PERIOPERATIVE NURSING FUNDAMENTAL SUCCESS (ANSWER KEY PAGE 442-452) 1. There are discharge criteria for clients in the post anesthesia care unit (PACU) regardless of the type of anesthesia used and additional criteria for specific types of anesthesia. Which is the criterion specific for the client who has received spinal anesthesia? 1. Oxygen saturation reaches the presurgical baseline. 2. Motor and sensory function returns. 3. Nausea and vomiting are minimal. 4. Headache is reported as tolerable. 2. A client is admitted to the postanesthesia care unit. Which nursing action is most important during the client’s stay in this unit? 1. Monitoring urinary output 2. Assessing level of consciousness 3. Ensuring patency of drainage tubes 4. Suctioning mucus from respiratory passages 3. A postoperative client is transferred back to the surgical unit with an abdominal dressing and a Penrose drain. Which is the most important nursing action associated with caring for a client with a Penrose drain? 1. Removing the excess external portion until drainage stops 2. Changing the soiled dressing carefully 3. Maintaining the negative pressure 4. Pinning the drain to the dressing 4. A client has abdominal surgery. Which should the nurse do to best assess for a sign of postoperative ileus in this client after surgery? 1. Identify the time of the first bowel movement. 2. Monitor the tolerance of a clear liquid diet. 3. Palpate for abdominal distention. 4. Auscultate for bowel sounds. 5. Four days after abdominal surgery, while being transferred from a bed to a chair, a client says to a nurse, “My incision feels funny all of a sudden.” Which should the nurse do first? 1. Take the vital signs. 2. Apply an abdominal binder immediately. 3. Place the client in the low-Fowler position. 4. Encourage slow deep breathing by the client. 6. Which factor places a client at the highest risk for postoperative nausea and vomiting after receiving general anesthesia. 1. Obesity 2. Inactivity 3. Hypervolemia 4. Unconsciousness 7. On the second postoperative day after an above-the-knee amputation, the client’s elastic dressing accidentally comes off. Which should the nurse do first? 1. Wrap the residual limb with an elastic compression bandage. 2. Apply a saline dressing to the residual limb. 3. Notify the primary health-care provider. 4. Place two pillows under the limb. 7745_Ch05_297-452 29/11/18 3:37 PM Page 432 8. A nurse is caring for a postoperative client. Which action is effective in preventing postoperative urinary tract infections? 1. Eating foods with roughage 2. Taking sitz baths twice a day 3. Drinking an adequate amount of fluid 4. Increasing the intake of citrus fruit juices 9. A client received conscious sedation during a colonoscopy. Which should the nurse expect regarding the client’s experience with this procedure? 1. Client will be unresponsive and pain free. 2. Client will be at risk for malignant hyperthermia. 3. Client will be sleepy but able to follow verbal commands. 4. Client will be positioned in the supine position to prevent headache. 10. Which client having emergency surgery should the nurse anticipate to be at the highest risk for postoperative mortality? 1. Individual who has alcoholism 2. Person who has epilepsy 3. Middle-age adult 4. Infant 11. A nurse is caring for a client who had an abdominal hysterectomy. Which intervention best prevents postoperative thrombophlebitis? 1. Utilization of compression stockings at night 2. Deep breathing and coughing exercises daily 3. Leg exercises 10 times per hour when awake 4. Elevation of the legs on 2 pillows 12. An obese client has abdominal surgery for removal of the gallbladder. Which should the nurse be most concerned about if exhibited by the client? 1. Constipation 2. Urinary retention 3. Shallow breathing 4. Inability to provide self-care 13. A client arrives in the postanesthesia care unit. Which is the most important information that the nurse needs to know? 1. Anxiety level before surgery 2. Type and extent of the surgery 3. Type of intravenous fluids administered 4. Special requests that were expressed by the client 14. Which client responses best support the decision to discharge the client from the postanesthesia care unit? 1. Sao2 of 95%, vital signs stable for 30 minutes, active gag reflex 2. Tolerable pain, ability to move extremities, dry intact dressing 3. Urinary output of 30 mL/hr, awake, turning from side to side 4. Afebrile, adventitious breath sounds, ability to cough 15. How many days after surgery should the nurse anticipate that a postoperative client will begin to exhibit signs and symptoms of a wound infection if it should occur? 