Chapter 50: Perioperative Nursing Care
Potter et al.: Fundamentals of Nursing, 10th Edition
MULTIPLE CHOICE
1. The nurse is caring for a surgical patient, when the family member asks what perioperative nursing means. How should the nurse
respond?
a. Perioperative nursing occurs in preadmission testing.
b. Perioperative nursing occurs primarily in the postanesthesia care unit.
c. Perioperative nursing includes activities before, during, and after surgery.
d. Perioperative nursing includes activities only during the surgical procedure.
ANS: C
Perioperative nursing care occurs before, during, and after surgery. Preadmission testing occurs before surgery and is considered
preoperative. Nursing care provided during the surgical procedure is considered intraoperative, and in the postanesthesia care unit,
it is considered postoperative. All of these are parts of the perioperative phase, but each individual phase does not explain the term
completely.
DIF: Understand (comprehension)
TOP: Teaching/Learning
OBJ: Explain the concept of perioperative nursing care.
MSC: Management of Care
2. The nurse is caring for a patient who is scheduled to undergo a surgical procedure. The nurse is completing an assessment and
reviews the patient’s laboratory tests and allergies and prepares the patient for surgery. In which perioperative nursin g phase is the
nurse working?
a. Perioperative
b. Preoperative
c. Intraoperative
d. Postoperative
ANS: B
Reviewing the patient’s laboratory tests and allergies is done before surgery in the preoperative phase. Perioperative means before,
during, and after surgery. Intraoperative means during the surgical procedure in the operating suite; postoperative means after the
surgery and could occur in the postanesthesia care unit, in the ambulatory surgical area, or on the hospital unit.
DIF: Understand (comprehension)
TOP: Implementation
OBJ: Explain the concept of perioperative nursing care.
MSC: Management of Care
3. The nurse is caring for a patient in the postanesthesia care unit. The patient has developed profuse bleeding from the surgical site,
and the surgeon has determined the need to return to the operative area. How will the nurse classify this procedure?
a. Major
b. Urgent
c. Elective
d. Emergency
ANS: D
An emergency procedure must be done immediately to save a life or preserve the function of a body part. An example would be
repair of a perforated appendix, repair of a traumatic amputation, or control of internal hemorrhaging. An urgent procedure is
necessary for a patient’s health and often prevents additional problems from developing. An example would be excision of a
cancerous tumor, removal of a gallbladder for stones, or vascular repair for an obstructed artery. An elective procedure is
performed on the basis of the patient’s choice; it is not essential and is not always necessary for health. An example would be a
bunionectomy, plastic surgery, or hernia reconstruction. A major procedure involves extensive reconstruction or alteration in body
parts; it poses great risks to well-being. An example would be a coronary artery bypass or colon resection.
DIF: Understand (comprehension)
TOP: Implementation
OBJ: Explain the concept of perioperative nursing care.
MSC: Management of Care
4. The nurse is caring for a patient in preadmission testing. The patient has been assigned a physical status classification by the
American Society of Anesthesiologists of ASA III. Which assessment will support this classification?
a. Normal, healthy patient
b. Denial of any major illnesses or conditions
c. Poorly controlled hypertension with implanted pacemaker
d. Moribund patient not expected to survive without the operation
ANS: C
An ASA III rating is a patient with a severe systemic disease, such as poorly controlled hypertension with an implanted pacemaker.
ASA I is a normal healthy patient with no major illnesses or conditions. ASA II is a patient with mild systemic disease. ASA V is a
moribund patient who is not expected to survive without the operation and includes patients with ruptured abdominal/thoracic
aneurysm or massive trauma.
DIF: Understand (comprehension)
OBJ: Explain the concept of perioperative nursing care.
TOP: Assessment MSC: Reduction of Risk Potential
Copyright © 2021, Elsevier Inc. All rights reserved.
1
5. The patient presented to the ambulatory surgery center to have a colonoscopy is scheduled to receive moderate sedation (conscious
sedation) during the procedure. How will the nurse interpret this information?
a. The procedure results in loss of sensation in an area of the body.
b. The procedure requires a depressed level of consciousness.
c. The procedure will be performed on an outpatient basis.
d. The procedure necessitates the patient to be immobile.
ANS: B
Moderate sedation (conscious sedation) is used routinely for procedures that do not require complete anesthesia but rather a
depressed level of consciousness. Not all patients who are treated on an outpatient basis receive moderate sedation. Regional
anesthesia such as local anesthesia provides loss of sensation in an area of the body. General anesthesia is used for patients who
need to be immobile and to not remember the surgical procedure.
DIF: Understand (comprehension)
OBJ: Explain the concept of perioperative nursing care.
TOP: Evaluation
MSC: Reduction of Risk Potential
6. The nurse is caring for a patient in the postanesthesia care unit who has undergone a left total knee arthroplasty. The anesthesia
provider has indicated that the patient received a left femoral peripheral nerve block. Which assessment will be an expected finding
for this patient?
a. Sensation decreased in the left leg
b. Patient report of pain in the left foot
c. Pulse decreased at the left posterior tibia
d. Left toes cool to touch and slightly cyanotic
ANS: A
Induction of regional anesthesia results in loss of sensation in an area of the body—in this case, the left leg. The peripheral nerve
block influences the portions of sensory pathways that are anesthetized in the targeted area of the body. Decreased pulse, toes cool
to touch, and cyanosis are indications of decreased blood flow and are not expected findings. Reports of pain in the left foot may
indicate that the block is not working or is subsiding and is not an expected finding in the immediate postoperative period.
