Flashcards in Perioperative Deck (120)
The nurse requests a client to sign the surgical consent form for an emergency appendectomy.
Which statement by the client indicates that further teaching is needed?
1. “I will be glad when this is over so that I can go home.”
2. “I will not be able to eat or drink anything prior to my surgery.”
3. “I need to practice relaxing by listening to my favorite music.”
4. “I will need to get up and walk as soon as possible.”
1. When recuperating from emergency surgery, the client will be in the hospital for a few days. This is not a day-surgery procedure. The client needs more teaching.
The nurse in the holding area of the surgery department is interviewing a client who
requests to keep his religious medal on during surgery. Which intervention should the
1. Notify the surgeon about the client’s request to wear the medal.
2. Tape the medal to the client and allow the client to wear the medal.
3. Request that the family member take the medal prior to surgery.
4. Explain that taking the medal to surgery is against the policy.
2. The medal should be taped and the client should be allowed to wear the medal because meeting spiritual needs is essential to this client's care.
The nurse must obtain surgical consent forms for the following clients who are scheduled
for surgery. Which client would not be able to consent to surgery?
1. The 65-year-old client who cannot read or write.
2. The 30-year-old client who does not understand English.
3. The 16-year-old client who has a fractured ankle.
4. The 80-year-old client who is not oriented to the day.
3. A 16 year old client is not legally able to give permission for surgery unless the adolescent is given an emancipated status by a judge. This information was not given in the stem.
When preparing a client for surgery, which intervention should the nurse implement
1. Check the permit for the spouse’s signature.
2. Take and document intake and output.
3. Administer the “on call” sedative.
4. Complete the preoperative checklist.
4. Completing the preoperative checklist has
the highest priority to ensure that all details
are completed without omissions.
When interviewing the surgical client in the holding area, which information should the
nurse report to the health-care provider? Select all that apply.
1. The client has loose, decayed teeth.
2. The client is experiencing anxiety.
3. The client smokes two packs of cigarettes a day.
4. The client has had a chest x-ray that does not show infiltrates.
5. The client reports using herbs.
1. Loose teeth or caries need to be reported
to the health-care provider so he or she can
make provisions to prevent breaking the
teeth and causing the client to possibly
2. The nurse should report any client who is
3. Smokers are at a higher risk for complications
5. Herbs—for example, St. John’s wort,
licorice, and ginkgo—have serious interactions
with anesthesia and with bodily functions
such as coagulation.
Which nursing task can the nurse delegate to the unlicensed nursing assistant (NA)?
1. Complete the preoperative checklist.
2. Assess the client’s preoperative vital signs.
3. Teach the client about coughing and deep breathing.
4. Assist the client to remove clothing and jewelry.
4. The NA can remove clothing and jewelry.
7. When completing the assessment for the client in the day surgery unit, the client states,
“I am really afraid of having this surgery. I’m afraid of what they will find.” Which statement
would be the best therapeutic response by the nurse?
1. “Don’t worry about your surgery. It is safe.”
2. “Tell me why you’re worried about your surgery.”
3. “Tell me about your fears of having this surgery.”
4. “I understand how you feel. Surgery is frightening.”
3. This statement focuses on the emotion that the client identified and is therapeutic.
The 68-year-old client scheduled for intestinal surgery does not have clear fecal contents
after three tap water enemas. Which intervention should the nurse implement first?
1. Notify the surgeon of the client’s status.
2. Continue giving enemas until clear.
3. Increase the client’s IV fluid rate.
4. Obtain stat serum electrolytes.
1. The nurse should contact the surgeon because the client is at risk for fluid and electrolyte imbalance after three enemas. Clients who are NPO, elderly clients, and pediatric clients are more likely to have these imbalances.
The nurse is caring for a client scheduled for abdominal surgery. Which interventions
should the nurse include in the plan of care? Select all that apply.
1. Perform range-of-motion exercises.
2. Discuss how to cough effectively.
3. Explain how to perform deep-breathing exercises.
4. Teach ways to manage postoperative pain.
5. Discuss events that occur in the post-anesthesia care unit.
1. These exercises help prevent postoperative
deep vein thrombosis.
2. Coughing effectively aids in the removal of
pooled secretions that can cause pneumonia.
3. Deep-breathing exercises keep the alveoli
inflated and prevent atelectasis.
4. The client’s postoperative pain should be
kept within a tolerable range.
5. These interventions help decrease the
The client is scheduled for total hip replacement. Which behavior indicates to the
nurse the need for further preoperative teaching?
1. The client uses the diaphragm and abdominal muscles to inhale through the nose
and exhale through the mouth.
