which anatomic area may the client expect to experience postoperative discomfort?
125. Shoulders.
126. Thighs.
127. Legs.
128. Feet.

Answer 124

124. 1. The client who has been positioned in the lithotomy position under general anesthesia may
        experience discomfort in the shoulders postoperatively because the client is placed in the
        Trendelenburg position to expose the perineal area. The client’s weight is then shifted toward the
        shoulders and the client experiences muscle soreness postoperatively.
        CN: Basic care and comfort; CL: Apply

Question 125

125. Which of the following does not aid in meeting the goal of clear breath sounds?
126. Offering pain relief before having the client cough.
127. Providing a minimum of 1,000 mL of fluid per day.
128. Using an incentive spirometer.
129. Assisting with early ambulation.

Answer 125

125. 2. The client should drink a minimum of 2,500 mL of fluid per day (not 1,000 mL) to keep
        secretions liquefied and easier to cough up and eliminate from the upper respiratory tract. The client
        should use pain medication before coughing. The client should use the incentive spirometer every 2 to
        4 hours. The nurse should monitor the client’s breath sounds and temperature to detect early signs of
        infection. The nurse should assist with early ambulation.
        CN: Reduction of risk potential; CL: Synthesize

Question 126

126. The nurse is teaching the client about deep-breathing techniques. Which of the following
     client statements indicates the need for additional education?
127. “I will use my incentive spirometer every hour while I’m awake.”
128. “I should place my hands lightly over my lower ribs and upper abdomen.”
129. “I should get into a comfortable position before doing my breathing exercises.”
130. “I should take four deep breaths and then cough deeply from the lungs.”

Answer 126

126. 3. The client should sit in an upright position when doing breathing exercises to allow for
        full chest expansion of both lungs and all fields and bases. Using an incentive spirometer every hour
        while awake is appropriate and allows the client visual feedback. Placing his hands lightly over the
        lower ribs and upper abdomen allows the client to see muscles of inspiration and expiration and is
        appropriate. Coughing deeply from the lungs after four deep breaths allows the client to effectively
        cough up secretions.
        CN: Reduction of risk potential; CL: Evaluate

Question 127

127. A client has had a nasogastric tube connected to low intermittent suction. The client is at
     risk for which of the following complications?
128. Confusion.
129. Muscle cramping.3. Edema.
130. Tremors.

Answer 127

127. 2. Muscle cramping is a sign of hypokalemia. Potassium is an electrolyte lost with
        nasogastric suctioning. Confusion is seen with hypercalcemia. Edema is seen with protein deficit or
        fluid volume overload. Tremors are seen with hypomagnesemia.
        CN: Reduction of risk potential; CL: Analyze

Question 128

Legal and Ethical Issues Associated with Surgery
128. On admission to same-day surgery, the nurse reviews the chart to verify the client’s
identification documentation. Which of the following is most important?
1. Admitting record.
2. Addressograph labels.
3. Identification bracelet.
4. Location of family.

Answer 128

Legal and Ethical Issues Associated with Surgery
128. 3. The most critical piece of information is the client identification bracelet.
Misidentification of clients can result in serious harm to the client. The nurse also needs the admitting
records and Addressograph labels as part of verifying the client’s identification. The location of thefamily is not included in verifying identification.
CN: Reduction of risk potential; CL: Synthesize

Question 129

129. Which of the following items of documentation is not required for the nurse to have on the
     chart before the client is transported to the operating suite?
130. Operative consent.
131. History and physical information.
132. Laboratory test results.
133. Anesthesia note.

Answer 129

129. 4. The nurse is not required to have the anesthesia note on the chart before the client is
        transported to the operating room suite. The anesthesia record is on the chart after the surgical
        procedure is completed and is a good source of client information. The operative consent, history and
        physical information, and laboratory test results should be on the chart before the client is transported
        to the operating suite.
        CN: Management of care; CL: Apply

Question 130

130. A 15-year-old client needs life-saving emergency surgery, but the relatives live an hour
     away from the hospital and cannot sign the consent form. What is the nurse’s best response?
131. Send the client to surgery without the consent.
132. Call the family for a consent over the telephone and have another nurse listen as a witness.
133. No action is necessary in this case because consent is not needed.
134. Have the family sign the consent form as soon as they arrive.