DIF: Understand (comprehension)
OBJ: Describe factors to assess in a patient during postoperative recovery.
TOP: Assessment MSC: Reduction of Risk Potential
7. Which nursing goal is a priority for assessing the patient before surgery?
a. Plan for care after the procedure.
b. Establish a patient’s baseline of normal function.
c. Educate the patient and family about the procedure.
d. Gather appropriate equipment for the patient’s needs.
ANS: B
The goal of the preoperative assessment is to identify a patient’s normal preoperative function and the presence of any risks to
recognize, prevent, and minimize possible postoperative complications. Gathering appropriate equipment, planning care, and
educating the patient and family are all important interventions that must be provided for the surgical patient; they are part of the
nursing process but are not the priority reason/goal for completing an assessment of the surgical patient.
DIF: Understand (comprehension)
OBJ: Describe preoperative assessment data to collect for a surgical patient.
TOP: Planning
MSC: Reduction of Risk Potential
8. The nurse is completing a medication history for the surgical patient in preadmission testing. Which medication should the nurse
instruct the patient to hold (discontinue) in preparation for surgery according to protocol?
a. Warfarin
b. Vitamin C
c. Prednisone
d. Acetaminophen
ANS: A
Medications such as warfarin or aspirin alter normal clotting factors and thus increase the risk of hemorrhaging. Discontinue at
least 48 hours before surgery. Acetaminophen is a pain reliever that has no special implications for surgery. Vitamin C actually
assists in wound healing and has no special implications for surgery. Prednisone is a corticosteroid, and dosages are often
temporarily increased rather than held.
DIF: Apply (application)
OBJ: Discuss common surgical risk factors and related nursing implications.
TOP: Implementation
MSC: Pharmacological and Parenteral Therapies
Copyright © 2021, Elsevier Inc. All rights reserved.
2
9. The nurse is prescreening a surgical patient in the preadmission testing unit. The medication history indicates that the patient is
currently taking an anticoagulant. Which action should the nurse request when consulting with the health care provider?
a. A radiological examination of the chest
b. An international normalized ratio (INR)
c. A blood urea nitrogen (BUN)
d. A serum sodium (Na)
ANS: B
INR, PT (prothrombin time), APTT (activated partial thromboplastin time), and platelet counts reveal the clotting ability of the
blood. Anticoagulants can be utilized for different conditions, but its action is to increase the time it takes for the blood to clot. This
action can put the surgical patient at risk for bleeding tendencies. Typically, if at all possible, this medication is held several days
before a surgical procedure to decrease this risk. Chest x-ray, BUN, and Na are diagnostic screening tools for surgery but are not
specific to anticoagulants.
DIF: Apply (application)
OBJ: Discuss common surgical risk factors and related nursing implications.
TOP: Implementation
MSC: Reduction of Risk Potential
10. The nurse is encouraging the postoperative patient to utilize diaphragmatic breathing. Which priority goal is the nurse trying to
achieve?
a. Manage pain.
b. Prevent atelectasis.
c. Reduce healing time.
d. Decrease thrombus formation.
ANS: B
After surgery, patients may have reduced lung volume and may require greater effort to cough and deep breathe; inadequate lung
expansion can lead to atelectasis and pneumonia. Purposely utilizing diaphragmatic breathing can decrease this risk. During general
anesthesia, the lungs are not fully inflated during surgery and the cough reflex is suppressed, so mucus collects within airway
passages. Diaphragmatic breathing does not manage pain; in some cases, if splinting and pain medications are not given, it can
cause pain. Diaphragmatic breathing does not reduce healing time or decrease thrombus formation. Better, more effective
interventions are available for these situations.
DIF: Understand (comprehension)
OBJ: Describe the rationale for nursing interventions designed to prevent postoperative complications. TOP:
Reduction of Risk Potential
Planning
MSC:
11. The nurse caring for a postoperative patient will encourage what activity to prevent venous stasis and the formation of thrombus?
a. Diaphragmatic breathing
b. Incentive spirometry
c. Leg exercises
d. Coughing
ANS: C
After general anesthesia, circulation slows, and when the rate of blood slows, a greater tendency for clot formation is noted.
Immobilization results in decreased muscular contractions in the lower extremities; these promote venous stasis. Coughing,
diaphragmatic breathing, and incentive spirometry are utilized to decrease atelectasis and pneumonia.
DIF: Understand (comprehension)
OBJ: Describe the rationale for nursing interventions designed to prevent postoperative complications. TOP:
MSC: Reduction of Risk Potential
Implementation
12. The nurse caring for a preoperative patient teaches the principles and demonstrates leg exercises for the patient. The patient is
unable to perform leg exercises correctly. What is the nurse’s best next step?
a. Encourage the patient to practice at a later date.
b. Assess for the presence of anxiety, pain, or fatigue.
c. Ask the patient why exercises are not being done.
d. Evaluate the educational methods used to educate the patient.
ANS: B
If the patient is unable to perform leg exercises, the nurse should look for circumstances that may be impacting the patient’s ability
to learn. In this case, the patient can be anticipating the upcoming surgery and may be experiencing anxiety. The patient may also
be in pain or may be fatigued; both of these can affect the ability to learn. Evaluation of educational methods may be needed, but in
this case, principles and demonstrations are being utilized. Asking anyone “why” can cause defensiveness and may not help in
attaining the answer. The nurse is aware that the patient is unable to do the exercises. Moving forward without ascertaining that
learning has occurred will not help the patient in meeting goals.
DIF: Apply (application)
TOP: Implementation
Copyright © 2021, Elsevier Inc. All rights reserved.