2. The client takes three slow, deep, breaths and coughs forcefully after inhaling for
the third time.
3. The client uses the incentive spirometer and inhales slowly and deeply so that the
piston rises to the preset volume.
4. The client gets out of bed by lifting straight upright from the waist and then swings
both legs along the side of the bed.
4. The correct way to get out of bed postoperatively
is to roll onto the side, grasp the
side rail to maneuver to the side, and then
push up with one hand while swinging the
legs over the side. The client needs further
While completing the preoperative assessment, the male client tells the nurse that he
is allergic to codeine. Which intervention should the nurse implement first?
1. Apply an allergy bracelet on the client’s wrist.
2. Label the client’s allergies on the front of the chart.
3. Ask the client what happens when he takes the drug.
4. Document the allergy on the medication administration record.
3. The nurse should first assess the events
that occurred when the client took this
medication because many clients think that
a side effect, such as nausea, is an allergic
Which laboratory result would require immediate intervention by the nurse for the
client scheduled for surgery?
1. Calcium 9.2 mg/dL.
2. Bleeding time 2 minutes.
3. Hemoglobin 15 gm/dL.
4. Potassium 2.4 mEq/L.
4. This potassium level is low and should be
reported to the health-care provider
because potassium is important for muscle
function, including the cardiac muscle.
Which activities are the circulating nurse’s responsibilities in the operating room?
1. Monitor the position of the client, prepare the surgical site, and ensure the client’s
2. Give preoperative medication in the holding area and monitor the client’s response
3. Prepare sutures; set up the sterile field; and count all needles, sponges, and instruments.
4. Prepare the medications to be administered by the anesthesiologist and change the
tubing for the anesthesia machine.
1. The circulating nurse has many responsibilities
in the OR, including coordinating
the activities in the OR; keeping the OR
clean; ensuring the safety of the client; and
maintaining the humidity, lighting, and
safety of the equipment.
While working in the operating room the circulating nurse observes the surgical scrub
technician remove a sponge from the edge of the sterile field with a clamp and place
the sponge and clamp in a designated area. Which action should the nurse implement?
1. Place the sponge back where it was.
2. Tell the technician not to waste supplies.
3. Do nothing because this is the correct procedure.
4. Take the sponge out of the room immediately.
3. The technician followed the correct procedure.
Sponges are counted to maintain
client safety, so all sponges must be kept
together to repeat the count before the
incision site is sutured. The sponge must be
removed, not used, and placed in a designated
area to be counted later.
While the circulating nurse compares the final sponge count with that of the scrub
nurse, a discrepancy in the count is found. Which action should the circulating nurse
1. Notify the client’s surgeon.
2. Complete an Occurrence Report.
3. Contact the surgical manager.
4. Re-count all sponges.
4. A re-count of sponges may lead to the discovery of the cause of the presumed error.
Usually it is just a miscount or a result of a
sponge being placed in a location other
than the sterile field, such as the floor or a
Which violation of surgical asepsis would require immediate intervention by the circulating
1. Surgical supplies were cleaned and sterilized prior to the case.
2. The circulating nurse is wearing a long-sleeved sterile gown.
3. Masks covering the mouth and nose are being worn by the surgical team.
4. The scrub nurse setting up the sterile field is wearing artificial nails.
4. According to the Centers for Disease
Control (CDC), the American Operating
Room Nurses Association (AORN), and the
Association of Professionals in Infection
Control, artificial nails harbor microorganisms,
which increase the risk for infection.
The nurse identifies the nursing diagnosis “risk for injury related to positioning” for
the client in the operating room. Which nursing action should the nurse implement?
1. Avoid using the cautery unit that does not have a biomedical tag on it.
2. Carefully pad the client’s elbows before covering the client with a blanket.
3. Apply a warming pad on the OR table before placing the client on the table.
4. Check the chart for any prescription or over-the-counter medication use.
2. Padding the elbows decreases pressure so
that nerve damage and pressure ulcers are
prevented. This addresses the etiology of
the nursing diagnosis.
When positioning the intraoperative client for surgery, which client should the nurse
consider at the highest rank for irreparable nerve damage?
1. The 16-year-old client in the dorsal recumbent position having an appendectomy.
2. The 68-year-old client in the Trendelenburg position having a cholecystectomy.
3. The 45-year-old client in the reverse Trendelenburg position having a biopsy.
4. The 22-year-old client in the lateral position having a nephrectomy.
2. The client’s age, along with positioning
with increased weight and pressure on the
shoulders, puts this client at higher risk.
Which situation demonstrates the circulating nurse acting as the client’s advocate?