Answer 130

130. 2. When the client cannot sign the operative consent and it is a true life-saving emergency,
        consent may be obtained over the telephone from the client’s next-of-kin or guardian. The surgeon
        must obtain the telephone consent, but if it is a true life-saving emergency the surgeon often is already
        in surgery, so the nurse makes the telephone call and another nurse witnesses the call. Some
        institutions have a special consent form for emergency surgery. Consent can be waived in situations in
        which no family is available; however, if the family can be reached by telephone before surgery,
        verbal consent is legally required.
        CN: Management of care; CL: Synthesize

Question 131

131. A client is being prepared to have a craniotomy for a brain tumor. As a client advocate, the
     nurse is evaluating the client’s understanding of the informed consent before witnessing the client’s
     signature on the operative consent form. Which of the following indicates that the nurse needs to
     contact the surgeon for further communication with the client?
132. “We talked about the effect of my diabetes on healing.”
133. “The surgeon explained how the craniotomy was done.”
134. “There are no major risks from this surgery.”
135. “I will die if the tumor is not removed from my brain.”

Answer 131

131. 3. There are risks with both the surgical procedure and the general anesthesia required for a
        craniotomy. The risks involved in the procedure are a part of the informed consent. Other information
        that is part of an informed consent includes potential complications, expected benefits, inability of the
        surgeon to predict results, irreversibility of the procedure (if applicable), and other available
        treatments. Talking about the effects of the diabetes on healing, explaining how the craniotomy is
        performed, and explaining the consequences of declining treatment (eg, death if the tumor is not
        removed) represent appropriate actions to provide information to the client.
        CN: Management of care; CL: Evaluate

Question 132

132. The nurse is helping to prepare a client for nonemergency surgery. The nurse should:
133. Obtain informed consent from the client.
134. Explain the surgical procedure in detail.
135. Verify that the client understands the consent form.
136. Inform the client about the risks of the surgery to be performed.

Answer 132

132. 3. The surgeon is responsible for explaining the surgical procedure to be performed and the
        risks of the procedure, as well as for obtaining the informed consent from the client. A nurse may be
        responsible for obtaining and witnessing a client’s signature on the consent form. The nurse is the
        client’s advocate, verifying that a client (or family member) understands the consent form and its
        implications, and that consent for the surgery is truly voluntary.
        CN: Reduction of risk potential; CL: Apply

Question 133

133. When a client cannot read or write but is of sound mind, the nurse should read the consent to
     the client in the presence of two witnesses and:
134. Have the client’s next-of-kin sign the consent.
135. Have the client put an “X” on the signature line.
136. Have a court appoint a guardian for the client.
137. Have a hospital quality management coordinator sign for the client.

Answer 133

133. 2. When the client cannot read or write, the consent can be read to the client and the client
        can sign in the presence of two witnesses. The client (not the next-of-kin) should always sign for
        himself unless he is a minor or not of sound mind. The court does not appoint a guardian for a person
        of sound mind just because he cannot read or write. Hospital personnel would not and could not sign
        a consent form for a client.
        CN: Management of care; CL: Apply

Question 134

134. The nurse applies which ethical principle when telling the truth to a client about the
prognosis?
1. Nonmaleficence.
2. Fidelity.
3. Beneficence.
4. Veracity.