OBJ: Demonstrate postoperative exercises.
MSC: Health Promotion and Maintenance
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13. Which nursing assessment will indicate the patient is performing diaphragmatic breathing correctly?
a. Hands placed on the border of the rib cage with fingers extended will touch as the
b.
c.
d.
chest wall contracts.
Hands placed on the chest wall with fingers extended will separate as the chest
wall contracts.
The patient will feel upward movement of the diaphragm during inspiration.
The patient will feel downward movement of the diaphragm during expiration.
ANS: A
Positioning the hands along the borders of the rib cage allows the patient to feel movement of the chest and abdomen as the
diaphragm descends and the lungs expand. As the patient takes a deep breath and slowly exhales, the middle fingers will touch
while the chest wall contracts. The fingers will separate as the chest wall expands. The patient will feel normal downward
movement of the diaphragm during inspiration and normal upward movement during expiration.
DIF: Apply (application)
OBJ: Demonstrate postoperative exercises.
TOP: Evaluation
MSC: Reduction of Risk Potential
14. The nurse is caring for a postoperative patient with an abdominal incision. When the nurse provides a pillow to use during
coughing, which activity is the nurse promoting?
a. Pain relief
b. Splinting
c. Distraction
d. Anxiety reduction
ANS: B
Deep breathing and coughing exercises place additional stress on the suture line and cause discomfort. Splinting incision with
hands and a pillow provides firm support and reduces incisional pull. Providing a pillow during coughing does not provide
distraction or reduce anxiety. Providing a pillow does not provide pain relief. Coughing can increase anxiety because it can cause
pain. Analgesics provide pain relief.
DIF: Understand (comprehension)
OBJ: Describe the rationale for nursing interventions designed to prevent postoperative complications. TOP:
MSC: Basic Care and Comfort
Implementation
15. The nurse is encouraging a reluctant postoperative patient to deep breathe and cough. Which explanation can the nurse provide that
may encourage the patient to comply?
a. “If you don’t deep breathe and cough, you will get pneumonia.”
b. “You will need to cough only a few times during this shift.”
c. “Let’s try clearing the throat because that will work just as well.”
d. “Deep breathing and coughing will clear your lungs of the anesthesia.”
ANS: D
Deep breathing and coughing expel retained anesthetic gases and facilitate a patient’s return to consciousness. Although it is
correct that a patient may experience atelectasis and pneumonia if deep breathing and coughing are not performed, the way this is
worded sounds threatening and could be communicated in a more therapeutic manner. Deep breathing and coughing are
encouraged every 2 hours while the patient is awake. Just clearing the throat does not remove mucus from deeper airways.
DIF: Apply (application)
TOP: Teaching/Learning
OBJ: Demonstrate postoperative exercises.
MSC: Reduction of Risk Potential
16. The nurse and the nursing assistive personnel are assisting a postoperative patient to turn in bed. To assist in minimizing
discomfort, which instruction should the nurse provide to the patient?
a. “Close your eyes and think about something pleasant.”
b. “Hold your breath and count to three.”
c. “Grab my shoulders with your hands.”
d. “Use your hand to support your incision.”
ANS: D
Instruct the patient to place the right hand over the incisional area to splint it, providing support and minimizing pulling during
turning. Closing one’s eyes, holding one’s breath, and holding the nurse’s shoulders do not help support the incision during a turn.
DIF: Apply (application)
TOP: Implementation
OBJ: Demonstrate postoperative exercises.
MSC: Basic Care and Comfort
17. The nurse is preparing to assist the patient in using the incentive spirometer. Which nursing intervention should the nurse provide
first?
a. Perform hand hygiene.
b. Explain use of the mouthpiece.
c. Instruct the patient to inhale slowly.
d. Place in the reverse Trendelenburg’s position.
ANS: A
Performing hand hygiene reduces microorganisms and should be performed first. Placing the patient in the correct position such as
high Fowler’s for the typical postoperative patient or reverse Trendelenburg’s for the bariatric patient would be the next step in the
process. Demonstration of use of the mouthpiece followed by the instruction to inhale slowly would be the last step in this scenario.
DIF: Apply (application)
TOP: Implementation
Copyright © 2021, Elsevier Inc. All rights reserved.
OBJ: Demonstrate postoperative exercises.
MSC: Safety and Infection Control
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18. The nurse and the nursing assistive personnel (NAP) are caring for a group of postoperative patients who need turning, coughing,
deep breathing, incentive spirometer, and leg exercises. Which task will the nurse assign to the NAP?
a. Teaching postoperative exercises
b. Doing nothing associated with postoperative exercises
c. Documenting in the medical record when exercises are completed
d. Informing the nurse if the patient is unwilling to perform exercises
ANS: D
The nurse can delegate to the NAP to encourage patients to practice postoperative exercises regularly after instruction and to
inform the nurse if the patient is unwilling to perform these exercises. The skills of demonstrating and teaching postoperative
exercises and documenting are not within the scope of practice for the nursing assistant. Doing nothing is not appropriate.
DIF: Apply (application)
TOP: Implementation
OBJ: Demonstrate postoperative exercises.
MSC: Management of Care
19. The nurse is providing preoperative teaching for the ambulatory surgery patient who will be having a cyst removed from the right
arm. Which will be the best explanation for diet progression after surgery?
a. “Start with clear liquids, soup, and crackers. Advance to a normal diet as
tolerated.”
b. “Stay with ice chips for several hours. After that, you can have whatever you
want.”
c. “Stay on clear liquids for 24 hours. Then you can progress to a normal diet.”
d. “Start with clear liquids for 2 hours and then full liquids for 2 hours. Then
progress to a normal diet.”