1. Fifth day 2. Third day 3. Ninth day 4. Seventh day 16. A nurse is assessing a client who had spinal anesthesia. For which common response should the nurse assess the client? 1. Headache 2. Neuropathy 3. Lower back discomfort 4. Increased blood pressure 17. A hospitalized client who has been receiving medications via a variety of routes for several days is scheduled for surgery at 10 a.m. Which should the nurse plan to do on the day of surgery? 1. Use an alternative route for the oral medications. 2. Withhold all the previously prescribed medications. 3. Withhold the oral medications and administer the other drugs. 4. Obtain directions from the primary health-care provider regarding the medications. 18. Which is the most common dietary prescription the nurse can anticipate after a client who had abdominal surgery exhibits a return of intestinal peristalsis. 1. Clear liquids 2. Full liquids 3. Low fiber 4. Regular 19. A nurse compares the advantages and disadvantages of a central venous catheter inserted into a peripheral vein and a central venous catheter inserted into a subclavian vein. Which of the following does the nurse conclude is the reason why a peripheral catheter is more desirable? 1. Because it will not be in the superior vena cava 2. Because it will not cause a tension pneumothorax 3. Because it will not prevent the development of an infection 4. Because it will not allow large volumes of fluid to be administered 20. A nurse is caring for a client who had abdominal surgery. Which type of incisional drainage should the nurse expect 4 hours after surgery? 1. Serous wound drainage 2. Purulent wound drainage 3. Sanguineous wound drainage 4. Serosanguineous wound drainage 21. A nurse is assessing a postoperative client. Which client response identified by the nurse indicates altered renal perfusion. 1. Oliguria 2. Cachexia 3. Yellow sclera 4. Suprapubic distention 22. A nurse is evaluating the effectiveness of nursing interventions for meeting the nutrient needs of clients during the first 2 days after abdominal surgery. Which outcome is most important? 1. Nausea and vomiting have not occurred. 2. Fluid and electrolytes are balanced. 3. Wound healing is progressing. 4. Oral intake is reestablished. 23. Which is the next most important assessment made by the nurse after ensuring a postoperative client has a patent airway? 1. Condition of drains 2. Level of consciousness 3. Stability of the vital signs 4. Location of the surgical dressing 24. A client’s perineal area must be examined by the primary health-care provider prior to surgery. In which position should the nurse place the client for this physical assessment? 1. Sims 2. Supine 3. Lithotomy 4. Trendelenburg 25. A nurse is caring for two clients. One of the clients has a Jackson-Pratt drain and the another client has a Hemovac drain. Which does the nurse understand is the difference between these two drains? 1. The size of the collection container 2. How the pressure within the collection container is reestablished 3. The type of pressure that promotes drainage to the collection container 4. Where the collection container should be placed in relation to the insertion site 26. A nurse is caring for several clients who received general anesthesia. A client with which concurrent health problem poses the highest risk for the development of a postoperative complication? 1. Gastroesophageal reflux disease 2. Reduced reflexes 3. Hypothyroidism 4. Emphysema 27. A postoperative client experiences tachycardia, sudden chest pain, and low blood pressure. Which complication associated with the postoperative period should the nurse conclude that the client most likely experienced? 1. Pulmonary embolus 2. Hemorrhage 3. Heart attack 4. Pneumonia 28. A client spikes a fever during the first postoperative day after major abdominal surgery. The nurse suspects that the fever indicates an infection. Which site does the nurse conclude most likely is the source of the infection? 1. Intestines 2. Bladder 3. Wound 4. Lungs 29. A nurse is to apply a transparent wound barrier over a client’s incision. Which nursing action is appropriate? 1. Stretch the transparent dressing snugly over the entire wound. 2. Clean the skin with normal saline before applying the dressing. 3. Cover the transparent wound barrier with a gauze dressing and secure with paper tape. 4. Ensure the reinforcing tape extends several inches beyond the edges of the transparent wound barrier. 30. A nurse is to position a client in the postanesthesia care unit. Which factor is most important for the nurse to consider? 