Original

The nurse has just reassessed the condition of a postoperative client who was admitted 1 hour
ago to the surgical unit. The nurse plans to monitor which parameter most carefully during the
next hour?
1. Urine output of 20ml/hour
2. Temperature of 37.6 C
3. Blood pressure of 114/70
4. Serous drainage on the surgical dressing
1.
Urine output should be maintained at a minimum of 30mL/hour for an adult. An output of less
than that for each of 2 consecutive hours should be reported to the health care provider.
A postoperative client asks the nurse why it is so important to deep-breathe and cough after
surgery. When formulating a response, the nurse incorporates the understanding that retained
pulmonary secretions in a postoperative client can lead to which condition?
1. Pneumonia
2. Hypoxemia
3. Fluid imbalance
4. Pulmonary embolism
1.
Postoperative respiratory problems are atelectasis, pneumonia and pulmonary emboli.
Pneumonia is the inflammation of lung tissue that causes productive cough, dyspnea, and lung
crackles and can be caused by the retention of pulmonary secretions.
The nurse is developing a plan of care for a client scheduled for surgery. The nurse should
include which activity in the nursing care plan for the client on the day of surgery?
1. Avoid oral hygiene and rinsing with mouthwash
2. Verify that the client has not eaten for the last 24 hours
3. Have the client void immediately before going into surgery
4. Report immediately any slight increase in BP or pulse
3.
The nurse would assist the client to void immediately before surgery so that the bladder will be
empty. Oral hygiene is allowed, but the client should not swallow any water. The client usually
has a restriction of food and fluids for 6 to 8 hours before surgery instead of 24 hours. A slight
increase in BP and pulse is common during the preoperative period due to anxiety.
A client with a perforated gastric ulcer is scheduled for surgery. The client cannot sign the
operative consent form because of sedation from opioid analgesics that have been
administered. The nurse should take which most appropriate action in the care of this client?
1. Obtain a court order for the surgery.
2. Have the charge nurse sign the informed consent immediately
3. Send the client to surgery without the consent form being signed
4. Obtain a telephone consent from a family member, following agency policy
4.
Every effort should be made to obtain permission from a responsible family member to perform
surgery if the client is unable to sign the consent form. A telephone consent must be witnessed
by two persons who hear the family member's oral consent. The two witnesses then sign the
consent with the name of the family member, noting that an oral consent was obtained. Consent
is not informed if it is obtained from a client who is confused, unconscious, mentally
incompetent, or under the influence of sedatives. In an emergency the client may not be able to
sign and family members may not be available. In this situation, a health care provider is
permitted legally to perform surgery without consent, but tin this case it is not an emergency.
Agency policies regarding informed consent should always be followed.
A preoperative client expresses anxiety to the nurse about upcoming surgery. Which response
by the nurse is most likely to stimulate further discussion between the client and the nurse?
1. "If it's any help, everyone is nervous before surgery."
2. "I will be happy to explain the entire surgical procedure with you."
3. "Can you share with me what you've been told about your surgery?"
4. "Let me tell you about the care you'll receive after surgery and the amount of pain you can
anticipate".
3.
Explanations should begin with the information that the client knows. By providing the client with
individualized explanations of care and procedures, the nurse can assist the client in handling
anxiety and fear for a smooth preoperative experience. Clients who are calm and emotionally
prepared for surgery withstand anesthesia better and experience fewer postoperative
complications.
The nurse is conducting preoperative teaching with a client about the use of an incentive
spirometer. The nurse should include which piece of information in discussions with the client?
1. Inhale as rapidly as possible
2. Keep a loose seal between the lips and the mouthpiece
3. After maximum inspiration, hold the breath for 15 seconds and exhale.
4. The best results are achieved when sitting up or with the head of the bed elevated 45 to 90
degrees
4
For optimal lung expansion with the incentive spirometer, the client should assume the semi-
Fowlers or high fowlers position. The mouthpiece should be covered completely and tightly
while the client inhales slowly, with a constant flow through the unit. The breath should be held
for 5 seconds before exhaling slowly.
The nurse has conducted preoperative teaching for a client scheduled for surgery in 1 week.
The client has a history of arthritis and has been taking acetylsalicylic acid. The nurse
determines that the client needs additional teaching if the client makes which statement?
1. "Aspirin can cause bleeding after surgery."
2. "Aspirin can cause my ability to clot blood to be abnormal."
3. "I need to continue to take the aspirin until the day of surgery."
4. "I need to check with my HCP about the need to stop the aspirin before the scheduled
surgery."
3.
Anticoagulants altered normal clotting factors and increase the risk of bleeding after surgery.
Aspirin has properties that can alter the clotting mechanism and should be discontinued at least