ANS: A
Patients usually receive a normal diet the first evening after surgery unless they have undergone surgery on GI structures.
Implement diet intake while judging the patient’s response. For example, provide clear liquids such as water, apple juice, broth, or
tea after nausea subsides. If the patient tolerates liquids without nausea, advance the diet as ordered. There is no need to stay on ice
chips for several hours or clear liquids for 24 hours after this procedure. Putting a time frame on the progression is too prescriptive.
Progression should be adjusted for the patient’s needs.
DIF: Apply (application)
OBJ: Explain the elements of a typical preoperative teaching plan.
TOP: Implementation
MSC: Basic Care and Comfort
20. The nurse explains the pain-relief measures available after surgery during preoperative teaching for a surgical patient. Which
comment from the patient indicates the need for additional education on this topic?
a. “I will be asked to rate my pain on a pain scale.”
b. “I will have minimal pain because of the anesthesia.”
c. “I will take the pain medication as the provider prescribes it.”
d. “I will take my pain medications before doing postoperative exercises.”
ANS: B
Anesthesia will be provided during the procedure itself, and the patient should not experience pain during the procedure; however,
this will not minimize the pain after surgery. Pain management is utilized after the postoperative phase. Inform the patient of
interventions available for pain relief, including medication, relaxation, and distraction. The patient needs to know and understand
how to take the medications that the health care provider will prescribe postoperatively. During the stay in the facility, the level of
pain is frequently assessed by the nurses. Coordinating pain medication with postoperative exercises helps to minimize discomfort
and allows the exercises to be more effective.
DIF: Analyze (analysis)
OBJ: Explain the elements of a typical preoperative teaching plan.
TOP: Evaluation
MSC: Basic Care and Comfort
21. The nurse is making a preoperative education appointment with a patient. The patient asks if a family member should come to the
appointment. Which is the best response by the nurse?
a. “There is no need for an additional person at the appointment.”
b. “Your family can come and wait with you in the waiting room.”
c. “We recommend including family members at this appointment.”
d. “It is required that you have a family member at this appointment.”
ANS: C
Including family members in perioperative education is advisable. Often a family member is a coach for postoperative exercises
when the patient returns from surgery. If anxious relatives do not understand routine postoperative events, it is likely that their
anxiety will heighten the patient’s fears and concerns. Preoperative preparation of family members before surgery helps to
minimize anxiety and misunderstanding. An additional person is needed at the appointment if at all possible, and he or she needs to
be involved in the process, not just waiting in the waiting room; however, it is certainly not a requirement for actually completing
the surgery that someone comes to this appointment.
DIF: Apply (application)
OBJ: Explain the elements of a typical preoperative teaching plan.
TOP: Communication and Documentation
MSC: Psychosocial Integrity
Copyright © 2021, Elsevier Inc. All rights reserved.
5
22. The nurse is reviewing the surgical consent with the patient during preoperative education and finds the patient does not understand
what procedure will be performed. What is the nurse’s best next step?
a. Notify the health care provider about the patient’s question.
b. Explain the procedure that will be completed.
c. Continue with preoperative education.
d. Ask the patient to sign the form.
ANS: A
Surgery cannot be legally or ethically performed until the patient fully understands the need for a procedure and all the
implications. It is the surgeon’s responsibility to explain the procedure, associated risks, benefits, alternatives, and possible
complications. It is important for the nurse to pause with preoperative education to notify the health care provider of the patient’s
questions. It is not within the nurse’s scope to explain the procedure. The nurse can certainly reinforce what the health care
provider has explained, but the information needs to come from the health care provider. It is not prudent to ask a patient to sign a
form for a procedure that he/she does not understand.
DIF: Apply (application)
OBJ: Prepare a patient physically and psychologically for surgery.
TOP: Implementation
MSC: Management of Care
23. During preoperative assessment for a 7:30 AM (0730) surgery, the nurse finds the patient drank a cup of coffee this morning. The
nurse reports this information to the anesthesia provider. Which action does the nurse anticipate next?
a. A delay in or cancellation of surgery
b. Questions regarding components of the coffee
c. Additional questions about why the patient had coffee
d. Instructions to determine what education was provided in the preoperative visit
ANS: A
The recommendations before nonemergent procedures requiring general and regional anesthesia or sedation/analgesia include
fasting from intake of clear liquids for 2 or more hours. A delay in or cancellation of surgery will be in order for this case.
Questions regarding components of the coffee, asking why, and evaluating the preoperative education may all be items to be
addressed, especially from a performance improvement perspective, but at this time in caring for this patient, a delay or
cancellation is in order to prevent aspiration.
DIF: Understand (comprehension)
OBJ: Describe the perioperative assessment data to collect for a surgical patient.
TOP: Planning
MSC: Reduction of Risk Potential
24. The nurse has administered a preoperative medication to the patient going to surgery. Which action will the nurse take next?
a. Notify the operating suite that the medication has been given.
b. Instruct the patient to call for help to go to the restroom.
c. Waste any unused medication according to policy.
d. Ask the patient to sign the consent for surgery.
ANS: B
Once a preoperative medication has been administered, instruct the patient to call for help when getting out of bed to prevent falls.
For patient safety, explain the purpose of a preoperative medication and its effects. Notifying the operating suite that the medication
has been given may be part of a facilities procedure but is not the best next step. It is important to have the patient sign consents
before the patient has received medication that may make him/her drowsy. Wasting unused medication according to policy is
important but is not the best next step.
DIF: Apply (application)
OBJ: Prepare a patient physically and psychologically for surgery.
