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Flashcards in Perioperative Deck (120)
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1

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.

2

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
nurse implement?
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.

3

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.

4

When preparing a client for surgery, which intervention should the nurse implement
first?
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.

5

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
aspirate pieces.
2. The nurse should report any client who is
extremely anxious.
3. Smokers are at a higher risk for complications
from anesthesia.
5. Herbs—for example, St. John’s wort,
licorice, and ginkgo—have serious interactions
with anesthesia and with bodily functions
such as coagulation.

6

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

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.

8

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.

9

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
client’s anxiety.

10

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
teaching.

11

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
reaction.

12

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.

13

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
safety.
2. Give preoperative medication in the holding area and monitor the client’s response
to anesthesia.
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.

14

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.

15

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
take first?
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
lower shelf.

16

Which violation of surgical asepsis would require immediate intervention by the circulating
nurse?
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.

17

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.

18

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.

19

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.

20

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.

21

Which nursing intervention has the highest priority when preparing the client for a
surgical procedure?
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
priority.

22

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.

23

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.

24

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.

25

When receiving the client from the OR, which intervention should the PACU nurse
implement first?
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.

26

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.

27

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
first?
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.

28

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.

29

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.

30

Which data indicate the nursing care has been effective for the client who is one (1)
day postoperative surgery?
1. Urine output was 160 mL in the past eight (8) hours.
2. Bowel sounds occur four (4) times per minute.
3. T 99.0F, P 98, R 20, and BP 100/60.
4. Lungs are clear bilaterally in all lobes.

4. Lung sounds that are clear bilaterally in all lobes indicate the client has adequate gas exchange, which prevents postoperative complications and indicates effective nursing care.

31

When working on the surgical floor, which task can the nurse delegate to the unlicensed nursing assistant (NA)?
1. Take vital signs every four (4) hours.
2. Check the Jackson-Pratt insertion site.
3. Hang the client’s next IV bag.
4. Ensure that the client gets pain relief.

1. Taking the vital signs of the stable client may be delegated to the NA

32

The charge nurse is making the shift assignments. Which postoperative client would be the most appropriate assignment to the graduate nurse?
1. The four (4)-year-old client who had a tonsillectomy and is swallowing frequently.
2. The 74-year-old client with a repair of the left hip who is unable to ambulate.
3. A 24-year-old client who had an uncomplicated appendectomy the previous day.
4. An 80-year-old client with small bowel obstruction and congestive heart failure.

3. A young client who had an appendectomy would require routine postoperative care and would be the most appropriate client to assign to the inexperienced nurse.

33

Which statement would be an expected outcome for the postoperative client who had general anesthesia?
1. The client will be able to sit in the chair for 30 minutes.
2. The client will have a pulse oximetry reading of 97% on room air.
3. The client will have a urine output of 30 mL per hour.
4. The client will be able to distinguish sharp from dull sensations.


2. The anesthesia machine takes over the function of the lungs during surgery so the expected outcome should directly reflect the client's respiratory status; the alveoli can collapse, causing atelectasis.

34

The postoperative client is transferred from the PACU to the surgical floor. Which
action should the nurse implement first?
1. Apply anti-embolism hose to the client.
2. Attach the drain to 20 cm suction.
3. Assess the client’s vital signs.
4. Listen to the report from the anesthesiologist.

3. Assessing the client's status after transfer from the PACU should be the nurse's first intervention.

35

Which client problem would be priority for client who is one (1) day postoperative?
1. Potential for hemorrhaging.
2. Potential for injury.
3. Potential for fluid volume excess.
4. Potential for infection.

1. All clients who undergo surgery are at risk for hemorrhagin, which is the priority problem.

36

The unlicensed nursing assistant reports the vital signs for a first-day postoperative
client of T 100.8F, P 80, R 24, and B/P 148/80. Which intervention would be most
appropriate for the nurse to implement?
1. Administer the antibiotic earlier than scheduled.
2. Change the dressing over the wound.
3. Help the client turn, cough, and deep breathe every two (2) hours.
4. Encourage the client to ambulate in the hall.

3. Having the client turn, cough, and deep breathe is the best intervention for the nurse to implement because if a client has a fever within the first day, it is usually caused by a respiratory problem.

37

The client is complaining of left shoulder pain. Which response would be best for the
nurse to assess the pain?
1. Request that the client describe the pain.
2. Inquire if the pain is intense, throbbing, or stabbing.
3. Ask if the client wants pain medication.
4. Instruct the client to complete the pain questionnaire.

1. This request allows the client to use terms and descriptions so that the nurse can evaluate the pain and the effectiveness of the treatment.

38

When preparing the plan of care for the client in acute pain as a result of surgery, the
nurse should include which intervention?
1. Administer pain medication as soon as the time frame allows.
2. Use nonpharmacological methods to replace medications.
3. Use cryotherapy after heat therapy because it works faster.
4. Instruct family members to administer medication with the PCA.

1. Pain medications should be administered at the frequency ordered by the HCP, not just when the client requests them, especially for acute pain.

39

Which situation is an example of the nurse fulfilling the role of client advocate?
1. The nurse brings the client pain medication when it is due.
2. The nurse collaborates with other disciplines during the care conference.
3. The nurse contacts the health-care provider when pain relief is not obtained.
4. The nurse teaches the client to ask for medication before the pain gets to a “5.”

3. When the nurse contacts the HCP about unrelieved pain, the nurse is speaking when the client cannot, which is the definition of a client advocate.

40

Which statement would be an expected outcome for a client experiencing acute pain?
1. The client will have decreased use of medication.
2. The client will participate in self-care activities.
3. The client will use relaxation techniques.
4. The client will repeat instructions about medications.

2. Clients experiencing acute pain will not be involved in self-care because of their reluctance to move, which increases the pain; therefore, participation indicates the client's pain is tolerable.

41

Which intervention has the highest priority when administering pain medication to a
client experiencing acute pain?
1. Monitor the client’s vital signs.
2. Verify the time of the last dose.
3. Check for the client’s allergies.
4. Discuss the pain with the client.

4. The nurse should question the client to rule out complications and to determine which medication and amount would be most appropriate for the client. This is assessment.