48 hours before surgery. However, the client should always check with his or her health care
provider regarding when to stop taking the aspirin when a surgical procedure is scheduled.
The nurse assess a client's surgical incision for signs of infection. Which finding by the nurse
would be interpreted as a normal finding at the surgical site?
1. Red, hard skin
2. Serous drainage
3. Purulent drainage
4. Warm tender skin
2
Serous drainage is an expected finding at a surgical site. The other options indicate signs of
wound infection. Wound infection usually appears 3 to 6 days after surgery.
A client who has had abdominal surgery complains of feeling as though "something gave way"
in the incisional site. The nurse removes the dressing and notes the presence of a loop of bowel
protruding through the incision. Which nursing interventions should the nurse take? Select all
that apply
1. Contact the surgeon
2. Instruct the client to remain quiet
3. Prepare the client for wound closure
4. Document the findings and actions taken
5. Place a sterile saline dressing and icepacks over the wound
6. Place the client in a prone position without a pillow under the head.
1, 2, 3 ,4
Wound dehiscence is the separation of the wound edges. Wound evisceration is protrusion of
the internal organs through an incision. If wound dehiscence or evisceration occurs, the nurse
should call for help, stay with the client, and ask another nurse to contact the surgeon and
obtain needed supplies to care for the client. The nurse places the client in a low fowlers
position and the client is kept quite and instructed not to cough. Protruding organs are covered
with a sterile saline dressing. Ice is not applied because of its vasoconstrictive effect. The
treatment for evisceration is usually immediate wound closure under local or general
anesthesia. The nurse also documents the findings and actions taken.
A client who has undergone preadmission testing, has had blood drawn for serum lab studies,
including a complete blood count, coagulation studies and electrolytes and creatine levels.
Which lab result should be reported to the surgeon's office by the nurse, knowing that it could
cause surgery to be postponed?
1. Sodium, 141mEq/L
2. Hemoglobin, 8.0 g/dL
3. Platelets, 210,000/mm3
4. Serum creatine, 0.8 mg/dL
The complete blood count includes the hemoglobin analysis. All these values are within normal
range except for hemoglobin. If a client has a low hemoglobin level, the surgery likely could be
postponed by the surgeon
The nurse receives a telephone call from the postanesthesia care unit stating that a client is
being transferred to the surgical unit. The nurse plans to take which action first on arrival of the
client?
1. Assess the patency of the airway
2. Check tubes or drains for patency
3. Check the dressing to assess for bleeding
4. Assess the vital signs to compare with preoperative measurements
1.
The first action of the nurse is to assess the patency of the airway snd respiratory function. If the
airway is not patent, the nurse must take immediate measures for the survival of the client. The
nurse then takes vital signs followed by checking of the dressing and tubes or drains.
The nurse is reviewing a prescription sheet for preoperative client that states that he client must
be NPO after midnight. The nurse would telephone the physician to clarify that which medication
should be given to the client and not withheld?
1. Prednisone
2. Ferrous sulfate
3. Cyclobenzaprine (Flexeril)
4. Conjugated estrogen (Premarin)
1.
Prednisone is a corticosteroid. With prolonged use, corticosteroids cause adrenal atrophy, which
reduces the ability of the body to withstand stress. When stress is severe corticosteroids are
essential to life. Before and during surgery, dosages may be increased temporarily. These last
few medications may be withheld before surgery without undue effects on the client.
Original
A perioperative nurse is preparing a patient for surgery for treatment of a ruptured spleen as the
result of an automobile crash. The nurse knows that this type of surgery belongs in what
category?
a. Minor, diagnostic
b. Minor, elective
c. Major, emergency
d. Major, palliative
c. This surgery would involve a major body organ, has the potential for postoperative
complications, requires hospitalization, and must be done immediately to save the patient's life.
Elective surgery is a procedure that is preplanned by essentially healthy people. Diagnostic
surgery is performed to confirm a diagnosis. Palliative surgery is not curative, rather it is done to
relieve or reduce the intensity of an illness.
A nurse is preparing a patient for a cesarean section and teaches her the effects of the regional
anesthesia she will be receiving. Which effects would the nurse expect? Select all that apply.
a. Loss of consciousness
b. Relaxation of skeletal muscles
c. Reduction or loss of reflex action
d. Localized loss of sensation
e. Prolonged pain relief after other anesthesia wears off
f. Infiltrates the underlying tissues in an operative area
c, d. A localized loss of sensation and possible loss of reflexes occurs with a regional anesthetic.
Loss of consciousness and relaxation of skeletal muscles occurs with general anesthesia.
Prolonged pain relief after other anesthesia wears off and infiltration of the underlying tissues in
an operative area occur with topical anesthesia.
A nurse has been asked to witness a patient signature on an informed consent form for surgery.
What information should be included on the form? Select all that apply.