TOP: Implementation
MSC: Reduction of Risk Potential
25. The nurse has completed a preoperative assessment for a patient going to surgery and gathers assessment data. Which will be the
most important next step for the nurse to take?
a. Notify the operating suite that the patient has a latex allergy.
b. Document that the patient had a bath at home this morning.
c. Administer the ordered preoperative intravenous antibiotic.
d. Ask the nursing assistive personnel to obtain vital signs.
ANS: A
The most important step is notifying the operating suite of the patient’s latex allergy. Many products that contain latex are used in
the operating suite and the postanesthesia care unit (PACU). When preparing for a patient with this allergy, special considerations
are required from preparation of the room to the types of tubes, gloves, drapes, and instruments utilized. Obtaining vital signs,
documenting, and administering medications are all part of the process and should be done—with the latex allergy in mind.
However, making sure that the patient has a safe environment is the first step.
DIF: Apply (application)
OBJ: Describe preoperative assessment data to collect for a surgical patient.
TOP: Implementation
MSC: Reduction of Risk Potential
Copyright © 2021, Elsevier Inc. All rights reserved.
6
26. The nurse is preparing a patient for a surgical procedure on the right great toe. Which action will be most important to include in
this patient’s preparation?
a. Place the patient in a clean surgical gown.
b. Ask the patient to remove all hairpins and cosmetics.
c. Ascertain that the surgical site has been correctly marked.
d. Determine where the family will be located during the procedure.
ANS: C
Because errors have occurred in the past with patients undergoing the wrong surgery on the wrong site, the universal protocol
guidelines have been implemented and are used with all invasive procedures. Part of this protocol includes marking the operative
site with indelible ink. Knowing where the family is during a procedure, placing the patient in a clean gown, and asking the patient
to remove all hairpins and cosmetics are important but are not most important in this list of items.
DIF: Apply (application)
OBJ: Prepare a patient physically and psychologically for surgery.
TOP: Implementation
MSC: Reduction of Risk Potential
27. The circulating nurse is caring for a patient intraoperatively. Which primary role of the circulating nurse will be implemented?
a. Suturing the surgical incision in the OR suite
b. Managing patient care activities in the OR suite
c. Assisting with applying sterile drapes in the OR suite
d. Handing sterile instruments and supplies to the surgeon in the OR suite
ANS: B
The circulating nurse is an RN who remains unscrubbed and uses the nursing process in the management of patient care activities
in the OR suite. The circulating nurse also manages patient positioning, antimicrobial skin preparation, medications, implants,
placement and function of intermittent pneumatic compression (IPC) devices, specimens, warming devices and surgical counts of
instruments, and dressings. The RN first assistant collaborates with the surgeon by handling and cutting tissue, using instruments
and medical devices, providing exposure of the surgical area and hemostasis, and suturing. The scrub nurse, who can be a
registered nurse, a licensed practical nurse, or a surgical technologist, maintains the sterile field, assists with appl ying the sterile
drapes, and hands sterile instruments and supplies to the surgeon.
DIF: Understand (comprehension)
OBJ: Explain the registered nurse’s role in the operating room.
MSC: Management of Care
TOP: Implementation
28. The nurse is caring for a patient in the preoperative holding area of an ambulatory surgery center. Which nursing action will be
most appropriate for this area?
a. Counting the sterile surgical instruments
b. Emptying the urinary drainage bag
c. Checking the surgical dressing
d. Appling a warm blanket
ANS: D
The temperature in the preoperative holding area and in adjacent operating suites is usually cold. Offer the patient an extra warm
blanket. Counts are taken by the circulating and scrub nurses in the operating room. Emptying a urinary drainage bag and checking
the surgical dressing occur in the postanesthesia care unit, not in the holding area.
DIF: Apply (application)
OBJ: Explain the registered nurse’s role in the operating room.
MSC: Reduction of Risk Potential
TOP: Implementation
29. The nurse is caring for a patient in the operating suite. Which outcome will be most appropriate for this patient at the end of the
intraoperative phase?
a. The patient will be free of burns at the grounding pad.
b. The patient will be free of nausea and vomiting.
c. The patient will be free of infection.
d. The patient will be free of pain.
ANS: A
A primary focus of intraoperative care is to prevent injury and complications related to anesthesia, surgery, positioning, and
equipment use, including use of the electrical cautery grounding pad for the prevention of burns. The perioperative nurse is an
advocate for the patient during surgery and protects the patient’s dignity and rights at all times. Signs and symptoms of infection do
not have the time to present during the intraoperative phase. During the intraoperative phase, the patient is anesthetized and
unconscious and typically has an endotracheal tube that prevents conversation. Nausea, vomiting, and pain typically begin in the
postoperative phase of the experience.
DIF: Analyze (analysis)
OBJ: Explain the registered nurse’s role in the operating room.
MSC: Reduction of Risk Potential
Copyright © 2021, Elsevier Inc. All rights reserved.
TOP: Planning
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30. The nurse is concerned about the skin integrity of the patient in the intraoperative phase of surgery. Which action will the nurse
take to minimize skin breakdown?
a. Encouraging the patient to bathe before surgery
b. Securing attachments to the operating table with foam padding
c. Periodically adjusting the patient during the surgical procedure
d. Measuring the time a patient is in one position during surgery
ANS: B
Although it may be necessary to place a patient in an unusual position, try to maintain correct alignment and protect the patient
from pressure, abrasion, and other injuries. Special mattresses, use of foam padding, and attachments to the operating suite table
provide protection for the extremities and bony prominences. Bathing before surgery helps to decrease the number of microbes on
the skin. Periodically adjusting the patient during the surgical procedure is impractical and can present a safety issue with regard to
maintaining sterility of the field and maintaining an airway. Measuring the time the patient is in one position may help with
monitoring the situation but does not prevent skin breakdown.