1. Allow for skeletal deformities. 2. Prevent pressure on bony prominences. 3. Provide for adequate thoracic expansion. 4. Avoid stretching of neuromuscular tissue. 31. When should the nurse initiate planned interventions regarding a client’s perioperative management? 1. When the consent form is signed 2. When the decision for surgery is made 3. When the client is admitted for surgery 4. When the client is transferred to the operating room 32. One hour after the reduction of a compound fracture of the ulna and radius and application of a cast, the nurse observes a centimeter circle of drainage on the client’s cast. Which should the nurse do first? 1. Inform the surgeon immediately. 2. Reinforce the cast with a gauze dressing. 3. Monitor the area frequently for expansion. 4. Circle the spot with a pen and date, time, and initial the area. 33. A nurse is caring for a client with a nasogastric tube attached to suction. What is the most important nursing action in relation to the nasogastric tube? 1. Using sterile technique when irrigating the tube 2. Recording intake and output every 2 hours 3. Providing oral hygiene every 4 hours 4. Setting suction at the prescribed level 34. A nurse is considering the commonalities and differences of equipment used for gastric decompression. Which is the major advantage to using a double-lumen tube? 1. Minimizes the risk of bowel obstruction 2. Ensures drainage of the intestines 3. Prevents gastric mucosal damage 4. Promotes gastric rest 35. A nurse is performing preoperative teaching a week before surgery. The client is taking 650 mg of aspirin twice a day for arthritis. Which instruction should the nurse expect the surgeon to have the nurse include in the preoperative teaching? 1. Continue to take the aspirin indefinitely. 2. Stop taking the aspirin 5 days before surgery. 3. Withhold the dose of aspirin on the morning of surgery. 4. Reduce the dose of aspirin to 81 mg a day until after surgery. 36. A client has negative pressure wound therapy (vacuum-assisted closure [VAC]) after the amputation of a toe. The tubing is connected to intermittent negative pressure. What should the nurse do when the film over the wound collapses when negative pressure is exert? 1. Notify the primary health-care provider. 2. Decrease the extent of negative pressure. 3. Apply a new transparent film over the wound. 4. Continue to observe the functioning of the device. 37. A primary health-care provider prescribes antiembolism stockings for a client. Place the following steps in the order in which they should be implemented when applying these stockings. 1. Assess the client for contraindications to the use of antiembolism stockings. 2. Apply the antiembolism stockings before getting the client out of bed in the morning. 3. Ensure that the applied stockings are 1 to 2 inches below the popliteal fold (bend) in the back of the knee. 4. Explain that antiembolism stockings are prescribed by the primary healthcare provider and what is to be done and why. 5. Measure the smallest circumference of the ankle, the largest circumference of the calf, and the length from the heel to 1 to 2 inches below the popliteal fold (bend) in the back of the knee. 6. Turn the stocking inside out so that the foot portion is inside the stocking leg, stretch each side of the stocking and ease it over the toes, center the heel, and pull the stocking over the heel and up the leg. Answer: _______________________ 38. A nurse is caring for a client recovering from abdominal surgery. Which nursing action is effective in facilitating ventilation. Select all that apply. 1. _____ Encouraging fluid intake 2. _____ Preventing abdominal distention 3. _____ Positioning in the side-lying position 4. _____ Implementing passive range-of-motion exercises 5. _____ Ensuring that an incentive spirometer is used every hour when awake 39. A nurse is caring for a client in the ambulatory surgery unit who just had a laparoscopic cholecystectomy. The client reports the presence of pain that is commonly associated with the migration of CO2 used to inflate the abdominal cavity to improve visualization during surgery. Shade in the location of this referred pain on the illustration. 40. A client had a tonsillectomy and is on a soft diet. Which of the following should the nurse encourage this client to have during the first 24 hours after surgery? Select all that apply. 