42

Which intervention should the nurse delegate to the unlicensed nursing assistant when
caring for the client experiencing acute pain?
1. Take the pain medication to the room.
2. Apply an ice pack to the site of pain.
3. Check on the client 30 minutes after he or she takes the pain medication.
4. Observe the patient’s ability to use the PCA.

2. This task does not require teaching, evaluating, or nursing judgment and therefore can be delegated.

43

When administering an opioid narcotic, which interventions should the nurse implement to provide for client safety? Select all that apply.
1. Compare the hospital number on the MAR to the client’s bracelet.
2. Have a witness verify the wasted portion of the narcotic.
3. Assess the client’s vital signs prior to administration.
4. Determine if the client has any allergies to medications.
5. Clarify all orders with the health-care provider.

1. This procedure ensures client safety by preventing medication from being given to the wrong client.
3. This intervention would prevent giving a narcotic to a client who is unstable or compromised.
4. Determining allergies addresses client safety.

44

Which intervention would be the best way for the nurse to assess a four (4)-year-old
client for acute pain?
1. Use words that a four (4)-year-old child can remember.
2. Explain the 0–10 pain scale to the child’s parent.
3. Have the child point to the face that describes the pain.
4. Administer the medication every four (4) hours.

3. The face scale is the best way to assess pain for a four year old child.

45

Which nursing intervention would be priority for the client experiencing acute pain?
1. Assess verbal and nonverbal behavior.
2. Wait for the client to request pain medication.
3. Bring the pain medication on a scheduled basis.
4. Teach the client to use only imagery every hour for the pain.

1. Assessing verbal and nonverbal cues is the priority intervention because pain is subjective.

46

While conducting an interview with a 75-year-old client admitted with acute pain,
which question would have priority when assisting with pain management?
1. “Have you ever had difficulty getting your pain controlled?”
2. “What types of surgery have you had in the last 10 years?”
3. “Have you ever been addicted to narcotics?”
4. “Do you have a list of your prescription medications?”

1. The answer to this request would indicate if the client has had a negative experience that may influence the client's pain management.

47

At the end of the shift, the nurse clears the PCA and discovers that the client has used
only a small amount of medication. Which intervention should the nurse implement?
1. Determine why the client is not using the PCA.
2. Document the amount and take no action.
3. Chart that the client is not having pain.
4. Contact the HCP and request oral medication.

1. Assessing why the client is not using the medication is a priority and then, based on the client's response a plan of care can be determined.

48

Which client problem would be most appropriate for the client experiencing acute
physical pain?
1. Ineffective coping.
2. Potential for injury.
3. Alteration in comfort.
4. Altered sensory input.

3. Alteration in comfort is addressing the client's acute physical pain.

49

Which client would the nurse identify as having the highest risk for developing postoperative
complications?
1. The 67-year-old client who is obese, has diabetes, and takes insulin.
2. The 50-year-old client with arthritis taking nonsteroidal anti-inflammatory drugs.
3. The 45-year-old client having abdominal surgery to remove the gallbladder.
4. The 60-year-old client with anemia who smokes one (1) pack of cigarettes per day.

1. This client has co-morbid conditions- advanced age, obesity, and diabetes- that put this client at a higher risk for postoperative complications

50

The nurse is completing the preoperative checklist on a client going to surgery. Which
information should the nurse report to the surgeon?
1. The client understands the purpose of the surgery.
2. The client stopped taking aspirin three (3) weeks ago.
3. The client uses the oral supplements licorice and garlic.
4. The client has mild levels of preoperative anxiety.

3. Licorice and garlic can interfere with coagulation; therefore the surgeon should be notified.

51

Which statement explains the nurse’s responsibility when obtaining a surgical permit for
the client undergoing a surgical procedure?
1. The nurse should provide detailed information about the procedure.
2. The nurse should inform the client of any legal consultation needed.
3. The nurse should write a list of the risks for postoperative complications.
4. The nurse should ensure that the client is voluntarily giving consent.

4. The nurse is responsible for ensuring that the client voluntarily signs the surgical consent form giving permission for the surgery without coercion.

52

Which client outcome would the nurse identify for the preoperative client?
1. The client’s abnormal laboratory data will be reported to the anesthesiologist.
2. The nurse will develop a plan of care to prevent all postoperative complications.
3. The client will demonstrate the use of a pillow to splint while deep breathing.
4. The client will complete an advance directive before having the surgery.

3. This would be the expected outcome for the client during the preoperative phase. After the teaching has been completed, the client should be able to demonstrate how to splint with the pillow while deep breathing and coughing.

53

Which client problem would be appropriate for the preoperative client preparing for an
ankle repair?
1. Alteration in skin integrity.
2. Knowledge deficit of postoperative care.
3. Alteration in gas exchange and pattern.
4. Alteration in urinary elimination.

2. This would be an appropriate client problem for the preoperative client who is scheduled for ankle repair. Teaching is priority.

54

The nurse and unlicensed nursing assistant (NA) are caring for clients in a surgery holding
area. Which nursing task could be delegated to the NA?
1. Explain to the client how to cough and deep breathe.
2. Discuss preoperative plans with the client and family.
3. Determine the ability of the caregivers to provide postoperative care.
4. Perform the skin preparation with povidone-iodine (Betadine).

4. Preparing the skin can be delegated to the NA.

55

Which action by the client would indicate that the preoperative teaching has been effective?
1. The client demonstrates how to use the incentive spirometer device.
2. The client demonstrates the use of the patient-controlled analgesia pump.
3. The client names two (2) anesthesia agents that will be used.
4. The client ambulates down the hall to the nurse’s station each hour.

1. The teaching is effective if the client is able to demonstrate the use of the spirometer prior to surgery.

56

Which intervention has priority for the nurse in the surgical holding area?
1. Verify the surgical checklist.
2. Prepare the client’s surgical site.
3. Assist the client to the bathroom.
4. Restrain the client on the surgery table.

1. The surgical checklist is assessed when the client arrives in the surgery department holding area where clients wait for a short time before entering the operating room.

57

The client in the surgical holding area tells the nurse “I am so scared. I have never had
surgery before.” Which statement would be the nurse’s most appropriate response?
1. “Why are you afraid of the surgery?”
2. “This is the best hospital in the city.”
3. “Does having surgery make you afraid?”
4. “There is no reason to be afraid.”