a) The option of nontreatment

b) The underlying disease process and its natural course
c) Notice that once the form is signed, the patient cannot withdraw consent
d) Explanation of the guaranteed outcome of the procedure or treatment
e) Name and qualifications of the provider of the procedure or treatment
f) Explanation of the risks and benefits of the procedure or treatment
a, b, e, f
A 72-year-old woman who is scheduled for a hip replacement is taking several medications on a
regular basis. Which drug category might create a surgical risk for this patient?
a. Anticoagulants
b. Antacids
c. Laxatives
d. Sedatives
a. Anticoagulant drug therapy would increase the risk for hemorrhage during surgery.
A nurse is caring for an obese patient who has had surgery. The nurse monitors this patient for
what postoperative complication?
a. Anesthetic agent interactions
b. Impaired wound healing
c. Hemorrhage
d. Gas pains
b. Fatty tissue is less vascular and, therefore, less resistant to infection and more prone to
delayed wound healing.
A responsibility of the nurse is the administration of preoperative medications to patients. Which
statements describe the action of these medications? Select all that apply.
a. Diazepam is given to alleviate anxiety.
b. Ranitidine is given to facilitate patient sedation.
c. Atropine is given to decrease oral secretions.
d. Morphine is given to depress respiratory function.
e. Cimetidine is given to prevent laryngospasm.
f. Fentanyl citrate-droperidol is given to facilitate a sense of calm.
a, c, f.
Sedatives, such as diazepam (Valium), midazolam (Versed), or lorazepam (Ativan) are given to
alleviate anxiety and decrease recall of events related to surgery. Anticholinergics, such as
atropine and glycopyrrolate (Robinul) are given to decrease pulmonary and oral secretions and
to prevent laryngospasm. Neuroleptanalgesic agents, such as fentanyl citrate-droperidol
(Innovar) are given to cause a general state of calm and sleepiness. Histamine-2 receptor
blockers, such as cimetidine (Tagamet) and ranitidine (Zantac) are given to decrease gastric
acidity and volume. Narcotic analgesics, such as morphine, are given to facilitate patient
sedation and relaxation and to decrease the amount of anesthetic agent needed.
A nurse is teaching a man scheduled to have same-day surgery. Which teaching method would
be most effective in preoperative teaching for ambulatory surgery?
a. Lecture
b. Discussion
c. Audiovisuals
d. Written instructions
d. Written instructions are most effective in providing information for same-day surgery
A 70-year-old male is scheduled for surgery. He says to the nurse, "I am so frightened—what if I
don't wake up?" What would be the nurse's best response?
a. "You have a wonderful doctor."
b. "Let's talk about how you are feeling."
c. "Everyone wakes up from surgery!"
d. "Don't worry, you will be just fine."
b. This answer allows the patient to talk about his feelings and fears, and is therapeutic.
A nurse is explaining pain control methods to a patient undergoing a bowel resection. The
patient is interested in the PCA pump and asks the nurse to explain how it works. What would
be the nurse's correct response?
a. "The pump allows the patient to be completely free of pain during the postoperative period."
b. "The pump allows the patient to take unlimited amounts of medication as needed."
c. "The pump allows the patient to choose the type of medication given postoperatively."
d. "The pump allows the patient to self-administer limited doses of pain medication."
d. PCA infusion pumps allow patients to self-administer doses of pain-relieving medication
within physician-prescribed time and dose limits. Patients activate the delivery of the medication
by pressing a button on a cord connected to the pump or a button directly on the pump.
A patient had a surgical procedure that necessitated a thoracic incision. The nurse anticipates
that he will have a higher risk for postoperative complications involving which body system?
a. Respiratory system
b. Circulatory system
c. Digestive system
d. Nervous system
a. A thoracic incision makes it more painful for the patient to take deep breaths or cough.
Shallow respirations and ineffective coughing increase the risk for respiratory complications.
While assessing a patient in the PACU, a nurse notes increased wound drainage, restlessness,
a decreasing blood pressure, and an increase in the pulse rate. The nurse interprets these
findings as most likely indicating:
a. Thrombophlebitis
b. Atelectasis
c. Infection
d. Hemorrhage
d. Increased wound drainage, restlessness, decreasing blood pressure, and increasing pulse
rate are assessment findings that indicate hemorrhage. Manifestations of thrombophlebitis are
pain and cramping in the calf or thigh of the involved extremity, redness and swelling in the
affected area, elevated temperature, and an increase in the diameter of the involved extremity.
Manifestations of atelectasis include decreased lung sounds over the affected area, dyspnea,
cyanosis, crackles, restlessness, and apprehension. Signs of infection include elevated white
blood count and fever.
A patient tells the nurse she is having pain in her right lower leg. How does the nurse determine
if the patient has developed a DVT?
a. By palpating the skin over the tibia and fibula
b. By documenting daily calf circumference measurements
c. By recording vital signs obtained four times a day
d. By noting difficulty with ambulation
b. Inflammation from thrombophlebitis increases the size of the affected extremity and can be
assessed by measuring circumference on a regular basis.
A scrub nurse is assisting a surgeon with a kidney transplant. What are the patient
responsibilities of the scrub nurse? Select all that apply.
a. Maintaining sterile technique
b. Draping and handling instruments and supplies
c. Identifying and assessing the patient on admission
d. Integrating case management
e. Preparing the skin at the surgical site
f. Providing exposure of the operative area
a, b. The scrub nurse is a member of the sterile team who maintains sterile technique while
draping and handling instruments and supplies. Two duties of the circulating nurse are to
identify and assess the patient on admission to the operating room and prepare the skin at the
surgical site. The RNFA actively assists the surgeon by providing exposure of the operative
area. The APRN coordinates care activities, collaborates with physicians and nurses in all
phases of perioperative and postanesthesia care, and integrates case management, critical
paths, and research into care of the surgical patient.
Older adults often have reduced vital capacity as a result of normal physiologic changes. Which
nursing intervention would be most important for the postoperative care of an older surgical
patient specific to this change?
a. Take and record vital signs every shift.
b. Turn, cough, and deep breathe every 4 hours.
c. Encourage increased intake of oral fluids.
d. Assess bowel sounds daily.
b. Reduced vital capacity in older adults increases the risk for respiratory complications,
including pneumonia and atelectasis. Having the patient turn, cough, and deep breathe every 4
hours maintains respiratory function and helps to prevent complications.
A nurse is explaining the rationale for performing leg exercises after surgery. Which reason
would the nurse include in the explanation?
a. Promote respiratory function
b. Maintain functional abilities
c. Provide diversional activities
d. Increase venous return
d. Leg exercises in the postoperative period increase venous return. As a result, the patient has
a decreased risk for thrombophlebitis and emboli.
Original
A 26-year old client comes into the clinic prior to a tonsillectomy. Which action is priority during
this phase of surgery?