DIF: Apply (application)
OBJ: Explain the registered nurse’s role in the operating room.
MSC: Reduction of Risk Potential
TOP: Implementation
31. The nurse is assessing a postoperative patient with a history of obstructive sleep apnea for airway obstruction. Which assessment
finding will best alert the nurse to this complication?
a. Drop in pulse oximetry readings
b. Moaning with reports of pain
c. Shallow respirations
d. Disorientation
ANS: A
One of the greatest concerns after general anesthesia is airway obstruction, especially in patients with obstructive sleep apnea. A
drop-in oxygen saturation by pulse oximetry is a sign of airway obstruction in patients with obstructive sleep apnea. Weak
pharyngeal/laryngeal muscle tone from anesthetics; secretions in the pharynx, bronchial tree, or trachea; and laryngeal or subglottic
edema also contribute to airway obstruction. In the postanesthetic patient, the tongue is a major cause of airway obstruction.
Shallow respirations are indicative of respiratory depression. Moaning and reports of pain are common in all surgical patients and
are an expected event. Disorientation is common when first awakening from anesthesia but can be a sign of hypoxia.
DIF: Apply (application)
OBJ: Describe factors to assess in a patient during postoperative recovery.
TOP: Assessment MSC: Reduction of Risk Potential
32. The nurse is caring for a patient in the operating suite who is experiencing hypercarbia, tachypnea, tachycardia, premature
ventricular contractions, and muscle rigidity. Which condition does the nurse suspect the patient is experiencing?
a. Malignant hyperthermia
b. Fluid imbalance
c. Hemorrhage
d. Hypoxia
ANS: A
A life-threatening, rare complication of anesthesia is malignant hyperthermia. Malignant hyperthermia causes hypercarbia,
tachycardia, tachypnea, premature ventricular contractions, unstable blood pressure, cyanosis, skin mottling, and muscular rigidity.
It often occurs during anesthesia induction. Hypoxia would manifest with decreased oxygen saturation as one of its signs and
symptoms. Fluid imbalance would be assessed with intake and output and can manifest with tachycardia and blood pressure
fluctuations but does not have muscle rigidity. Hemorrhage can manifest with tachycardia and decreased blood pressure, along with
a thready pulse. Usually some sign or symptom of blood loss is noted (e.g., drains, incision, orifice, and abdomen).
DIF: Understand (comprehension)
OBJ: Describe factors to assess in a patient during postoperative recovery.
TOP: Evaluation
MSC: Physiological Adaptation
33. The nurse is caring for a postoperative patient who has had a minimally invasive carpel tunnel repair. The patient has a temperature
of 97° F and is shivering. Which reason will the nurse most likely consider as the primary cause when planning care?
a. Anesthesia lowers metabolism.
b. Surgical suites have air currents.
c. The patient is dressed only in a gown.
d. The large open body cavity contributed to heat loss.
ANS: A
The operating suite and recovery room environments are extremely cool. The patient’s anesthetically depressed level of body
function results in lowering of metabolism and a fall in body temperature. Although the patient is dressed in a gown and there are
air currents in the operating room, these are not the primary reasons for the low temperature. Also, the patient in this type of case
does not have a large open body cavity to contribute to heat loss.
DIF: Understand (comprehension)
OBJ: Describe factors to assess in a patient during postoperative recovery.
TOP: Planning
MSC: Physiological Adaptation
Copyright © 2021, Elsevier Inc. All rights reserved.
8
34. The nurse is monitoring a patient in the postanesthesia care unit (PACU) for postoperative fluid and electrolyte imbalance. Which
action will be most appropriate for the nurse to take?
a. Encourage copious amounts of water.
b. Start an additional intravenous (IV) line.
c. Measure and record all intake and output.
d. Weigh the patient and compare with preoperative weight.
ANS: C
Accurate recording of intake and output assesses renal and circulatory function. Measure and record all sources of intake and
output. Encouraging copious amounts of water in a postoperative patient might encourage nausea and vomiting. In the PACU, it is
impractical to weigh the patient while waking from surgery, but in the days afterward, it is a good assessment parameter for fluid
imbalance. Starting an additional IV is not necessary and is not important at this juncture.
DIF: Apply (application)
OBJ: Describe the rationale for nursing interventions designed to prevent postoperative complications. TOP:
MSC: Basic Care and Comfort
Implementation
35. The nurse is caring for a patient in the postanesthesia care unit. The patient asks for a bedpan and states to the nurse, “I feel like I
need to go to the bathroom, but I can’t.” Which nursing intervention will be most appropriate initially?
a. Assess the patient for bladder distention.
b. Encourage the patient to wait a minute and try again.
c. Inform the patient that everyone feels this way after surgery.
d. Call the health care provider to obtain an order for catheterization.
ANS: A
Depending on the surgery, some patients do not regain voluntary control over urinary function for 6 to 8 hours after anesthesia.
Palpate the lower abdomen just above the symphysis pubis for bladder distention. Another option is to use a bladder scan or
ultrasound to assess bladder volume. The nurse must assess before deciding if the patient can try again. Not everyone feels as if
they need to go but can’t after surgery. Calling the health care provider is not the initial best action. The nurse needs to have data
before calling the provider.