3. This response is therapeutic and promotes communication of feelings.

58

The unlicensed nursing assistant (NA) can be overheard talking loudly to the scrub
technologist discussing a problem that occurred during one (1) of the surgeries. Which
intervention should the nurse implement?
1. Close the curtains around the client’s stretcher.
2. Instruct the NA and scrub tech to stop the discussion.
3. Tell the surgeon on the case what the nurse overheard.
4. Inform the client that the discussion was not about their surgeon.

2. The NA and scrub tech are violating HIPAA and should be told to stop the conversation immediately.

59

The nurse is completing the preoperative checklist. Which laboratory value should be
reported to the surgeon immediately?
1. Hemoglobin 13.1 g/dL.
2. Glucose 90 mg/dL.
3. White blood cells 6.0 mm (103).
4. Potassium 3.2 mEq/L.

4. This potassium level is low and would place the client at risk for cardiac complications.

60

Which client problem would be appropriate for the client in the intraoperative phase
of the surgery?
1. Alteration in comfort.
2. Disuse syndrome.
3. Risk for injury.
4. Altered gas exchange.

3. This problem would be appropriate for the intraoperative phase. The circulating nurse would strap and carefully pad areas to prevent damage to tissues and nerves.

61

The client has been placed in the lithotomy position during surgery. Which nursing
intervention should be implemented to decrease the risk of developing hypotension?
1. Increase the intravenous fluids.
2. Lower one leg at a time.
3. Raise the foot of the stretcher.
4. Administer epinephrine, a vasopressor.

2. The lithotomy position has both legs elevated and placed in stirrups. The legs should be lowered one leg at a time to prevent hypotension from the shift of the blood.

62

The circulating nurse notices that a sponge is on the edge of the sterile field. Which
action should the circulating nurse take?
1. Don’t include the sponge in the sponge count.
2. Take the sponge off the field with forceps.
3. Tell the surgical technologist about the sponge.
4. Throw the sponge in the sterile trashcan.

3. The circulating nurse should inform the surgical technologist of any break in sterile technique or field.

63

The nurse notes a discrepancy in the needle count. What action should the nurse
implement first?
1. Inform the other members of the surgical team about the problem.
2. Assume that the original count was wrong and change the record.
3. Call the radiology department to perform a portable x-ray.
4. Complete an occurrence report and notify the risk manager.

1. If the needle count does not correlate, the surgical technologist and the other surgical team members should be informed. After repeating the count, a search for the missing needle should be conducted.

64

The nurse has received a client from the post-anesthesia care unit. Which assessment
data would warrant immediate intervention?
1. The client’s vital signs are T 97F, P 108, R 24, and BP 80/40.
2. The client is sleepy but opens the eyes to his name.
3. The client is complaining of pain at a “5” on a 1–10 pain scale.
4. There is 20 mL of urine in the drainage bag.

1. These are symptoms of hypovolemic shock and require immediate intervention

65

The client in the surgery holding area identifies the left arm as the correct surgical site,
but the operative permits designate surgery to be performed on the right arm. Which
interventions should the nurse implement? Select all that apply.
1. Review the client’s chart.
2. Notify the surgeon.
3. Immediately call a “time out.”
4. Change the surgical permit.
5. Have the client mark the left arm.

1. When the client in the holding area states
that the surgery site differs from the scheduled
surgery, the nurse should identify the
client and review the client’s chart.
2. If there is a discrepancy, the nurse should
notify the surgeon to explain the situation
and resolve the issue.
3. In the current Joint Commission for
Accreditation of Healthcare Organizations
(JCAHO) surgical standards, a “time out”
period is called and everything stops until
the discrepancy is resolved.
5. Clients are encouraged to mark the correct
side or site with indelible ink.

66

The client received naloxone (Narcan), an opioid antagonist, in the post-anesthesia
care unit. Which nursing intervention should the nurse include in the care plan?
1. Measure intake and output hourly.
2. Administer sleep medications at night.
3. Encourage the client to verbalize feelings.
4. Monitor respirations every 15 to 30 minutes.

4. Narcan is given to reverse respiratory
depression from opioid analgesic medications
and has a short half-life. The client
may experience a rebound respiratory
depression in 15–20 minutes, so this nursing
intervention of monitoring respirations
every 15–30 minutes is appropriate.

67

Which nursing task would be appropriate to delegate to the unlicensed nursing assistant
(NA) on a postoperative unit?
1. Change the dressing over the surgical site.
2. Teach the client how to perform incentive spirometry.
3. Empty and record the amount of drainage in the J-P drain.
4. Auscultate the bowel sounds in all four (4) quadrants.

3. Emptying the drainage devices and recording the amounts on the bedside intake and output forms can be delegated.

68

Which assessment data have priority when caring for clients in the post-anesthesia care
unit?
1. Breath sounds.
2. Vital signs.
3. IV fluid rate.
4. Surgical site.

1. The post-anesthesia care unit nurse should follow the ABGs format described by the AHA. A is for airway, B is for breathing, and C is for circulation.

69

The male client in the postoperative day surgery unit complains of difficulty urinating.
Which intervention should the nurse implement?
1. Insert an indwelling catheter.
2. Increase the intravenous fluid rate.
3. Assist the client to stand to void.
4. Encourage the client to increase fluids.

3. Helping the male client to stand can offer the assistance needed to void. The safety of the client should be ensured.

70

The postoperative client complains of hearing a “popping sound” and feeling “something
opening” when ambulating in the room. Which intervention should the nurse
implement first?
1. Notify the surgeon that the client has had an evisceration.
2. Contact the surgery department to prepare for emergency surgery.
3. Assess the operative site and cover the site with a moistened dressing.
4. Explain that this is a common feeling and tell the client to continue with activity.

3. The nurse should assess the surgical site and, if the site has eviscerated, cover the opening with a sterile 0.9% saline. This will prevent the tissues from becoming dry and infected.

71

The nurse received a report that the elderly postoperative client became confused
during the previous shift. Which client problem would the nurse include in the plan of
care?
1. Altered gas exchange.
2. Altered comfort level.
3. Impaired circulation.
4. Impaired skin integrity.