a. Intraoperative consent signed

b. Intraoperative medication

c. Preoperative assessment

d. Postoperative assessment
c. Preoperative assessment

The client is in the preoperative phase of surgery and must be assessed and prepared for
surgery. The client may have labs drawn, medication administered, and consent forms signed.
The intraoperative phase is the actual surgery; the client is anesthetized, prepped, draped, and
surgery performed. The postoperative phase is the recovery phase of surgery where the client
continues to recover until maximum health is achieved.
A 76-year old client is to undergo a hernia repair. The nurse knows that in order to aid in the
healing process, the perioperative nurse must assist the client with which concept during what
surgical phase?

a. Perfusion therapy during the intraoperative phase

b. Wound healing during the postoperative phase

c. Wound healing during the preoperative and intraoperative phase

d. Infection during the postoperative phase

c. Wound healing during the preoperative and intraoperative phase

Inadequate control of stress and coping mechanisms can prolong the perioperative healing
process and a client's prognosis. Perioperative care includes assessing client stress and coping
mechanisms during the preoperative phase and reassessing following the procedure.
Postoperative infections may occur as a result of improper wound care or hospital acquired
infections may occur as a result of infection control protocols not being followed. Adequate
perfusion enhances wound healing and perioperative recovery. Nurses providing intraoperative
and postoperative care must follow infection protocols.
A 65-year old client is having neck surgery. Which nursing diagnosis does the nurse include for
this client?

a. Risk for burns

b. Risk for fluid volume: Deficient

c. Ineffective pain control

d. Risk for fluid volume: Excess

b. Risk for fluid volume: Deficient

Risk for Fluid Volume: Deficient is related to any blood loss during the client's surgery and NPO
status. Risk for Burns is unrelated; there is no indication for Fluid Volume: Excess or Ineffective
Pain Control.
An 18-year old client is admitted to the emergency room for an emergency appendectomy. The
nurse knows that which assessment is priority with each perioperative phase

a. Medication assessment

b. Pain assessment

c. History and physical

d. Systems assessment
d. Systems assessment

While the other assessments are important, a systems assessment is priority and can be
completed with each perioperative phase, making sure the client remains at baseline
throughout.
A 43-year old client is undergoing a CABG. What priority understanding does the nurse have
about perioperative documentation?

a. If it was not written, it was not done

b. It includes all steps of the nursing process

c. It's a legal document subject to internal review

d. It keeps the nurse and patient safe

b. It includes all steps of the nursing process
All answers are correct; however, the priority understanding of perioperative documentation is
that it includes all steps of the nursing process including assessment, diagnosis, identified
outcomes, planning, implementation, and evaluation.
A client diagnosed with gallbladder disease decides to undergo a laparoscopic cholecystectomy
as opposed to an open procedure. The nurse realizes the client chose the laparoscopic surgery
due to what reason?

a. The laparoscopic surgery has a higher infection rate

b. The laparoscopic surgery requires a shorter hospital stay and recovery

c. The open surgery is more expensive

d. The open surgery scars are less noticeable

b. The laparoscopic surgery requires a shorter hospital stay and recovery

Laparoscopic surgeries are less invasive and usually require a shorter hospital stay and
recovery. Also, due to the small incision sites the patient is at a lower risk for acquiring a surgical
site infection (SSI) and experiences less blood loss. Open procedures usually require a longer
hospital stay and longer recovery period. Open procedures also place the client at a higher risk
for blood loss. Larger incisions place the client at a higher risk for complications, such as
hypothermia and surgical site infections.
A 55-year old woman with sleep apnea is having a double mastectomy with reconstruction
performed today. What priority complication is important for this client?

a. Loss of blood and infection complications

b. Infection and airway complications

c. Injury and loss of blood complications

d. Airway and VTE complications

d. Airway and VTE complications

A double mastectomy with reconstruction can take from 9-12 hours. The client has sleep apnea,
so the length of the procedure increases the client's risk for complications. Shorter procedures
benefit clients of all ages: Less exposure time decreases the risk for physiologic complications
and reduces the time required for healing. The longer the client is exposed to anesthesia, the
more it lengthens recovery time and risk for complications. The client's risk of hypothermia
increases with the time required for healing and increases the risk for venous thromboembolism
(VTE). Procedures lasting 30 minutes or longer may call for clients to wear SCDs (mechanical
method used to prevent venous thromboembolism (VTE)). The greater risk for blood loss
necessitates a blood transfusion either intraoperatively or on admission to the medical unit.
A client is rushed into surgery following an MVA. The client must receive a blood transfusion to
sustain life but is a Jehovah's Witness. What priority intervention by the nurse is the most
appropriate?

a. Obtain consent for an autologous blood transfusion

b. Do not ask for consent; give the blood anyway

c. Tell the family the client will die without the blood

d. Do nothing; the family will not change their minds

a. Obtain consent for an autologous blood transfusion

Many Jehovah's Witness clients, due to their beliefs, do not receive blood, even if it is a life
saving measure. Some Jehovah's Witness clients sign only the consent to receive autologous
blood. The perioperative nurse needs to understand and accept this belief. Therefore, when the
nurse presents the Jehovah's Witness client with the blood consent to sign, the nurse cannot
ask questions or try to persuade the client.
The nurse identifies the postoperative client as being at an increased risk for impaired
oxygenation. Which is the best nursing intervention to address this client's problem?