DIF: Apply (application)
OBJ: Describe the rationale for nursing interventions designed to prevent postoperative complications. TOP:
MSC: Reduction of Risk Potential
Implementation
36. The postanesthesia care unit (PACU) nurse transports the inpatient surgical patient to the medical-surgical floor. Before leaving the
floor, the medical-surgical nurse obtains a complete set of vital signs. What is the rationale for this nursing action?
a. This is done to complete the first action in a head-to-toe assessment.
b. This is done to compare and monitor for vital sign variation during transport.
c. This is done to ensure that the medical-surgical nurse checks on the postoperative
patient.
d. This is done to follow hospital policy and procedure for care of the surgical
patient.
ANS: B
Before the PACU nurse leaves the acute care area, the staff nurse assuming care for the patient takes a complete set of vital signs to
compare with PACU findings. Minor vital sign variations normally occur after transporting the patient. The PACU nurse reviews
the patient’s information with the medical-surgical nurse, including the surgical and PACU course, physician orders, and the
patient’s condition. While vital signs may or may not be the first action in a head-to-toe assessment, this is not the rationale for this
situation. While following policy or ascertaining that the floor nurse checks on the patient are good reasons for safe care, they are
not the best rationale for obtaining vital signs.
DIF: Understand (comprehension)
OBJ: Explain the components of an effective perioperative communication hand-off.
TOP: Assessment MSC: Reduction of Risk Potential
37. The nurse is caring for a patient who will undergo a removal of a lung lobe. Which level of care will the patient require
immediately post procedure?
a. Acute care—medical-surgical unit
b. Acute care—intensive care unit
c. Ambulatory surgery
d. Ambulatory surgery—extended stay
ANS: B
Patients undergoing extensive surgery and requiring anesthesia of long duration recover slowly. If a patient is undergoing major
surgery such as a procedure on the lung, a stay in the hospital and specifically in the intensive care unit is required to monitor for
potential risks to well-being. This patient would require more care than can be provided on a medical-surgical unit. It is not
appropriate for this type of patient to go home after the procedure or to stay in an extended stay area of an ambulatory surgery area
because of the complexity and associated risks.
DIF: Understand (comprehension)
OBJ: Describe patients at risk for postoperative complications.
MSC: Management of Care
Copyright © 2021, Elsevier Inc. All rights reserved.
TOP: Planning
9
38. The nurse is caring for a group of patients. Which patient will the nurse see first?
a. A patient who had cataract surgery is coughing.
b. A patient who had vascular repair of the right leg is not doing right leg exercises.
c. A patient after knee surgery is wearing intermittent pneumatic compression
d.
devices and receiving heparin.
A patient after surgery has vital signs taken every 15 minutes twice, every 30
minutes twice, hourly for 2 hours then every 4 hours.
ANS: A
For patients who have had eye, intracranial, or spinal surgery, coughing may be contraindicated because of the potential increase in
intraocular or intracranial pressure. The nurse will need to see this patient first to control the cough and intraocular pressure. All the
rest are normal postoperative patients. Leg exercise should not be performed on the operative leg with vascular surgery. A patient
after knee surgery should receive heparin and be wearing intermittent pneumatic compression devices; while the nurse will check
on the patient, it does not have to be first. Monitoring vital signs after surgery is required and this is the standard schedule.
DIF: Analyze (analysis)
OBJ: Describe patients at risk for postoperative complications.
MSC: Management of Care
TOP: Assessment
39. The nurse demonstrates postoperative exercises for a patient. In which order will the nurse instruct the patient to perform the
exercises?
1. Turning
2. Breathing
3. Coughing
4. Leg exercises
a. 4, 1, 2, 3
b. 1, 2, 3, 4
c. 2, 3, 4, 1
d. 3, 1, 4, 2
ANS: A
The sequence of exercises is leg exercises, turning, breathing, and coughing.
DIF: Understand (comprehension)
TOP: Teaching/Learning
OBJ: Demonstrate postoperative exercises.
MSC: Reduction of Risk Potential
MULTIPLE RESPONSE
1. The nurse is participating in a “time-out.” In which activities will the nurse be involved? (Select all that apply.)
a. Verify the correct site.
b. Verify the correct patient.
c. Verify the correct procedure.
d. Perform “time-out” after surgery.
e. Perform the actual marking of the operative site.
ANS: A, B, C
A time-out is performed just before starting the procedure for final verification of the correct patient, procedure, site, and any
implants. The marking and time-out most commonly occur in the holding area, just before the patient enters the OR. The individual
performing surgery and who is accountable for it must personally mark the site, and the patient must be involved if possible.
DIF: Understand (comprehension)
OBJ: Explain the components of an effective perioperative communication hand-off.
TOP: Implementation
MSC: Reduction of Risk Potential
2. The nurse is using a forced air warmer for a surgical patient preoperatively. Which goals is the nurse trying to achieve? (Select all
that apply.)
a. Induce shivering.
b. Reduce blood loss.
c. Induce pressure ulcers.
d. Reduce cardiac arrests.
e. Reduce surgical site infection.
ANS: B, D, E
Evidence suggests that pre-warming for a minimum of 30 minutes may reduce the occurrence of hypothermia. Prevention of
hypothermia (core temperature <36° C) helps to reduce complications such as shivering, cardiac arrest, blood loss, SSI, pressure
ulcers, and mortality.
DIF: Understand (comprehension)
OBJ: Discuss the benefits of preoperative warming.
TOP: Planning
MSC: Reduction of Risk Potential
Copyright © 2021, Elsevier Inc. All rights reserved.
10
3. The nurse is caring for a postoperative patient with an incision. Which actions will the nurse take to decrease wound infections?