1. When a previously alert and oriented client becomes confused, the nurse should first consider hypoxia as the cause.

72

The client one (1) day postoperative develops an elevated temperature. Which intervention
would have priority for the client?
1. Encourage client to deep breathe and cough every hour.
2. Encourage the client to drink 200 mL of water every shift.
3. Monitor the client’s wound for drainage every eight (8) hours.
4. Assess the urine output for color and clarity every four (4) hours.

1. When a postoperative client develops a fever within the first 24 hours, the cause is usually in the respiratory system. The client should increase deep breathing and coughing to assist the client to expand the lungs and decrease pulmonary complications.

73

Which statement made by the client being discharged after abdominal surgery indicates
that teaching has been effective?
1. “I will take my temperature each week and report any elevation.”
2. “I will not need any pain medication when I go home.”
3. “I will take all of my antibiotics until they are gone.”
4. “I will not take a shower until my three (3)-month checkup.”

3. This statement about taking all the antibiotics ordered indicates that teaching is effective.

74

The client diagnosed with appendicitis has undergone an appendectomy. At two (2)
hours postoperative the nurse takes the vital signs and notes T 102.6F, P 132, R 26,
and BP 92/46. Which interventions should the nurse implement? List in order of
priority.
1. Increase the IV rate.
2. Notify the health-care provider.
3. Elevate the foot of the bed.
4. Check the abdominal dressing.
5. Determine if the IV antibiotics have been administered.

In order of priority: 1, 3, 5, 4, 2.
1. The nurse should increase the IV rate to
maintain the circulatory system function
until further orders can be obtained.
3. The foot of the bed should be elevated to
help treat shock, the symptoms of which
include elevated pulse and decreased blood
pressure. Those signs and an elevated temperature
indicate that an infection may be
present and that the client could be developing
septicemia.
5. The nurse should administer any IV antibiotics
that are ordered. A delay in administering
IV antibiotics could cost the client
his or her life. If the antibiotics have been
given, then possibly the infection is resistant
to the antibiotic. The nurse will need
this information when reporting to the
health-care provider.
4. The dressing is two (2) hours old and would
have been assessed when the client
returned from PACU. This could provide
some information, but it is not as important
as the vital signs and antibiotic information.
2. The health-care provider should be notified
when the nurse has the needed information

75

An overweight patient (BMI 28.1 kg/m2) is scheduled for a laparoscopic cholecystectomy at an outpatient surgery setting. The nurse knows that
a. surgery will involve multiple small incisions
b. this setting is not appropriate for this procedure.
c. surgery will involve removing a portion of the liver

A. surgery will involve multiple small incisions.

76

The patient tells the nurse in the preoperative setting that she has noticed she has a reaction when wearing rubber gloves. What is the most appropriate intervention?
a. notify the surgeon so the case can be cancelled
b. ask additional questions to assess for a possible latex allergy
c. notify the OR staff immediately so that latex free supplies can be used
d. no intervention is needed because the patient's rubber sensitivity has no bearing on surgery

B. ask additional questions to assess for a possible latex allergy

77

A 59 year old man is scheduled for a herniorrhaphy in 2 days. During the preoperative evaluation he reports that he takes ginkgo daily. What is the priority intervention?
a. inform the surgeon, since the procedure may need to be rescheduled.
b. notify the anesthesia care provider, since this herb interferes with anesthetics
c. ask the patient if he has noticed any side effects from taking this herbal supplement
d. tell the patient to continue to take the herbal supplement up to the day before surgery.

A. inform the surgeon, since the procedure may need to be rescheduled

78

A 17 year old patient with a leg fracture is scheduled for surgery. She reports that she is living with a friend and is an emancipated minor. She has a statement from the court for verification. Which intervention is most appropriate?
a. witness the permit after consent is obtained by the surgeon.
b. call a parent or legal guardian to sign the permit, since the patient is under 18.
c. obtain verbal consent, since written consent is not necessary for emancipated minors.
d. investigate your state's nurse practice act related to emancipated minors and consent forms.

A. witness the permit after consent is obtained by the surgeon

79

A priority nursing intervention to assist a preoperative patient in coping with fear of postoperative pain would be to
a. inform the patient that pain medication will be available.
b. teach the patient to use guided imagery to help manage pain
c. describe the type of pain expected with the patient's particular surgery
d. explain the pain management plan, including the use of pain rating scale.

D. explain the pain management plan, including the use of pain rating scale.

80

A patient is scheduled for surgery requiring general anesthesia at an ambulatory surgical center. The nurse asks him when he ate last. He replies that he had a light breakfast a couple of hours before coming to the surgery center. What should the nurse do first?
a. tell the patient to come back tomorrow, since he ate a meal
b. Proceed with the preoperative checklist, including site identification
c. notfiy the anesthesia care provider of when and what the patient last ate
d. have the patient void before administering any preoperative medications.

C. notify the anesthesia care provider of when and what the patient last ate

81

A patient who normally takes 40 units of glargine insulin (long acting) at bedtime asks the nurse what to do about her dose the night before surgery. The best response would be to have her
a. skip her insulin altogether the nigh before surgery
b. take her usual dose at bedtime and eat a light breakfast in the morning
c. eat a moderate meal before bedtime and then take half her usual insulin dose
d. get instructions from her surgeon or HCP on any insulin adjustments.

D. get instructions from her surgeon or HCP on any insulin adjustments

82

Preoperative considerations for older adults include (select all that apply)
a. only using large print educational materials
b. speaking louder for patients with hearing aids
c. recognizing that sensory deficits may be present
d. providing warm blankets to prevent hypothermia
e. teaching important information early in the morning.

C and D

83

Five minutes after receiving a preoperative sedative medication by IV injection, a patient asks to get up to go to the bathroom to urinate. What is the most appropriate action for the nurse to take?

A. Offer the patient to use the urinal/bedpan after explaining the need to maintain safety.
B. Assist the patient to the bathroom and stay next to the door to assist patient back to bed when done.
C. Allow the patient to go to the bathroom since the onset of the medication will be more than 5 minutes.
D. Ask the patient to hold the urine for a short period since a urinary catheter will be placed in the operating room.

A.
The prime issue after administration of either sedative or opioid analgesic medications is safety. Because the medications affect the central nervous system, the patient is at risk for falls and should not be allowed out of bed, even with assistance. The other options would not be safe for the patient.