a. Provide antibiotics as prescribed

b. Medicate for pain as prescribed

c. Administer 1 unit platelets as prescribed

d. Apply oxygen 2 liters by face mask as prescribed

d. Apply oxygen 2 liters by face mask as prescribed

For a client at risk of impaired oxygenation, applying oxygen 2 liters by face mask would be the
appropriate intervention to implement. Providing an antibiotic as prescribed would be applicable
if the client were at risk for an infection. Medicating for pain would address the problem of
comfort. Providing platelets would be appropriate for perfusion or coagulation problems.
The nurse measures the client's blood pressure, pulse, and capillary refill prior to sending the
client to the operating room. Which concept related to perioperative care is the nurse
implementing?

a. Quality control

b. Perfusion

c. Safety

d. Infection control
b. Perfusion

The concept of perfusion is related to perioperative care. Nurses must be aware of the client's
hemodynamic status and understand the guidelines for perfusion. The client's hemodynamic
status is measured through blood pressure, pulse, and capillary refill. Measuring blood
pressure, pulse, and capillary refill does not directly support the concepts of safety, quality
control, or infection control.
A preoperative client asks if blood products will be used during the procedure. Which laboratory
values should the nurse explain are used to determine the client's need for blood products?
(SELECT ALL THAT APPLY)

a. Hemoglobin

b. Hematocrit

c. Prothrombin time

d. Red blood cell count

e. Platelets
a. Hemoglobin
b. Hematocrit
d. Red blood cell count
e. Platelets

The diagnostic tests of platelets, hematocrit, hemoglobin, and red blood cell count are used to
determine if a blood transfusion is needed during the surgical procedure. Prothrombin time is
used to determine the client's risk for bleeding.
The nurse is preparing a client for a surgical procedure to remove a portion of the transverse
colon. Which priority actions should the nurse include to reduce the client's risk of developing a
postoperative complication?
(SELECT ALL THAT APPLY)

a. Observe for muscle twitching

b. Monitor body temperature

c. Monitor blood pressure and heart rate

d. Ensure aseptic technique is used for the procedure

e. Monitor urine concentration

b. Monitor body temperature
c. Monitor blood pressure and heart rate
d. Ensure aseptic technique is used for the procedure
Open procedures place the client at a higher risk for blood loss, hypothermia and surgical site
infections (SSIs). The nurse should monitor body temperature, blood pressure, and heart rate
and ensure aseptic technique is used for the procedure. Urine concentration is used to monitor
for hypernatremia and hypovolemia. Muscle twitching is associated with hyponatremia.
What postoperative assessment would indicate to the nurse a change in a client's
cardiovascular status?
(SELECT ALL THAT APPLY)

a. Capillary refill time greater than 3 seconds

b. Vomiting moderate amount of green emesis

c. Absent gag reflex

d. Pedal pulse non-palpable

e. Dropping blood pressure

a. Capillary refill time greater than 3 seconds
d. Pedal pulse non-palpable
e. Dropping blood pressure

Changes in cardiovascular status affect blood pressure, pulses, and capillary refill. Dropping
blood pressure, non-palpable pedal pulse, and capillary refill time greater than 3 seconds reflect
a change in the cardiovascular status. An absent gag reflex indicates a change in a protective
neurological reflex. Vomiting indicates a change in gastrointestinal status.
The circulating nurse is ensuring that a client is adequately positioned for surgery and
determines that the procedure is going to take longer than 30 minutes to complete. What did the
nurse assess to make this determination?

a. Client is in the lithotomy position

b. Client has a device on a finger to measure oxygen saturation

c. Client is wearing sequential compression devices

d. Client has pillows placed under the knees

c. Client is wearing sequential compression devices

For procedures expected to last 30 minutes or longer, clients may be prescribed to wear
sequential compression devices to reduce the risk of venous thromboembolism development
from prolonged inactivity. The use of the lithotomy position does not determine the length of the
surgical procedure. Placing pillows under the knees is a preventive action for the client in the
supine position for a surgical procedure. Most clients receiving anesthesia will have oxygen
saturation monitored during the surgical procedure.
A 5-year old client scheduled for a tonsillectomy asks the nurse if the operation is going to hurt.
What is the best response by the nurse?

a. Yes, but it will hurt less than the sore throat you have now

b. No, you will have no pain

c. Yes, but we will give you medicine to stop the pain before it starts

d. Yes, but don't worry. I can give you a shot to help with the pain
c. Yes, but we will give you medicine to stop the pain before it starts

Nurses preparing children for surgery should be honest regarding expectations about
postoperative pain and how the care team is ready to respond and treat pain. The nurse should
acknowledge that there will be pain but also explain that medicine can be used to stop the pain
before it starts. Denying the presence of pain is not an honest response. Saying that the pain
will be less than the client's current sore throat does not address how pain will be managed.
Responding that pain medication will be provided with a shot could cause the child alarm.
The nurse is conducting the preoperative assessment. The client reports having a cup of black
coffee before arriving for the scheduled surgery. What should the nurse do with this information?

a. Instruct the client to refrain from further intake

b. Administer the preoperative medication

c. Notify the surgeon

d. Document the fluid intake in the medical record

c. Notify the surgeon

The nurse should notify the surgeon with the information if the client has had anything to eat or
drink within 8 hours prior to surgery, because this increases the client's risk of aspiration. The
surgical procedure will be cancelled, especially if the surgery is elective. The client should not
be given the preoperative medication until the surgeon in notified of the fluid intake. The nurse
needs to do more than document the information in the medical record. The client should have
been instructed to refrain from food or fluids for 8 hours before the surgery prior to arriving to the
hospital for the procedure.
Terms in this set (10)
Original
A patient was admitted with nausea, vomiting, and abdominal pain. The patient is scheduled for
an Endoscopic Retrograde Cholangiopancreatography (ERCP) procedure. What type of surgery
would this describe?