1. _____ Warm pudding 2. _____ Milk shakes 3. _____ Apple juice 4. _____ Ice pops 5. _____ Gelatin 41. A nurse in the postanesthesia care unit at 3 p.m. receives report from the nurse who is completing the day shift. The following information about a 65-year-old man who was admitted to the unit at 1:30 p.m. after repair of a double inguinal hernia is reported. Which information does not meet the standard criteria for discharge from the unit? 1. Stability of vital signs 2. Level of consciousness 3. Absence of bowel sounds 4. Presence of a urinary catheter 42. A nurse is caring for a postoperative client. The client asks the nurse why vitamin C was prescribed by the primary health-care provider. Which information should the nurse include in a response to this question? Select all that apply. 1. _____ Facilitates healing 2. _____ Improves digestive processes 3. _____ Increases transport of oxygen to cells 4. _____ Encourages growth of red blood cells 5. _____ Minimizes formation of deep vein thrombosis 43. A nurse assesses the client on admission to the postanesthesia care unit and collects the following data: receiving 40% oxygen via a simple face mask; oxygen saturation 92%; opens eyes and responds to commands to move all four extremities; deep breathes and coughs; and vital signs are temperature—97.8°F, pulse—82 beats per minute, respirations—18 breaths per minute, and blood pressure—140/88 mm Hg, which is consistent with his previous blood pressures. Calculate the client’s Aldrete score. 1. 10 2. 9 3. 8 4. 7 44. A client has a right abdominal incision. Which should the nurse teach the client to do when getting out of bed? Select all that apply. 1. _____ Exit from the left side of the bed. 2. _____ Ask the nurse to apply an abdominal binder. 3. _____ Hold a pillow against the abdomen with both hands. 4. _____ Use the left arm to push up to a sitting position on the side of the bed. 5. _____ Sit on the side of the bed for a few minutes before moving to a standing position. 45. A nurse must initiate placement of a continuous passive motion machine after the client had a total knee replacement. Place the following steps in the order in which they should be implemented. 1. Position the extremity on the platform so the knee is centered over the break in the platform. 2. Set the degree of flexion, speed, and time on and off the machine as prescribed. 3. Ensure that the extremity is aligned with the client’s hips and torso. 4. Assess the client’s skin and provide skin care after the procedure. 5. Position sheepskin on the platform, especially at the gluteal fold. 6. Position the controller within easy reach of the client. Answer: _______________________ 46. A nurse is teaching a postoperative client the nutrients that are the best for supporting collagen production that promotes wound healing. Which food selected by the client indicates that the teaching was effective. Select all that apply. 1. _____ Yellow bell peppers 2. _____ Whole-grain bread 3. _____ Cantaloupe 4. _____ Oranges. 5. _____ Kiwi 47. A nurse is caring for a client with the following type of portable wound drainage device. Which should the nurse do when caring for a client with this type of drainage system? Select all that apply. 1. _____ Empty the container and then compress the collection container, close the port, and release hand compression. 2. _____ Wear sterile gloves when emptying the collection container. 3. _____ Keep the collection container below the insertion site. 4. _____ Shorten the length of the tubing by one inch daily. 5. _____ Empty the collection container when full. 6. _____ Attach tubing to clothing. 48. A nurse is caring for a postoperative client who had abdominal surgery. The client states, “The incision just felt like it gave way.” The nurse identifies that the client had a dehiscence with slight evisceration. Which of the following should the nurse implement? Select all that apply. 1. _____ Instruct the client to avoid coughing or bearing down. 2. _____ Notify the primary health-care provider immediately. 3. _____ Position the client in the low-Fowler position. 4. _____ Cover the incision with a sterile dressing. 5. _____ Prepare the client for surgery. 49. Which of the following independent and dependent nursing interventions help prevent thrombophlebitis during the postoperative period? Select all that apply. 