84

What is the primary reason for accurately recording the patient's current medications during a preoperative assessment?

A. Some medications may alter the patient's perceptions about surgery.
B. Many anesthetics alter renal and hepatic function, causing toxicity of other drugs.
C. Some medications may interact with anesthetics, altering the potency and effect of the drugs. Correct
D. Routine medications are withheld the day of surgery, requiring dosage and schedule adjustments after surgery.


C.
Drug interactions may occur between prescribed medications and anesthetic agents used during surgery. For this reason, it is important to take a careful medication history and check that they have been communicated to the anesthesia care provider. Routine medications may or may not be prescribed for use the day of surgery.

85

The nurse is doing a preoperative assessment on a male patient who has type 2 diabetes mellitus, weighs 146 kg, and is 5 feet 8 inches tall. Which patient assessment is a priority related to anesthesia?

A. Has hemoglobin A1C of 8.5%
B. Has several seasonal allergies
C. Has body mass index of 48.8 kg/m2
D. Has history of postoperative vomiting

C.

The patient's body mass index is the priority because it indicates the patient is severely obese. The patient's size may impair the anesthesiologist's ability to ventilate and medicate the patient properly, as well as the surgery room staff's ability to position the patient safely. The other factors are not the priority.

86

An alert male patient needs a tracheostomy because he has been intubated for 7 days with an endotracheal tube and cannot be weaned from the ventilator. The patient does not want the tracheostomy, but his family insists that the surgery be performed. What is the best action for the nurse to take?

A. Advocate for the patient's rights.
B. Try to change the patient's mind.
C. Call surgery to cancel the procedure.
D. Tell the family they cannot interfere.

A.

The nurse must act as the patient's advocate and assist the patient with fulfilling his wishes. However, as the patient's advocate the nurse must be sure he knows the risks and benefits of refusing a tracheostomy. Trying to change the patient's mind is unethical because it is contrary to acting as an advocate. As long as the patient is lucid, he retains the right of self-determination. Canceling the procedure is not indicated until discussion with the patient and surgeon has occurred. Telling the family they cannot interfere can aggravate or escalate the situation.

87

It is 6:00 AM. The anesthesiologist prescribes preoperative medications for a patient who is scheduled for surgery at 7:30 AM: cefazolin (Ancef) IV to be infused 30 minutes before surgery; midazolam (Versed) before surgery and scopolamine patch (Transderm Scop) behind the ear. Which medication should the nurse administer first?

A. Cefazolin (Ancef)
B. Fentanyl (Sulimaze)
C. Midazolam (Versed)
D. Scopolamine (Transderm Scop)

D.

The scopolamine patch (Transderm Scop) will be administered first to allow enough time for the serum level to become therapeutic. The cefazolin (Ancef) will be given at 7:00 AM to allow infusion 30 minutes before surgery. Fentanyl (Sulimaze) is a narcotic and was not ordered preoperatively. The midazolam (Versed), a short-acting benzodiazepine, is used as a sedative.

88


As the nurse is preparing a patient for outpatient surgery, the patient wants to give his hearing aid to his wife so it will not be lost during surgery. Which action by the nurse should be taken in this situation?

A. Give the hearing aid to the wife as he wishes.
B. Tape the hearing aid to his ear to prevent loss.
C. Encourage the patient to wear it for the surgery.
D. Tell the surgery nurse that he has his hearing aid out.

C.

Although jewelry is removed before surgery, hearing aids should be left in place to allow the patient to better follow instructions given in the surgical suite and the postanesthesia care unit (PACU), as well as the dismissal instructions that will be given before he returns home for recovery.

89

When reviewing the preoperative forms, the nurse notices that the informed consent form is not present or signed. What is the best action for the nurse to take?

A. Have the patient sign the consent form.
B. Have the family sign the form for the patient.
C. Call the surgeon to obtain consent for surgery.
D. Teach the patient about the surgery and get verbal permission.

C.

The informed consent for the surgery must be obtained by the physician. The nurse can witness the signature on the consent form and verify that the patient (or caregiver if patient is a minor, unconscious, or mentally incompetent to sign) understands the informed consent. Verbal consents are not enough. The state's nurse practice act and agency policies must be followed.

90

A 75-year-old patient is being prepared for surgery. What assessment data needs to be included for this patient (select all that apply)?

A. Fluid balance history
B. Attitude about surgery
C. Foods the patient dislikes
D. Current mobility problems
E. Current cognitive function
F. Patient's opinion about the surgeon

a.d.e.
Preoperative fluid balance history is especially critical for older adults as they have reduced adaptive capacity that puts them at greater risk for over- and under-hydration. Mobility problems must be assessed to assist with intraoperative and postoperative positioning and ambulation. Preoperative assessment of the older person's baseline cognition function is especially crucial for intraoperative and postoperative evaluation as they are more prone to adverse outcomes during and after surgery from the stressors of the surgery, dehydration, hypothermia, and anesthesia. Attitude about surgery and opinion or faith in the surgeon is important for all patients. Foods the patient dislikes are not important unless the patient is allergic to them, but this is no more important for older patients than it is for all patients.

91

While performing preoperative teaching, the patient asks when she needs to stop drinking water before the surgery. Based on the most recent practice guidelines established by the American Society of Anesthesiologists, the nurse tells the patient that

A. she must be NPO after breakfast.
B. she needs to be NPO after midnight.
C. she can drink clear liquids up to 2 hours before surgery.
D. she can drink clear liquids up until she is moved to the OR.

C.

Practice guidelines for preoperative fasting state the minimum fasting period for clear liquids is 2 hours. Evidence-based practice no longer supports the long-standing practice of requiring patients to be NPO after midnight.

92

This will be the patient's first surgical experience and the patient states, "I am nervous about this." The vital signs show BP 158/88, HR 96, RR 24. In the assessment, the nurse finds that the lungs are clear, bowel tones are evident, peripheral pulses are strong, and the patient is fidgeting nervously. The patient took alprazolam (Xanax) at bedtime last night and takes acetaminophen (Tylenol) for tension headaches. Related to this assessment information, what should the nurse do before the patient goes to surgery?

A. Review the surgery with the patient.
B. Notify the anesthesia care provider (ACP).
C. Administer another dose of alprazolam (Xanax).
D. Tell the patient that everything will be okay with the surgery.