a. Explorative
b. Diagnostic
c. Curative
d. Pallative
b. Diagnostic
A post-operative day 1 patient is found to have hypoactive bowel tones. The nurse knows this to
be an expected (though abnormal) finding because of which of the following reasons? Select all
that apply:

a. The patient was NPO prior to surgery

b. The patient is diabetic
c. The patient received general anesthetic and opioid pain medications
d. The patient has decreased physical mobility
a. The patient was NPO prior to surgery
c. The patient received general anesthetic and opioid pain medications
d. The patient has decreased physical mobility
A nurse is caring for a patient following a whipple procedure (removal of the head of the
pancreas, duodenum, part of the stomach, and common bile duct). The patient has nausea and
vomiting and absent bowel tones. The nurse inserts a nasogastric tube per physician order to
treat which surgical complication?

a. Pain
b. Constipation
c. Fluid volume deficit
d. Paralytic ileus
d. Paralytic ileus
A patient with reconstructive head and neck skin grafts following mouth cancer is crying when
the nurse enters the room and states that she doesn't want to see any visitors. Which of the
following best explains this behavior?

a. Cognition
b. Self-concept
c. Coping
d. Relationships
b. Self-concept
A surgeon phones the nursing unit and asks the nurse to send the patient to surgery and sign
the informed consent. Which of the following is most appropriate?

a. Review surgical complications and procedure with the patient and RN signs consent as a
witness.
b. Explain procedure and risks/benefits and ask the patient to sign.
c. Ask the patient to sign consent if they are comfortable, the RN signs as a witness.
d. Include unsigned consent in the chart and send the patient to the pre-operative induction
area.
c. Ask the patient to sign consent if they are comfortable, the RN signs as a witness.
Which of the following is the final step before making the first surgical incision?

a. Pre-operative teaching
b. Anesthesia induction
c. Procedural pause
d. Skin preparation for infection control
c. Procedural pause
Asepsis is paramount during surgery. Which of the following are used to preserve this
environment? Select all that apply:

a. Correct donning of sterile gowns/gloves

b. Inspection of sterile equipment packages prior to unwrapping and dispensing
c. Consider sterile field only at level of sterile draping
d. Keep unscrubbed personnel more than 1 foot away and not between sterile fields.
a. Correct donning of sterile gowns/gloves
b. Inspection of sterile equipment packages prior to unwrapping and dispensing
c. Consider sterile field only at level of sterile draping
d. Keep unscrubbed personnel more than 1 foot away and not between sterile fields.

All statements are correct.

A nurse is receiving a patient from surgery to the post-anesthesia care unit (PACU). she is most
interested in which of the following assessment data? Select all that apply:

a. Bowel function
b. Pain
c. Urinary output
d. Pupillary response
b. Pain
c. Urinary output
d. Pupillary response
A post-operative shoulder repair patient (post-op day 3) reports left calf pain. The nurse finds
redness and swelling on assessment. What complication best explains these findings?

a. Positioning during surgery

b. Wound infection
c. Atelectasis
d. Deep vein thrombosis
d. Deep vein thrombosis
The scrub nurse has donned her sterile gown and is ready for gloves. What should be done
next?