(Select all that apply.)
a. Maintain normoglycemia.
b. Use a straight razor to remove hair.
c. Provide bath and linen change daily.
d. Perform first dressing change 2 days postoperatively.
e. Perform hand hygiene before and after contact with the patient.
f. Administer antibiotics within 60 minutes before surgical incision.
ANS: A, E
Performing hand hygiene before and after contact with the patient helps to decrease the number of microorganisms and break the
chain of infection. Maintaining blood glucose levels at less than 150 mg/dL has resulted in decreased wound infection. Removing
unwanted hair by clipping instead of shaving decreases the numbers of nicks and cuts caused by a razor and the potential for the
introduction of microbes. The patient is postoperative; administration of an antibiotic 60 minutes before the surgical incision
supports the defense against infection preoperatively. Providing a bath and linen change daily is positive but is not necessarily
important for infection control. Many surgeons prefer to change surgical dressings the first time so they can inspect the incisional
area, but this is done before 2 days postoperatively.
DIF: Apply (application)
OBJ: Describe the rationale for nursing interventions designed to prevent postoperative complications. TOP:
MSC: Safety and Infection Control
Implementation
4. The nurse is preparing for a patient who will be going to surgery. The nurse screens for risk factors that can increase a person’s
risks in surgery. What risk factors are included in the nurse’s screening? (Select all that apply.)
a. Age
b. Race
c. Obesity
d. Nutrition
e. Pregnancy
f. Ambulatory surgery
ANS: A, C, D, E
Very young and old patients are at risk during surgery because of immature or declining physiological status. Normal tissue repair
and resistance to infection depend on adequate nutrients. Obesity increases surgical risk by reducing respiratory and cardiac
function. During pregnancy, the concern is for the mother and the developing fetus. Because all major systems of the mother are
affected during pregnancy, risks for operative complications are increased. Race and ambulatory surgery are not risks associated
with a surgical procedure.
DIF: Understand (comprehension)
OBJ: Discuss common surgical risk factors and related nursing implications.
TOP: Assessment MSC: Health Promotion and Maintenance
5. The nurse is providing preoperative education and reviews with the patient what it will be like to be in the surgical environment.
Which points should the nurse include in the teaching session? (Select all that apply.)
a. The operative suite will be very dark.
b. The family is not allowed in the operating suite.
c. The operating table or bed will be comfortable and soft.
d. The nurses will be there to assist you through this process.
e. The surgical staff will be dressed in special clothing with hats and masks.
ANS: B, D, E
The surgical staff is dressed in special clothing, hats, and masks—all for infection control. Families are not allowed in the operating
suite for several reasons, which include infection control and sterility. The nurse is there as the coordinator and patient advocate
during a surgical procedure. The rooms are very bright, so everyone can see, and the operating table is very uncomfortable for the
patient.
DIF: Understand (comprehension)
OBJ: Prepare a patient physically and psychologically for surgery.
TOP: Teaching/Learning
MSC: Psychosocial Integrity
6. The operating room nurse is providing a hand-off report to the postanesthesia care unit (PACU) nurse. Which components will the
operating room nurse include? (Select all that apply.)
a. IV fluids
b. Vital signs
c. Insurance data
d. Family location
e. Anesthesia provided
f. Estimated blood loss
ANS: A, B, E, F
The surgical teams report will include topics such as the type of anesthesia provided, vital sign trends, intraoperative medications,
IV fluids, estimated blood and urine loss, and pertinent information about the surgical wound (e.g., dressings, tubes, drains). When
the patient enters the PACU, the nurse and members of the surgical team discuss his or her status. A standardized approach or tool
for hand-off communications assists in providing accurate information about a patient’s care, treatment and services, current
condition, and any recent or anticipated changes. The hand-off is interactive, multidisciplinary, and done at the patient’s bedside,
allowing for a communication exchange that gives caregivers the chance to dialogue and ask questions. Insurance data and family
location are unnecessary.
DIF: Understand (comprehension)
OBJ: Explain the components of an effective perioperative communication hand-off.
TOP: Implementation
MSC: Management of Care
Copyright © 2021, Elsevier Inc. All rights reserved.
11
7. The nurse is caring for a group of postoperative patients on the surgical unit. Which patient assessments indicate the nurse needs to
follow up? (Select all that apply.)
a. Patient with abdominal surgery has patent airway.
b. Patient with knee surgery has approximated incision.
c. Patient with femoral artery surgery has strong pedal pulse.
d. Patient with lung surgery has 20 mL/hr of urine output via catheter.
e. Patient with bladder surgery has bloody urine within the first 12 hours.
f. Patient with appendix surgery has thready pulse and blood pressure is 90/60.
ANS: D, F
Thready pulse, low blood pressure, and urine output of 20 mL/hr need to have follow-up by the nurse. Hemorrhage results in a fall
in blood pressure; elevated heart and respiratory rates; thready pulse; cool, clammy, pale skin; and restlessness. Notify the surgeon
if these changes occur. If the patient has a urinary catheter, there should be a continuous flow of urine of approximately 30 to 50
mL/hr in adults; this patient requires follow-up since the output is 20 mL/hr. All the rest are normal findings. A patent airway, a
strong distal pulse, and approximated incision are all normal findings. Surgery involving portions of the urinary tract normally
causes bloody urine for at least 12 to 24 hours, depending on the type of surgery.
DIF: Analyze (analysis)
OBJ: Describe patients at risk for postoperative complications.
MSC: Management of Care
Copyright © 2021, Elsevier Inc. All rights reserved.
TOP: Assessment
12