B.

In determining the psychologic status of the patient, the nurse notes the patient's anxiety, which is supported by the elevated BP and heart rate and fidgeting. The nurse should notify the anesthesia care provider (ACP) after assessing the cause of the anxiety or fear the patient is experiencing. The patient may only need to talk about the surgery related to the situation, concerns with the unknown or body image, or past experiences to relieve the anxiety, but the nurse cannot assume that lack of knowledge is the cause of the anxiety. Medication administration will be prescribed by the ACP if needed, but medications can also be administered during surgery. Reassuring the patient is not taking the patient's needs into account.

93

The patient is having a mole removed that has changed appearance. What does the nurse teach the patient about the rationale for this surgical procedure?

A. It is to prevent malignancy.
B. It is to alleviate symptoms.
C. It is to cure the malignancy.
D. It is to provide cosmetic improvement.

A.

Removing a mole that is changing is to prevent as well as diagnose malignancy. There are no symptoms to alleviate mentioned or cosmetic problems for this patient.


94

A 70-year-old woman has been admitted prior to having surgery for a bilateral mastectomy and breast reconstruction. What should the nurse include in the patient's preoperative teaching (select all that apply)?

A. Information about various options for reconstructive surgery
B. Information about the risks and benefits of her particular surgery
C. Information about risk factors for breast cancer and the role of screening
D. Information about where in the hospital she will be taken postoperatively
E. Information about performing postoperative deep-breathing and coughing exercises

D. E.

During preoperative teaching, it is important to introduce the role of deep-breathing and coughing exercises and to inform the patient about the different locations involved in her hospital stay. The specific risks and benefits of her surgery and reconstruction options should be addressed by her surgeon. Teaching about breast cancer screening would be inappropriate, and likely insensitive, at this point in her disease trajectory.



95

Which preoperative patient has the greatest risk of bleeding as a result of his or her medication?

A. A woman who takes metoprolol (Lopressor) for the treatment of hypertension
B. A man whose type 1 diabetes is controlled with insulin injections four times daily
C. A man who is taking clopidogrel (Plavix) after the placement of a coronary artery stent
D. A man who recently started taking finasteride (Proscar) for the treatment of benign prostatic hyperplasia

C.

Any drug that inhibits platelet aggregation, such as clopidogrel (Plavix), represents a bleeding risk. Insulin, metoprolol (Lopressor), and finasteride (Proscar) are less likely to contribute to a risk for bleeding.

96

The nurse is admitting a patient to the same-day surgery unit. The patient tells the nurse that he was so nervous he had to take kava last evening to help him sleep. Which nursing action would be most appropriate?

A. Tell the patient that using kava to help sleep is often helpful.
B. Inform the anesthesiologist of the patient's recent use of kava.
C. Tell the patient that the kava should continue to help him relax before surgery.
D. Inform the patient about the dangers of taking herbal medicines without consulting his health care provider.

B.

Kava may prolong the effects of certain anesthetics. Thus the anesthesiologist needs to be informed of recent ingestion of this herbal supplement. Patients should not take anything before surgery without the health care provider's knowledge.

97

The nurse would be alerted to the occurrence of malignant hyperthermia when the patient demonstrates what manifestation?

A. Hypocapnia
B. Muscle rigidity
C. Decreased body temperature
D. Confusion upon arousal from anesthesia


B. Muscle rigidity

Malignant hyperthermia is a metabolic disease characterized by hyperthermia with rigidity of skeletal muscles from altered control of intracellular calcium occurring as a result of exposure to certain anesthetic agents in susceptible patients. Hypoxemia, hypercapnia, and ventricular dysrhythmias may also be seen with this disorder.

98

In which surgical area will the patient's skin be prepped for surgery, and what clothing will the person doing the prepping be wearing?

A. Surgical suite wearing a lab coat Incorrect
B. Preoperative holding area wearing street clothes
C. Postanesthesia care unit (PACU) wearing scrubs
D. Operating room wearing surgical attire and masks


D. Operating room wearing surgical attire and masks

Surgical attire includes pants and shirts (or scrubs), a cap or hood, masks, and protective eyewear. All surgical attire is worn when the patient's skin is being prepped in the operating room to avoid contamination of the site. The surgical suite includes all unrestricted, semirestricted, and restricted areas of the controlled surgical environment. A lab coat is usually worn by the staff over their scrubs when they leave the surgical area. The staff will not wear street clothes in the preoperative holding area, although the family may. The holding area and PACU will not include prepping the patient for surgery.

99

The patient is going to have a colonoscopy. Which type of anesthesia should the nurse expect to be used?

A. Local anesthesia
B. Moderate sedation
C. General anesthesia
D. Monitored anesthesia care (MAC)

D. Monitored anesthesia care (MAC)

The nurse should expect monitored anesthesia care (MAC) to be used for the patient having a colonoscopy because it can match the sedation level to the patient needs and procedural requirements. Local anesthesia would not be used because the area affected by a colonoscopy is larger than loss of sensation could be provided for with topical, intracutaneous, or subcutaneous application. Moderate sedation is used for procedures performed outside the OR, and the patient remains responsive. General anesthesia is not needed for a colonoscopy, and it requires advanced airway management.

100

A 78-year-old patient is having surgery. What risk areas will the nurse need to be especially aware of for this patient during surgery?

A. Sterility
B. Paralysis
C. Urine output
D. Skin integrity

D. Skin integrity

Skin of older adults has lost elasticity and is at increased risk for injury from tape, electrodes, warming or cooling blankets, and dressings. Pooling cleansing solution may create skin burns or abrasions. The nurse is responsible for monitoring patient safety and adjusting patient position as necessary to prevent pressure or misalignment. Sterility and urine output would be monitored for all patients. Paralysis would not be unusual during some types of surgery but would have an impact on any patient's skin integrity.

101

A patient having an open reduction internal fixation (ORIF) of a left lower leg fracture will receive regional anesthesia during the procedure. As the patient is prepared in the operating room, what should the nurse implement to maintain patient safety during surgery that is directly related to the type of anesthesia being used?

A. Apply grounding pad to unaffected leg.
B. Assess peripheral pulses and skin color.
C. Verify the last oral intake before surgery.
D. Ensure a smooth surface under the patient.