a. Pull hand out of the gown and open the glove package.
b. Use non-dominant hand to open the sterile glove package.
c. Fold cuffs of glove over gown cuff.
d. Pick up first glove by cuff and stretch over non-dominant gown cuff.
b. Use non-dominant hand to open the sterile glove package.
Terms in this set (20)
Original
The nurse measures the client's blood pressure, pulse, and capillary refill prior to sending the
client to the operating room. Which concept related to perioperative care is the nurse
implementing?
A. Quality control
B. Perfusion
C. Infection control
D. Safety
Answer: B
Rationale: The concept of perfusion is related to perioperative care. Nurses must be aware of
the client's hemodynamic status and understand the guidelines for perfusion. The client's
hemodynamic status is measured through blood pressure, pulse, and capillary refill. Measuring
blood pressure, pulse, and capillary refill does not directly support the concepts of safety, quality
control, or infection control.
The nurse is discussing the challenges when caring for a pediatric surgical client. Which is the
biggest challenge that must be included?
A. Reducing the risk of pneumonia
B. Preventing skin tears
C. Preventing hypothermia
D. Reducing the risk of venous thromboembolism
Answer: C
Rationale: For the pediatric client, temperature regulation may be the biggest challenge.
Preventing skin tears due to fragile skin, reducing the risk of pneumonia, and reducing the risk
of venous thromboembolism due to inactivity are concerns for nursing care of the older client
having a surgical procedure.
A preoperative client asks if blood products will be used during the procedure. Which laboratory
value should the nurse explain is used to determine the client's need for blood products? (Select
all that apply.)
A. Platelets
B. Hematocrit
C. Hemoglobin
D. Prothrombin time
E. Red blood cell count
Answer: A, B, C, E
Rationale: The diagnostic tests of platelets, hematocrit, hemoglobin, and red blood cell count
are used to determine if a blood transfusion is needed during the surgical procedure.
Prothrombin time is used to determine the client's risk for bleeding.
While preparing medications for a client scheduled for surgery, the nurse observes that
medications are scheduled for 0800 hours, analyzes the medication vial, and reviews the
client's armband. Which right of medication administration is the nurse performing? (Select all
that apply.)
A. Right time
B. Right client
C. Right teaching
D. Right medication
E. Right assessment
Answer: A, B, D
Rationale: The rights of medication administration include right time, right client, and right
medication. Right teaching and right assessment are not considered a part of the basic rights of
medication administration.
A 78-year-old client is scheduled for surgery. Which intervention should the nurse make a
priority when planning this client's care? (Select all that apply.)
A.Preventing infection
B. Promoting skin integrity
C. Ensuring adequate oral intake
D. Maximizing respiratory function
E. Maintaining a normal body temperature
Answer: A, B, D, E
Rationale: Lifespan considerations for an older client having surgery include maintaining skin
integrity, preventing surgical infections, preventing the development of pneumonia, and
maintaining a normal body temperature. Oral intake is not a specific lifespan consideration for
an older client having surgery.
The nurse assessed an 80-year-old client who is scheduled for surgery and becomes
concerned that the client is at risk for a postoperative complication. Which assessment finding
caused the nurse's concern?
A. Practices deep breathing and coughing
B. Bowel sounds audible in all four quadrants
C. Wears an anti-embolism stockings
D. Skin friable over bony prominences
Answer: D
Rationale: Friable skin increases the older client's risk for developing pressure ulcers, which
could be exacerbated during the surgical case. This is the information that the nurse should
communicate to the intraoperative nurse. Wearing antiembolism stockings prevents the
development of venous thromboembolism. Audible bowel sounds indicate an intact
gastrointestinal system. Practicing deep breathing and coughing helps prevent the development
of postoperative respiratory complications.
During the preoperative assessment the client tells the nurse, "I had a cup of black coffee this
morning." Which intervention should be the nurse's priority?
A. Administer the preoperative medication.
B. Instruct the client to refrain from further intake.
C. Notify the surgeon.
D. Document the fluid intake in the medical record.
Answer: C
Rationale: The nurse should notify the surgeon with the information if the client has had
anything to eat or drink within 8 hours prior to surgery because this increases the client's risk of
aspiration. The surgical procedure will be cancelled, especially if the surgery is elective. The
client should not be given the preoperative medication until the surgeon is notified of the fluid
intake. The nurse needs to do more than document the information in the medical record. The
client should have been instructed to refrain from food or fluids for 8 hours before the surgery
prior to arriving to the hospital for the procedure.
The nurse is preparing a client for a surgical procedure. Which priority action should the nurse
include to reduce the client's risk of developing a postoperative complication? (Select all that
apply.)
A. Monitoring body temperature
B. Observing for muscle twitching
C. Monitoring urine concentration
D. Monitoring blood pressure and heart rate
E. Ensuring that aseptic technique is used for the procedure
Answer: A, D, E
Rationale: Open procedures place the client at a higher risk for blood loss, hypothermia and
surgical site infections (SSIs). The nurse should monitor body temperature, blood pressure, and
heart rate and ensure that aseptic technique is used for the procedure. Urine concentration is
used to monitor for hypernatremia and hypovolemia. Muscle twitching is associated with
hyponatremia.
The nurse is assessing a client preoperatively. Which finding should alert the nurse that the
client is at risk for developing a surgical infection? (Select all that apply.)
A. Body mass index of 33.7
B. Fasting blood glucose level of 258 mg/dL
C. Prescribed steroids for chronic lung disease
D. Takes acetaminophen daily for arthritis pain
E. Treated for gastric ulcers caused by H. pylori
Answer: A, B, C
Rationale: Clients with an increased body mass index (BMI), who have diabetes, or who take
immunosuppressants are at a higher risk for acquiring a postoperative infection. Taking
acetaminophen and having a history of H. pylori does not increase the risk for developing a
postoperative infection.
Which information should the nurse include in the preoperative preprocedure verification
process during the preoperative phase? (Select all that apply.)
A. Correct surgical procedure
B. Location of drains
C. Development of complications
D. Antibiotic administered
E. Mark of surgical site by the surgeon
Answer: A, E
Rationale: Information reviewed during the preoperative preprocedure verification processduring
the preoperative phase includes, but is not limited to, the correct surgical procedure and the
surgical site marked by the surgeon. The name of antibiotic administered is a part of the