Answer 134

134. 4. The ethical principle of veracity is the obligation to tell the truth and not to lie or deceive
        others. Nonmaleficence is the duty not to inflict harm as well as to prevent and remove harm. Fidelity
        is promise keeping—the duty to be faithful to one’s commitments. Beneficence is the duty to do good
        and the active promotion of benevolent acts (eg, goodness, kindness, charity).
        CN: Management of care; CL: Apply

Question 135

Managing Care Quality and Safety
135. A client is admitted on the day of surgery for an arthroscopy of the left knee. Which nursing
activities should be completed to avoid wrong-site surgery? Select all that apply.
1. Ask the surgeon preoperatively to mark with a permanent marker the correct knee for the
surgical site.
2. Verbally ask the client to state his name, surgical site, and procedure.
3. Verify the correct client with the correct operative site by medical records and radiographic
diagnostic reports.
4. Call a “time-out” in the operating room to have the surgeon verify the correct knee before
making the incision.
5. Show the client an anatomic model of the surgery site.

Answer 135

Managing Care Quality and Safety
135. 2, 3, 4. The root cause of wrong-site surgery involves a breakdown in communication
between the client and family and the health care team. Information retrieved from the client in the
preoperative assessment, such as the client’s name, surgical site, and procedure, should be verbally
assessed and verified with medical records and radiographic diagnostic reports. This information
should be compiled in a checklist that the intraoperative team can recheck, thus avoiding unnecessary
distraction and delay in the operating room. The nurse in the operating room is responsible for calling
a “time-out” so that every surgical team member can double-check the correct site of surgery, verify
the site using the operative consent form, and mark the operative site on the client. The client should
mark the operative site in the preoperative period, not the surgeon, in order to avoid any
miscommunication about the correct site of surgery. Showing the client an anatomic model will assist
the client in understanding the location of the surgery, but it will not prevent anyone from identifying
the wrong site on the client.
CN: Safety and infection control; CL: Apply

Question 136

136. The nurse is planning care for a client with severe postoperative pain. There is a
     prescription for morphine written as “10 mg MSO 4 ” on the chart. Which of the following should the
     nurse do first?
137. Obtain an intravenous infusion system.
138. Prepare the medication for administration.
139. Contact the Pharmacy Department.
140. Contact the physician who prescribed the medication.

Answer 136

136. 4. The nurse should first contact the physician because the prescription for the morphine is
        not complete. The Joint Commission of the United States and the Institute for Safe Medication
        Practices Canada recommend not to use MSO 4 because it can apply to morphine as well as to
        magnesium sulfate. There is no mention of an IV system being needed. The morphine should not be in
        the medication cabinet because the prescription is not complete. Although pharmacy may offer a
        suggestion as to what the medication prescribed is, the best means to confirm the intent of the
        prescription is to contact the physician who wrote the prescription.
        CN: Safety and infection control; CL: Synthesize

Question 137

137. The client has returned to the surgery unit from the postanesthesia care unit (PACU). The
     client’s respirations are rapid and shallow, the pulse is 120, and the blood pressure is 88/52. The
     client’s level of consciousness is deteriorating. The nurse should do which of the following first?
138. Call the PACU.
139. Call the primary care physician.
140. Call the respiratory therapist.
141. Call the Rapid Response Team (RRT).

Answer 137

137. 4. The nurse should first call the Rapid Response Team (RRT) or medical emergency team
        that provides a team approach to evaluate and treat immediately clients with alterations in vital signs
        or neurological deterioration. The client’s vital signs have changed since the client was in the PACU
        and immediate action is required to manage the changes; the staff in PACU are not responsible for
        managing care once the client is transferred to the surgical unit. The respiratory therapist may be a
        part of the RRT but should not be called first.
        CN: Management of care; CL: Synthesize

Question 138

138. When completing the Preoperative Checklist on the nursing unit, the nurse discovers an
     allergy that the client has not reported. What should the nurse do first?
139. Administer the prescribed preanesthetic medication.
140. Note this new allergy prominently at the front of the chart.
141. Contact the scrub nurse in the operating room.
142. Inform the nurse anesthetist.