D. Ensure a smooth surface under the patient.

Regional anesthesia decreases sensation to the anesthetized area without impairing level of consciousness, which means the affected leg will be without sensation while the anesthetic is effective. A double tourniquet on the affected leg is used to restrict blood flow. This increases the patient's risk of impaired skin integrity because the patient does not have sensation and cannot identify discomfort or foreign objects and will not be moving during surgery. The nurse's role includes positioning the patient for correct alignment, exposure of the surgical site, and preventing injury. The other options will be occurring but are not directly related to the regional anesthesia.

102

Which National Patient Safety Goal (NPSG) requirement is enacted immediately before surgery with a surgical time-out?

A. Prevention of infection
B. Improved staff communication
C. Identify patients at risk for suicide.
D. Patient, surgical procedure, and site are checked.

D. Patient, surgical procedure, and site are checked.

During the surgical time-out the Universal Protocol is used to verify the patient's identity, surgical procedure, and site to prevent mistakes in surgery. Prevention of infection is to be done at all times. Improved staff communication relates to getting important test results to the right staff on time. Identifying patient's safety risks for suicide is not usually vital before surgery and does not occur during the time-out.

103

The new nursing student is confused about where the patient's family (who are wearing street clothes) can be with the patient in the surgical suite. Which explanation should the perioperative nurse give to the student nurse?

A. The family is not allowed to talk to the nurse at the nursing station.
B. The family can be with the patient in the preoperative holding area.
C. The family cannot be with the patient until the postanesthesia care unit.
D. The family is only allowed in the conference room for preoperative teaching.

B. The family can be with the patient in the preoperative holding area.


The perioperative nurse should explain to the student nurse that the family can be in the preoperative holding area before the patient goes to surgery, but this includes talking to the nurse at the nursing station. They are also taken to the conference room for preoperative and postoperative meetings with staff, including teaching.

104

A surgical patient's premedication regimen includes midazolam (Versed). What are the most likely desired effects of this medication?

A. Monitored anesthesia care and amnesia
B. Potentiates volatile agents to speed induction
C. Analgesia and prevention of intraoperative vomiting
D. Relaxation of skeletal muscles and facilitation of endotracheal intubation

A. Monitored anesthesia care and amnesia

Midazolam is a benzodiazepine that is widely used for its ability to induce amnesia and provide moderate sedation (conscious sedation). Nitrous oxide is a gaseous agent that potentiates volatile agents to speed induction and reduce total dosage and side effects. Antiemetics prevent intraoperative vomiting. Neuromuscular blocking agents facilitate endotracheal intubation.

105

A 71-year-old male patient who is currently undergoing coronary artery bypass graft (CABG) surgery has just experienced intraoperative vomiting. The nurse should consequently anticipate the use of which drug?

A. Midazolam (Versed)
B. Fentanyl (Sublimaze)
C. Meperidine (Demerol)
D. Ondansetron (Zofran)

D. Ondansetron (Zofran)

Ondansetron (Zofran) is an antiemetic, whereas midazolam (Versed) is a benzodiazepine, and fentanyl (Sublimaze) and meperidine (Demerol) are opioid analgesics.

106

The perioperative nurse would recognize the need to monitor the patient for hallucinations and agitation when which anesthetic agent is administered?

A. Nitrous oxide
B. Ketamine (Ketalar)
C. Thiopental (Pentothal)
D. Halothane (Fluothane)

B. Ketamine (Ketalar)

A disadvantage of ketamine (Ketalar) is the associated risk of agitation, hallucinations, and nightmares. These unwanted effects are not associated with the use of thiopental (Pentothal), halothane (Fluothane), or nitrous oxide.

107

What event in the surgical suite represents a violation of aseptic technique?

A. A glove contacts the leg of the table that supports the sterile field.
B. The cuff of the scrub nurse's sterile gown contacts the sterile field.
C. The sterile field was established at 0650, and the current time is 0900.
D. Bacteria are present in the nares and upper respiratory passages of the nurse.

A. A glove contacts the leg of the table that supports the sterile field.

Tables are sterile only at tabletop level. Areas below this are considered contaminated. The sterile gown below the point 2 inches above the elbow is considered sterile. The passage of time in and of itself does not necessarily render a field contaminated. Bacteria are inevitable in the respiratory passages of team members, but they present a threat to sterility only if they are not confined by attire.

108

Which intraoperative nursing responsibilities should be performed by the scrub nurse (select all that apply)?

A. Documenting intraoperative care
B. Keeping track of irrigation solutions for monitoring of blood loss
C. Passing instruments and supplies to the surgeon by anticipating his or her needs
D. Coordinating the flow and activities of members of the surgical team in the surgical suite
E. Performing the count of sponges, needles, and instruments used during the surgical procedure

B. C. E.

Both the scrub nurse and circulating nurse will participate in the counting of surgical sponges, needles, and instruments, whereas passing instruments to the surgeon and other sterile activities are the exclusive responsibility of the scrub nurse. The circulating nurse takes primary responsibility for the coordination of the surgical suite and documentation.

109

Before admitting a patient to the operating room, which forms or results must the nurse make sure are in the chart of all patients (select all that apply)?

A. Electrocardiogram
B. Signed consent form
C. Functional status evaluation
D. Renal and liver function tests
E. A history and physical report

B. E.

The National Patient Safety Goals (NPSG) require documentation of a history and physical, signed consent form, and nursing and preanesthesia assessment in the chart of a patient going for surgery. The physical examination explains in detail the overall status of the patient before surgery for the surgeon and other members of the surgical team.

110

Unless contraindicated by the surgical procedure, which
position is preferred for the unconscious patient immediately postoperative?
A. Supine
B. Lateral
C. Semi-Fowler's
D. High-Fowler's


B. Lateral

Unless contraindicated by the surgical procedure, the unconscious patient is positioned in a lateral recovery position. This recovery position keeps the airway open and reduces the risk of aspiration if the patient vomits. Once the conscious patient is usually returned to a supine position with the head of the bed elevated.

111

The nurse is working on a surgical floor and is preparing to receive a postoperative patient from the postanesthesia care unit (PACU). What should the nurse's initial action be upon the patient's arrival?

A. Assess the patient's pain.
B. Assess the patient's vital signs.
C. Check the rate of the IV infusion.
D. Check the physician's postoperative orders.