intraoperative preprocedure handoff report. Drains and complications are a part of the
postoperative preprocedure handoff report.
Which consideration is a requirement for a surgical procedure that takes longer than 30 minutes
to complete.
A. The client has pillows placed under the knees.
B. The client has an order for a blood transfusion during the procedure.
C. The client is wearing sequential compression devices.
D. The client is in the lithotomy position.
Answer: C
Rationale: For procedures expected to last 30 minutes or longer, clients should wear sequential
compression devices to reduce the risk of venous thromboembolism development from
prolonged inactivity. The use of the lithotomy position does not determine the length of the
surgical procedure. Placing pillows under the knees is a preventive action for the client in the
supine position for a surgical procedure. Blood transfusions are not needed for all clients.
The nurse is placing a client into the prone position for surgery. What is the most important
action for the nurse to take?
A. Placing pillows under the knees
B. Protecting the eyes
C. Protecting the feet on a padded footboard
D. Securing the arms on padded arm boards with palms up
Answer: B
Rationale: When in the prone position, the eyes must be protected to prevent ocular injury.
Pillows are placed under the knees in the supine position. Feet are protected on a padded
footboard in the semi-Fowler position. Arms are secured on padded arm boards with the palms
up in the supine and semi-Fowler position.
The nurse is preparing a client to receive electrosurgery. What priority nursing action should be
implemented before this procedure is performed? (Select all that apply.)
A. Maintaining strict aseptic technique
B. Completing a baseline skin assessment
C. Removing the client's jewelry and eyeglasses
D. Covering windows and reflective surfaces with a towel
E. Ensuring that tattoos, metal implants, and scars are not used for pad placement
answer: C, E
Rationale: When using electrosurgery, the nurse needs to ensure that the pads are not placed
over metal implants, tattoos, or scars and that all jewelry and eyeglasses are removed from the
client. Strict aseptic technique is needed when an immobilizing device is being placed through
the client's skin. A baseline skin assessment is completed before using a pneumatic tourniquet.
Covering windows and reflective surfaces is done when a laser is being used.
Which hand hygiene should the nurse perform before participating in client care during a
surgical procedure? (Select all that apply.)
A. Washing hands when the case is completed
B. Washing the gloves when saturated with blood
C. Washing hands when surgical gloves are removed
D. Completing a 5-minute surgical scrub after removing the gloves
E. Completing a surgical scrub before applying sterile gloves
Answer: A, C, E
Rationale: When preparing to participate in intraoperative client care, the nurse should complete
a surgical hand scrub prior to applying sterile gloves. Once the case is completed, the nurse
should wash their hands thoroughly. Hand washing is also necessary when surgical gloves are
removed. The surgical gloves are never washed but may need to be replaced during the
procedure. A surgical scrub is not necessary at the conclusion of a surgical procedure.
Which information should the nurse identify as a part of intraoperative documentation? (Select
all that apply.)
A. Surgical counts
B. Systems assessment
C. Antibiotic infusion times
D. Total fluid intake and output
E. Start and stop times of anesthesia
Answer: A, C, D, E
Rationale: Intraoperative documentation includes surgical counts, antibiotic infusion times, total
fluid intake and output, and start and stop times of anesthesia. Medications administered and
dressings applied are also included. Systems assessment is a part of the postoperative
documentation
The nurse identifies the postoperative client as being at an increased risk for impaired
oxygenation. Which is the best collaborative intervention to address this client's problem?
A. Medicating for pain
B. Providing antibiotic
C. Applying oxygen 2 liters by nasal cannula
D. Administeringone unit of platelets
Answer: C
Rationale: For a client at risk of impaired oxygenation, applying oxygen 2 liters by nasal cannula
would be the appropriate intervention to implement. Providing an antibiotic would be applicable
if the client were at risk for an infection. Medicating for pain would address the problem of
comfort. Providing platelets would be appropriate for perfusion or coagulation problems.
Which postoperative assessment finding should indicate to the nurse a change in a client's
cardiovascular status? (Select all that apply.)
A. Absent gag reflex
B. Dropping blood pressure
C. Pedal pulse nonpalpable
D. Capillary refill time greater than 3 seconds
E. Vomiting moderate amount of green emesis
Answer: B, C, D
Rationale: Changes in cardiovascular status affect blood pressure, pulses, and capillary refill.
Dropping blood pressure, nonpalpable pedal pulse, and capillary refill time greater than 3
seconds reflect a change in the cardiovascular status. An absent gag reflex indicates a change
in a protective neurological reflex. Vomiting indicates a change in gastrointestinal status.
Which postoperative medication order should the nurse expect to implement while a client is in
the postanesthesia care unit? (Select all that apply.)
A. Analgesic
B. Antibiotics
C. Antiemetic
D. Antihypertensive
E. Anesthesia reversal agent
Answer: A, C, E
Rationale: Two types of medications typically are administered in the postanesthesia phase:
pain medications and antiemetic medications. Pain medications assist in lowering the client's
pain level and, in turn, decrease elevated blood pressure and pulse rate. Antiemetic medications
assist in decreasing nausea and vomiting. An antihypertensive medication would only be given if
a client's blood pressure was elevated and not responding to the effects of pain medication. An
antibiotic would only be given if the client is expected to have an infection. Anesthesia reversal
agents are typically given prior to the client leaving the operating suite if appropriate.
Which postoperative assessment finding should the nurse immediately report to the surgeon?
(Select all that apply.)
A. Complaints of pain
B. Urine output 10 mL/hr
C. Oxygen saturation 88%
D. Prolonged unresponsiveness
E. Dressing saturated in 15 minutes
Answer: B, C, D, E
Rationale: Findings that should be immediately reported to the surgeon or anesthesiologist
include prolonged unresponsiveness, urine output less than 30 mL/hr, oxygen saturation less
than 93%, and more than the expected amount of bleeding at the surgical site. Complaints of
pain do not have to be immediately reported to the surgeon and should be treated per the
surgeon's order.
Which criterion does the Aldrete scoring system measure in the postoperative client? (Select all
that apply.)
A. Eye opening
B. Respirations
C. Motor response
D. Oxygen saturation
E. Electrolyte balance
Answer: B, C, D
Rationale: The Aldrete score measures respiration, oxygen saturation, consciousness,
circulation, and activity of the client being assessed for preparation for discharge from the
postanesthesia unit. Eye opening is measured with the Glasgow Coma Scale. Electrolyte
balance is not a part of the Aldrete score.