1. Plays the client’s favorite audio book during surgery.
2. Keeps the family informed of the findings of the surgery.
3. Keeps the operating room door closed at all times.
4. Calls the client by the first name when the client is recovering.
3. This would keep the client’s dignity by
maintaining privacy. With this action, the
nurse is speaking for the client while they
cannot speak as a result of anesthesia and is
an example of client advocacy.
Which statement would be an expected outcome when the circulating nurse evaluates
the goal of the intraoperative client?
1. The client has no injuries from the OR equipment.
2. The client has no postoperative infection.
3. The client has stable vital signs during surgery.
4. The client recovers from anesthesia.
1. This expected outcome addresses the safety
of the client while in the OR.
Which nursing intervention has the highest priority when preparing the client for a
1. Pad the client’s elbows and knees.
2. Apply soft restraint straps to the extremities.
3. Prepare the client’s incision site.
4. Document the temperature of the room.
2. This action would prevent the client from
falling off the table, which is the highest
When making assignments for nurses working in the OR, which case would the
manager assign to the new nurse?
1. The client having open-heart surgery.
2. The client having a biopsy of the breast.
3. The client having laser eye surgery.
4. The client having a laparoscopic knee repair.
2. The case of a client having a biopsy of the
breast would be a good case for an inexperienced
nurse because it is simple.
While working in the operating room, the nurse notices that the client has tachycardia
and hypotension. Which interventions should the nurse anticipate?
1. Prepare ice packs and mix dantrolene sodium.
2. Request the defibrillator to be brought into the OR.
3. Draw a PTT and prepare a heparin drip.
4. Obtain fingerstick blood glucose immediately.
1. Unexplained tachycardia, hypotension, and
elevated temperature are signs of malignant
hyperthermia, which is treated with
ice packs and Dantrolene sodium.
When developing the plan of care for the surgical client having sedation, which intervention
has highest priority for the nurse?
1. Assess the client’s respiratory status.
2. Monitor the client’s urinary output.
3. Take a 12-lead ECG prior to injection.
4. Attempt to keep the client focused.
1. Assessing the respiratory rate, rhythm, and
depth is the most important action.
When receiving the client from the OR, which intervention should the PACU nurse
1. Assess the client’s breath sounds.
2. Apply oxygen via nasal cannula.
3. Take the client’s blood pressure.
4. Monitor the pulse oximeter reading.
1. The airway should be assessed first. When
caring for a client, the nurse should follow
the ABCs: airway, breathing, and circulation.
Which assessment data indicate the postoperative client who had spinal anesthesia is
suffering a complication of the anesthesia?
1. Loss of sensation on the lumbar (L5) dermatome.
2. Absence of the client’s posterior tibial pulse.
3. The client has a respiratory rate of eight (8).
4. The blood pressure is within 20% of client’s baseline.
3. If the effects of the spinal anesthesia move
up rather than down the spinal cord, respirations
can be depressed and even blocked.
After transferring the client from the PACU to the surgical unit, the client’s vital signs
are T 98F, P 106, R 24, and BP 88/40. The client is awake and oriented times three
(3). The client’s skin is pale and damp. Which intervention should the nurse implement
1. Call the surgeon and report the vital signs.
2. Start an IV of D5RL with 20 mEq KCl at 125 mL/hour.
3. Elevate the feet and lower the head.
4. Monitor the vital signs every 15 minutes.
3. By lowering the head of the bed and raising the feet, the blood is shunted to the brain until volume-expanding fluids can be administered, which is the first intervention for a client who is hemorrhaging.
The nurse receives a report that the postoperative client received Narcan, an opioid
antagonist, in PACU. Which client problem should the nurse add to the plan of care?
1. Alteration in comfort.
2. Risk for depressed respiratory pattern.
3. Potential for infection.
4. Fluid and electrolyte imbalance.
2. A client with respiratory depression treated with Narcan can have another episode within 15 minutes after receiving the drug as a result of the short half life of the medication.
The 26-year-old male client in the PACU has a heart rate of 110, has a rising temperature,
and complains of muscle stiffness. Which interventions should the nurse implement?
Select all apply.
1. Give a back rub to the client to relieve stiffness.
2. Apply ice packs to axillary and groin areas.
3. Prepare a nice slush for the client to drink.
4. Prepare to administer Dantrolene, a smooth-muscle relaxant.
5. Reposition the client on a warming blanket.
2. Ice packs should be applied to the axillary and groin areas for a client experiencing malignant hyperthermia.
3. The client would be NPO to prepare for intubation, but an ice sluch would be used to irrigate the bladder and stomach per nasogastric tube.
4. Dantrolene is the drug of choice for treatment.