B. Assess the patient's vital signs.

The highest priority action by the nurse is to assess the physiologic stability of the patient. This is accomplished in part by taking the patient's vital signs. The other actions can then take place in rapid sequence.

112

A patient is having elective cosmetic surgery performed on her face. The surgeon will keep her at the surgery center for 24 hours after surgery. What is the nurse's postoperative priority for this patient?

A. Manage patient pain.
B. Control the bleeding.
C. Maintain fluid balance.
D. Manage oxygenation status.

D. Manage oxygenation status.

The nurse's priority is to manage the patient's oxygenation status by maintaining an airway and ventilation. With surgery on the face, there may be swelling that could compromise her ability to breathe. Pain, bleeding, and fluid imbalance from the surgery may increase her risk for upper airway edema causing airway obstruction and respiratory suppression, which also indicate managing oxygenation status as the priority.

113

The patient had surgery at an ambulatory surgery center. Which criteria support that this patient is ready for discharge (select all that apply)?

A. Vital signs baseline or stable
B. Minimal nausea and vomiting
C. Wants to go to the bathroom at home
D. Responsible adult taking patient home
E. Comfortable after IV opioid 15 minutes ago

A. B. D.

Ambulatory surgery discharge criteria includes meeting Phase I PACU discharge criteria that includes vital signs baseline or stable and minimal nausea and vomiting. Phase II criteria includes a responsible adult driving patient, no IV opioid drugs for last 30 minutes, able to void, able to ambulate if not contraindicated, and received written discharge instruction with patient understanding confirmed.

114

An older patient who had surgery is displaying manifestations of delirium. What should the nurse do first to provide the best care for this new patient?

A. Check his chart for intraoperative complications.
B. Check which medications were used for anesthesia.
C. Check the effectiveness of the analgesics he has received.
D. Check his preoperative assessment for previous delirium or dementia.

D. Check his preoperative assessment for previous delirium or dementia.

If the patient's ABCs are okay, it is important to first know if the patient was mentally alert without cognitive impairments before surgery. Then intraoperative complications, anesthesia medications, and pain will be assessed as these can all contribute to delirium.

115

The patient donated a kidney, and early ambulation is included in her plan of care. But the patient refuses to get up and walk. What rationale should the nurse explain to the patient for early ambulation?

A. "Early walking keeps your legs limber and strong."
B. "Early ambulation will help you be ready to go home."
C. "Early ambulation will help you get rid of your syncope and pain."
D. "Early walking is the best way to prevent postoperative complications."

D. "Early walking is the best way to prevent postoperative complications."

The best rationale is that early ambulation will prevent postoperative complications that can then be discussed. Ambulating increases muscle tone, stimulates circulation that prevents venous stasis and VTE, speeds wound healing, and increases vital capacity and maintains normal respiratory function. These things help the patient be ready for discharge, but early ambulation does not eliminate syncope and pain. Pain management should always occur before walking.

116

When assessing a patient's surgical dressing on the first postoperative day, the nurse notes new, bright-red drainage about 5 cm in diameter. In response to this finding, what should the nurse do first?

A. Recheck in 1 hour for increased drainage.
B. Notify the surgeon of a potential hemorrhage.
C. Assess the patient's blood pressure and heart rate.
D. Remove the dressing and assess the surgical incision.

C. Assess the patient's blood pressure and heart rate.

The first action by the nurse is to gather additional assessment data to form a more complete clinical picture. The nurse can then report all of the findings. Continued reassessment will be done. Agency policy determines whether the nurse may change the dressing for the first time or simply reinforce it.

117

In planning postoperative interventions to promote repositioning, ambulation, coughing, and deep breathing, which action should the nurse recognize will best enable the patient to achieve the desired outcomes?

A. Administering adequate analgesics to promote relief or control of pain
B. Asking the patient to demonstrate the postoperative exercises every 1 hour
C. Giving the patient positive feedback when the activities are performed correctly
D. Warning the patient about possible complications if the activities are not performed

A. Administering adequate analgesics to promote relief or control of pain

Even when a patient understands the importance of postoperative activities and demonstrates them correctly, it is unlikely that the best outcome will occur unless the patient has sufficient pain relief to cooperate with the activities.

118

The patient had abdominal surgery. The estimated blood loss was 400 mL. The patient received 300 mL of 0.9% saline during surgery. Postoperatively, the patient is hypotensive. What should the nurse anticipate for this patient?

A. Blood administration
B. Restoring circulating volume
C. An ECG to check circulatory status
D. Return to surgery to check for internal bleeding

B. Restoring circulating volume

The nurse should anticipate restoring circulating volume with IV infusion. Although blood could be used to restore circulating volume, there are no manifestations in this patient indicating a need for blood administration. An ECG may be done if there is no response to the fluid administration, or there is a past history of cardiac disease, or cardiac problems were noted during surgery. Returning to surgery to check for internal bleeding would only be done if patient's level of consciousness changes or the abdomen becomes firm and distended.

119

In caring for the postoperative patient on the clinical unit after transfer from the PACU, which care can be delegated to the unlicensed assistive personnel (UAP)?

A. Monitor the patient's pain.
B. Do the admission vital signs.
C. Assist the patient to take deep breaths and cough.
D. Change the dressing when there is excess drainage.


C. Assist the patient to take deep breaths and cough.

The UAP can encourage and assist the patient to do deep breathing and coughing exercises and report complaints of pain to the nurse caring for the patient. The RN should do the admission vital signs for the patient transferring to the clinical unit from the PACU. The LPN or RN will monitor and treat the patient's pain and change the dressings.

120

Bronchial obstruction by retained secretions has contributed to a postoperative patient's recent pulse oximetry reading of 87%. Which health problem is the patient probably experiencing?

A. Atelectasis
B. Bronchospasm
C. Hypoventilation
D. Pulmonary embolism

A. Atelectasis

The most common cause of postoperative hypoxemia is atelectasis, which may be the result of bronchial obstruction caused by retained secretions or decreased respiratory excursion. Bronchospasm involves the closure of small airways by increased muscle tone, whereas hypoventilation is marked by an inadequate respiratory rate or depth. Pulmonary emboli do not involve blockage by retained secretions.