Answer 138

138. 4. The nurse anesthetist administers the anesthetic agent and monitors the client’s physical
        status throughout the surgery; the nurse anesthetist must have knowledge of all known allergies for
        client safety. The completed chart (with the Preoperative Checklist) accompanies the client to the
        operating room; any unusual last-minute observations that may have a bearing on anesthesia or
        surgery are noted prominently at the front of the chart. The preanesthetic medication can cause light-
        headedness or drowsiness. The nurse in the scrub role provides sterile instruments and supplies to the
        surgeon during the procedure.
        CN: Safety and infection control; CL: Synthesize

Question 139

139. Which of the following activities should the nurse encourage the unlicensed assistive
     personnel (UAP) to assist with in the care of postoperative clients? Select all that apply.
140. Empty and measure indwelling urinary catheter collection bags.
141. Reposition clients for pain relief.
142. Teach clients the proper use of the incentive spirometer.
143. Tell the nurse if clients report they are having pain.
144. Assess IV insertion site for redness.

Answer 139

139. 1, 2, 4. Nurses can delegate to the UAP to observe clients and promote their comfort
     following surgery and to empty and measure urinary catheter drainage bags. UAPs cannot teach
     clients; that is the responsibility of the registered nurse or respiratory therapist. UAPs cannot assess
     IV insertion sites, which is the responsibility of a registered nurse.CN: Management of care; CL: Synthesize

Question 140

140. A very elderly, drowsy client with fragile skin is being transferred from the surgery cart to
     the bed. How should the nurse plan to direct the transfer to prevent skin shearing?With two people at each side using a drawsheet.
     With two people, one at each side using a drawsheet, and one person at the head.
     With two people using a roller and a drawsheet.
     With two people, one at each side using a drawsheet, one person at the head, and one person at
     the feet.

Answer 140

140. 4. The nurse should plan for two people, one at each side using a drawsheet, one person at
        the head, and one person at the feet to transfer an elderly, drowsy client with fragile skin to avoid
        shearing of the integumentary system. Using only two or three people allows for dragging of some
        part of the client, which leads to shearing of the dependent part.
        CN: Safety and infection control; CL: Synthesize

Question 141

141. The client’s identification armband was cut and removed to start an IV line as a part of the
     preoperative preparation. The transport team has arrived to transport the client to the operating room.
     The nurse notices that the client’s identification band is not on either wrist. What is the nurse’s best
     response?
142. Send the removed armband with the chart and the client to the operating room.
143. Place a new identification armband on the client’s wrist before transport.
144. Tape the cut armband back onto the client’s wrist.
145. Send the client without an armband because the client is alert and can respond to questions
     about his or her identity.

Answer 141

141. 2. The client must have an identification bracelet properly secured on the wrist person
        before being transported to the operating room to ensure correct identification. It is incorrect to send
        the client without a properly secured identification bracelet. The perioperative nurse must verify the
        client’s identification by checking for the same name on the chart, armband, and schedule and by the
        client’s statement. The preoperative nurse may be asked to physically identify the client and obtain a
        new armband.
        CN: Management of care; CL: Synthesize

Question 142

On the second day after surgery, the nurse assesses an elderly client and finds the following:
BP 148/92, HR 98, RR 32
O 2 saturation of 88 on 4 L/min of oxygen administered by nasal cannula
Breath sounds are coarse and wet bilaterally with a loose, productive cough
Client voided 100 mL very dark, concentrated urine during the last 4 hours
Bilateral pitting pedal edema
Using the SBAR method to notify the health care provider of current assessment findings, which of the
following is the most appropriate recommendation to make?
1. Administer an antihypertensive medication.
2. Encourage additional fluid intake.
3. Administer a diuretic medication.
4. Increase oxygen liter flow rate.

Answer 142

142. 3. The client is experiencing a fluid overload and has vital signs that are outside of normal
        limits. The provider must be notified of the client’s current status. It would be appropriate to
        recommend the provider administer a diuretic to correct the fluid overload. It is not appropriate to
        administer an antihypertensive medication or administer more fluids. It may be appropriate to
        administer additional oxygen, but because of the fluid volume excess the client exhibits, diuretic
        administration is most important.
        CN: Physiologic adaptation; CL: Analyze

Question 143

143. Which of the following physician prescriptions is written correctly on the chart?
144. Fentanyl 50 mcg given IV every 2 hours as needed for pain greater than 6/10.
145. Give 4 U regular insulin IV now.
146. .5 mg MS given IM for c/o pain.
147. 60.0 mg Toradol given IM for c/o pain.