1. _____ Applying lower-extremity sequential compression devices when in bed 2. _____ Wearing antiembolism stockings when out of bed 3. _____ Walking in the hall several times a day 4. _____ Using an incentive spirometer 5. _____ Coughing and deep breathing 6. _____ Keeping the legs uncrossed 50. The primary health-care provider prescribes morphine sulfate 12 mg subcutaneously STAT for a postoperative client. The morphine sulfate vial states that there are 10 mg per mL. Indicate on the syringe the line to which it should be filled to administer the prescribed dose. ANSWER KEY PAGE 442- 452 FUNDAMENTAL SUCCESS STUDY GUIDE QUESTIONS: 1. Which of the following types of anesthesia is administered by injecting a local anesthetic around a nerve trunk supplying the area of surgery. a. Nerve block b. Subdural block c. Surface anesthesia d. Local infiltration with lidocaine 2. When obtaining a consent form from a patient scheduled to undergo surgery, the nurse should consider which of the following facts? a. A consent form is legal, even if the patient is confused or sedated. b. The form that is signed is not a legal document and would not hold up in court. c. In emergency situations, the doctor may obtain consent over the telephone. d. The responsibility for securing informed consent from the patient lies with the nurse. 3. A 9-month-old baby is scheduled for heart surgery. When preparing this patient for surgery, the nurse should consider which of the following surgical risks associated with infants? a. Prolonged wound healing b. Potential for hypothermia or hyperthermia c. Congestive heart failure d. Gastrointestinal upset 4. Mr. Lemke, age 42, is scheduled for elective hernia surgery. While taking a medical history for Mr. Lemke, you find out he is taking antibiotics for an infection. To which of the following surgical risks would Mr. Lemke be predisposed because of his use of antibiotics? a. Hemorrhage b. Electrolyte imbalances c. Cardiovascular collapse d. Respiratory paralysis 5. When preparing a patient who has diabetes mellitus for surgery, the nurse should be aware of which of the following potential surgical risks associated with this disease? a. Fluid and electrolyte imbalance b. Slow wound healing c. Respiratory depression from anesthesia d. Altered metabolism and excretion of drugs 6. Mr. Pete is an obese 62-year-old man scheduled for heart surgery. Which of the following surgical risks related to obesity should be considered when performing an assessment for this patient? a. Delayed wound healing and wound infection b. Alterations in fluid and electrolyte balance c. Respiratory distress d. Hemorrhage 7. When teaching a postoperative patient about pain control, the nurse should consider which of the following statements? a. When giving pain medication p.r.n., the patient should ask for the medication when the pain becomes severe. b. The nurse is responsible for ordering and administering pain medications. c. Medications for pain usually are given by injection for the first few days or as long as the patient is NPO. d. Alternate pain control methods, such as TENS and PCA, should not be used after surgery. 8. To prevent postoperative complications, which of the following measures should be taken after surgery? a. The patient should be instructed to avoid coughing if possible, to minimize damage to the incision. b. The patient should take shallow breaths to prevent collapse of the alveoli. c. The patient should be instructed to do leg exercises to increase venous return. d. The patient should not be turned in bed until the incision is no longer painful. 9. Which of the following is the most common postanesthesia recovery emergency? a. Respiratory obstruction b. Cardiac distress c. Wound infection d. Dehydration 10. Mr. Fischer has returned to your unit after cardiac surgery. Which of the following interventions would be appropriate to prevent cardiovascular complications for him? a. Position him in bed with pillows placed under his knees to hasten venous return. b. Keep him from ambulating until the day after surgery. c. Implement leg exercises and turn him in bed every 2 hours. d. Keep him cool and uncovered to prevent elevated temperature. 11. Which of the following interventions should be carried out by the nurse when a postoperative patient is in shock? a. Remove extra coverings on the patient to keep temperature down. b. Place the patient in a flat position with legs elevated 45 degrees. c. Do not administer any further medication. d. Place the patient in the Trendelenburg or “shock” position. 12. Which of the following is a recommended physical preparation for a patient undergoing surgery? a. Shave the area of the incision with a razor. b. Empty the patient’s bowel of feces. c. Do not allow the patient to eat or drink anything for 8 to 12 hours before surgery. d. Be sure the patient is well nourished and hydrated. 13. Which of the following preoperative medications would be prescribed to decrease pulmonary and oral secretions and prevent laryngospasm? a. Narcotic analgesics b. Anticholinergics c. Neuroleptanalgesia agents d. Histamine-receptor antihistaminic 14. Which of the following positions would be used in minimally invasive surgery of the lower abdomen or pelvis? a. Trendelenburg position b. Sims’ position c. Lithotomy position d. Prone position 15. Which of the following would be an appropriate reaction to a patient experiencing pulmonary embolus? a. Try to overhydrate the patient with fluids. b. Instruct the patient to perform Valsalva’s maneuver. c. Place the patient in semi-Fowler’s position. d. Assist the patient to ambulate every 2 to 3 hours. 16. Your postsurgical patient is experiencing decreased lung sounds, dyspnea, cyanosis, crackles, restlessness, and apprehension. Which of the following conditions would you diagnose? a. Atelectasis b. Pneumonia c. Pulmonary embolus d. Thrombophlebitis 17. Which of the following actions would be performed in the postoperative phase of the perioperative period? (Select all that apply.) a. The nurse prepares the patient for home care. b. The physician informs the patient that surgical intervention is necessary. c. The patient is transferred to the recovery room. d. The patient is admitted to the recovery area. e. The patient begins to emerge from anesthesia. f. The patient participates in a rehabilitation program after surgery. 18. Which of the following examples of surgery would be classified as surgical procedures based on purpose? (Select all that apply.) a. Control of hemorrhage b. Breast biopsy c. Cleft palate repair d. Colostomy e. Tracheostomy f. Breast reconstruction 19. Regional anesthesia may be accomplished through which of the following methods? (Select all that apply.) a. Inhalation b. Spinal block c. Intravenous d. Oral route e. Nerve block f. Epidural block 20. Which of the following pieces of information must be provided to a patient to obtain informed consent? (Select all that apply.) a. A description of the procedure or treatment, along with potential alternative therapies b. The name and qualifications of the nurse providing perioperative care c. The underlying disease process and its natural course d. Explanation of the risks involved and how often they occur e. Explanation that a signed consent form is binding and cannot be withdrawn f. Customary insurance coverage for the procedure 21. Which of the following statements accurately describe the surgical risks related to the developmental stage of the patient? (Select all that apply.) a. Infants are at a greater risk from surgery than are middle-aged adults. b. Infants experience a slower metabolism of drugs that require renal biotransformation. c. Muscle relaxants and narcotics have a shorter duration of action in infants. d. Older adults have decreased renal blood flow and a reduced bladder capacity, necessitating careful monitoring of fluid and electrolyte status and input and output. e. Older adults have an increased gastric pH and require monitoring of nutritional status during the perioperative period. f. Older adults have an increased hepatic blood flow, liver mass, and enzyme function that prolongs the duration of medication effects. 22. Which of the following statements accurately describe how preexisting disease states affect surgical risk? (Select all that apply.) a. Cardiovascular diseases increase the risk for dehydration after surgery. b. Patients with respiratory disease may experience alterations in acid–base balance after surgery. c. Kidney and liver diseases influence the patient’s response to anesthesia. d. Endocrine diseases increase the risk for hyperglycemia after surgery. e. Endocrine diseases increase the risk for slow surgical wound healing. f. Pulmonary disorders increase the risk for hemorrhage and hypovolemic shock after surgery. 23. Which of the following statements accurately describe the effects the patient’s medications may have on surgical risk? (Select all that apply.) a. Diuretics may precipitate hemorrhage. b. Anticoagulants may cause electrolyte imbalances. c. Diuretics may cause respiratory depression from anesthesia. d. Tranquilizers may increase the hypotensive effect of anesthetic agents. e. Adrenal steroids may cause respiratory paralysis. f. Abrupt withdrawal from adrenal steroids may cause cardiovascular collapse in long-term users. 