Answer 143

143. 1. Prescriptions should be written clearly to avoid confusion or misinterpretation. Clearly
        written prescriptions do not use a “trailing” zero (a zero following a decimal point) and do use a
        “leading” zero (a zero preceding a decimal point). Additionally, the prescribed medication should be
        written in full and avoid abbreviations of the drug and the dosage, for example “morphine sulfate”
        (avoiding use of “MS”), “ml” instead of “cc,” and “micrograms” instead of “mcg.”
        CN: Safety and infection control; CL: Apply

Question 144

144. The nurse has just received morning change-of-shift report on four clients assigned to this
     shift. In what order should the nurse do the following?
145. Discuss the plan for the day with the nursing assistant, delegating duties as appropriate.
146. Assess the client who has been vomiting according to the report from the night nurse.
147. Begin discharge paperwork for a client that is anxious to go home.4. Notify the physician about a client who has a serum potassium level of 6.2.

Answer 144

144.
4. Notify the physician about a client who has a serum potassium level of 6.2.
2. Assess the client who has been vomiting according to the report from the night nurse.
1. Discuss the plan for the day with the nursing assistant, delegating duties as appropriate.
3. Begin discharge paperwork for a client that is anxious to go home.
The nurse should first notify the physician of the high serum potassium level. Normal serum
potassium level is 3.5 to 5.0; a level of 6.2 must be called to the physician immediately because
hyperkalemia may cause serious cardiac arrhythmias, potentially leading to death if left untreated.The nurse should next assess the client who has been vomiting and if necessary contact the physician
for a prescription for an antiemetic if none has been prescribed. After assessing all clients, the nurse
should discuss the plan for the day, with the nurse assistant delegating duties as appropriate. Though
the client is eager to go home, the discharge paperwork must wait until all clients have been assessed
and immediate needs met.
CN: Reduction of risk potential; CL: Synthesize

Question 145

145. While making rounds, the nurse observes that a client’s primary bag of intravenous (IV)
     solution is light yellow. The label on the IV bag says the solution is D5W. What should the nurse do
     first?
146. Continue to monitor the bag of IV solution.
147. Ask another nurse to look at the solution.
148. Notify the physician.
149. Hang a new bag of D5W and complete an incident report.

Answer 145

145. 4. Maintenance of IV sites and systems includes regular assessment and rotation of the site
        and periodic changes of the dressing, solution, and tubing; these measures help prevent complications.
        The nurse should also observe the solution for discoloration, turbidity, and particulates. An IV
        solution is changed every 24 hours or as needed, and because the nurse noted an abnormal color, the
        nurse should change the bag of D5W and note this on an incident report. It is not necessary to verify
        this action with another nurse. Paging the physician is not necessary; maintaining the IV and using the
        correct solutions is a nursing responsibility. Although the first action is to hang a new bag, hospital
        policy should be followed if there is a question as to whether there could have been an unknown
        substance in the bag that caused it to change color.
        CN: Safety and infection control; CL: Synthesize

Question 146

146. A client informs the nurse that the venipuncture site “hurts.” The nurse should assess the site
for which of the following? Select all that apply.
1. Redness.
2. Pain.
3. Coolness.
4. Blanching.
5. Firmness.
6. Edema.

Answer 146

146. 1, 2, 3, 4, 5, 6. The venipuncture site must be assessed for signs of infection (redness and
     pain at the puncture site), infiltration (coolness, blanching, and edema at the site), and
     thrombophlebitis (redness, firmness, pain along the path of the vein, and edema).
     CN: Safety and infection control; CL: Analyze