24. Which of the following are significant abnormal findings related to presurgical screening tests? (Select all that apply.) a. An elevated white blood cell count, indicating an infection b. Decreased hematocrit and hemoglobin level, indicating bleeding or anemia c. Increased hyperkalemia or hypokalemia, indicating possible renal failure d. Elevated blood urea nitrogen or creatinine levels, indicating an increased risk for cardiac problems e. Abnormal urine constituents, indicating infection or fluid imbalances f. Increased hemoglobin level, indicating infection 25. Which of the following nursing interventions would be appropriate for a patient recovering from a surgical procedure? (Select all that apply.) a. Teach the patient to suppress urges to cough in order to protect the incision. b. Encourage the patient to take frequent shallow breaths to improve lung expansion and volume. c. Place the patient in a semi-Fowler’s position to perform deep breathing exercises every 1 to 2 hours for the first 24 to 48 hours after surgery and as necessary thereafter. d. Encourage the patient to lie still in bed with the incision facing upward to prevent putting pressure on the stitches. e. Teach the patient the appropriate leg exercises to increase venous blood return from the legs. f. Encourage the patient to use incentive spirometry 10 times each waking hour for the first 5 days after surgery. Prioritization Questions 26. Place the following guidelines for teaching a patient deep breathing in the order in which they would be performed: a. Ask the patient to inhale through the nose gently and completely. b. Place the patient in semi-Fowler’s position with the neck and shoulders supported. c. Ask the patient to exhale gently and completely. d. Repeat this exercise three times every 1 to 2 hours. e. Ask the patient to place the hands over the rib cage so he/she can feel the chest rise as the lungs expand. f. Ask the patient to exhale as completely as possible through the mouth with lips pursed (as if whistling). g. Ask the patient to hold his or her breath for 3 to 5 seconds and mentally count “one, one thousand, two, one thousand, etc.” ANSWER________________________________ 27. Place the following guidelines for teaching a patient effective coughing in the order in which they would be performed: a. Ask the patient to “hack out” for three short breaths. b. Repeat the exercise every 2 hours while awake. c. Place the patient in a semi-Fowler’s position, leaning forward and provide a pillow or bath blanket to splint the incision. d. Ask the patient to cough deeply once or twice and take another deep breath. e. Ask the patient to take a quick breath with mouth open. f. Ask the patient to inhale and exhale deeply and slowly through the nose three times. g. Ask the patient to take a deep breath and hold it for 3 seconds. ANSWER _______________________________ ANSWERS: 1. a 2. c 3. b 4. d 5. b 6. a 7. c 8. c 9. a 10. c 11. b 12. d 13. b 14. a 15. c 16. a 17. a, d, f 18. b, c, d, f 19. b, e, f 20. a, c, d 21. a, b, d, e 22. b, c, e 23. c, d, f 24. a, b, e 25. c, e, f 26. b – e – c – a – g—f -- d 27. c -- f – g—a – e – d -- b Textbook Question 1. a. b. c. d. 2. a. b. c. d. e. f. 3. a. b. c. d. e. f. 4. a. b. c. d. 5. a. b. c. d. A perioperative nurse is preparing a patient for surgery for treatment of a ruptured spleen as the result of an automobile crash. For what type of surgery would the nurse prepare this patient? Minor, diagnostic Minor, elective Major, emergency Major, palliative 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. Loss of consciousness Relaxation of skeletal muscles Reduction or loss of reflex action Localized loss of sensation Prolonged pain relief after other anesthesia wears off Infiltrates the underlying tissues in an operative area 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. The option of nontreatment The underlying disease process and its natural course Notice that once the form is signed, the patient cannot withdraw the consent Explanation of the guaranteed outcome of the procedure or treatment Name and qualifications of the provider of the procedure or treatment Explanation of the risks and benefits of the procedure or treatment 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? Anticoagulants Antacids Laxatives Sedatives A nurse is caring for an obese patient who has had surgery. The nurse monitors this patient for what postoperative complication? Anesthetic agent interactions Impaired wound healing Hemorrhage Gas pains 6. 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. 7. A nurse is providing teaching for a patient 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 8. 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.” 9. 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.” 10. A patient had a surgical procedure that necessitated a thoracic incision. The nurse anticipates that the patient will have a higher risk for postoperative complications involving which body system? a. Respiratory system b. Circulatory system c. Digestive system d. Nervous system 11. 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. 12. Hemorrhage 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 deep vein thrombosis (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 13. 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 14. 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 15. 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 ANSWERS WITH RATIONALES 1. 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 sq urgery 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. 2. c, d. A localized loss of sensation and possible loss of reflexes occur with a regional anesthetic. Loss of consciousness and relaxation of skeletal muscles occur 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. 3. a, b, e, f. The information contained in informed consent includes the description of the procedure or treatment, potential alternative therapies, and the option of nontreatment, the underlying disease process and its natural course, the name and qualifications of the health care provider performing the procedure or treatment, explanation of the risks and benefits, explanation that the patient has the right to refuse treatment and consent can be withdrawn, and explanation of expected (not guaranteed) outcome, recovery, and rehabilitation plan and course. 4. a. Anticoagulant drug therapy would increase the risk for hemorrhage during surgery. 5. b. Fatty tissue has a poor blood supply and, therefore, has less resistance to infection. As a result, postoperative complications of delayed wound healing, wound infection, and disruption in the integrity of the wound are more common. Patients with a large habitual intake of alcohol require larger doses of anesthetic agents and postoperative analgesics, increasing the risk for drug-related complications. Patients who use illicit drugs are at risk for interactions with anesthetic agents. These are specific to the illicit drug used and should be noted on the medical record for safe anesthetic management. Patients taking anticoagulants are at increased risk for hemorrhage. Gas pains are a common postoperative discomfort. 6. a, c, f. Sedatives, such as diazepam, midazolam, or lorazepam, are given to alleviate anxiety and decrease recall of events related to surgery. Anticholinergics, such as atropine and glycopyrrolate are given to decrease pulmonary and oral secretions and to prevent laryngospasm. Neuroleptanalgesic agents, such as fentanyl citrate–droperidol are given to cause a general state of calm and sleepiness. Histamine-2 receptor blockers, such as cimetidine and ranitidine, 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. 7. d. Written instructions are most effective in providing information for same-day surgery. 8. b. This answer allows the patient to talk about feelings and fears, and is therapeutic. 9. d. PCA infusion pumps allow patients to self-administer doses of pain-relieving medication within health care provider– 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. 10. 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. 11. d. Increased wound drainage, restlessness, decreasing blood pressure, and increasing pulse rate are assessment findings that indicate hemorrhage. Thrombophlebitis is an inflammation of a vein associated with thrombus (blood clot) formation. Thrombophlebitis is typically superficial and, in patients without an underlying condition, is often related to IV catheters. 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. 12. b. Manifestations of DVT 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. This increase in extremity circumference (typically the calf) is the most significant sign of a DVT and the provider should be notified. The priority for the patient with a known DVT is preventing a clot from breaking loose and becoming a VTE that propagates (travels) to the heart, brain, or lungs called a pulmonary embolism. Thrombophlebitis is an inflammation of a vein associated with thrombus (blood clot) formation. Thrombophlebitis is typically superficial and, in patients without an underlying condition, is often related to IV catheters. 13. 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 OR 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. 14. 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. 15. d. Leg exercises assist in preventing muscle weakness, promote venous return, and decrease complications related to venous stasis. As a result, the patient has a decreased risk for thrombophlebitis, DVT, and emboli.
