The surgery for a client scheduled for an 8:00 a.m. procedure is delayed until 11:00 a.m. What is the
appropriate nursing action regarding the administration of preoperative prophylactic antibiotic?
A. Administer at 8:00 a.m. as originally prescribed.
B. Adjust the administration time to be given at 10:00 a.m.
C. Do not administer, as preoperative prophylactic antibiotics are optional.
D. Hold the antibiotic until immediately following surgery, and then administer. - AnswerB
The nurse is caring for a client who is to undergo surgery at 6:00 a.m. today. Which assessment data
will the nurse communicate immediately to the surgeon and anesthesia provider? Select all that
apply.
A. Blood pressure 130/72 mm Hg
B. Serum potassium 3.5 mEq/L
C. Diffuse rash on upper torso
D. Took 650 mg of aspirin yesterday
E. Has not had food or water since 9:00 p.m. last night - AnswerC,D
The nurse is teaching a client about postoperative leg exercises. What teaching will the nurse
include? Select all that apply.
A. Begin practicing leg exercises prior to surgery.
B. Repeat leg exercises several times daily for each leg.
C. Push the ball of the foot into the bed until the calf and thigh muscles contract.
D. If pain or warmth in the calf is present, discontinue exercises and contact the surgeon.
E. Point toes of one foot toward bed bottom; then point toes of same leg toward face. Switch. -
AnswerA,C,D,E
The nurse has prepared a client for transport from the medical-surgical unit to surgery. Which client
statement will the nurse respond to as the priority?
A. "When I eat shrimp, my tongue swells and I have trouble breathing."
B. "I'm feeling more anxious about my surgery than I thought I would be."
C. "I'm not sure what I will do if insurance doesn't cover this expensive hip replacement."
, D. "My sister had anesthesia a few months ago and she said she didn't like the way she felt." -
AnswerA
The nurse is caring for a client who has been readmitted to the medical-surgical unit following
surgery for a hernia repair completed under general anesthesia. What is the priority nursing
assessment?
A. Perform thorough auscultation of the lungs
B. Assess response to pinprick stimulation from feet to mid-chest level
C. Determine level of consciousness and response to environmental stimuli
D. Compare blood pressure findings from preoperative assessment to the present - AnswerA
In the early postoperative phase, which assessment finding in a client who had an epidural during
surgery requires immediate nursing intervention?
A. Blood pressure of 142/90 mm Hg
B. Headache of 4 on a 1-10 scale
C. Gradual return of motor function
D. Increase in back pain when coughing - AnswerA
The nurse is caring for a client who reports being fearful of becoming dependent on opioid pain
medication after surgery. What is the appropriate nursing response? Select all that apply.
A. "Why do you think you're going to get hooked?"
B. "Don't worry, I won't give you any opioid medications."
C. "Have you had concerns with drug dependence in the past?"
D. "Tell me what makes you most fearful about taking opioid medication."
E. "There are proper ways of taking opioids so you will not become dependent." - AnswerC,D,E
The nurse is completing a preoperative physical assessment for a client who will have surgery this
afternoon. Which assessment finding will the nurse report to the operative team? Select all that
apply.
A. Left arm prosthesis
B. Skin turgor <3 seconds
C. Blood pressure 160/100 mm Hg
D. Presence of chest rigidity
appropriate nursing action regarding the administration of preoperative prophylactic antibiotic?
A. Administer at 8:00 a.m. as originally prescribed.
B. Adjust the administration time to be given at 10:00 a.m.
C. Do not administer, as preoperative prophylactic antibiotics are optional.
D. Hold the antibiotic until immediately following surgery, and then administer. - AnswerB
The nurse is caring for a client who is to undergo surgery at 6:00 a.m. today. Which assessment data
will the nurse communicate immediately to the surgeon and anesthesia provider? Select all that
apply.
A. Blood pressure 130/72 mm Hg
B. Serum potassium 3.5 mEq/L
C. Diffuse rash on upper torso
D. Took 650 mg of aspirin yesterday
E. Has not had food or water since 9:00 p.m. last night - AnswerC,D
The nurse is teaching a client about postoperative leg exercises. What teaching will the nurse
include? Select all that apply.
A. Begin practicing leg exercises prior to surgery.
B. Repeat leg exercises several times daily for each leg.
C. Push the ball of the foot into the bed until the calf and thigh muscles contract.
D. If pain or warmth in the calf is present, discontinue exercises and contact the surgeon.
E. Point toes of one foot toward bed bottom; then point toes of same leg toward face. Switch. -
AnswerA,C,D,E
The nurse has prepared a client for transport from the medical-surgical unit to surgery. Which client
statement will the nurse respond to as the priority?
A. "When I eat shrimp, my tongue swells and I have trouble breathing."
B. "I'm feeling more anxious about my surgery than I thought I would be."
C. "I'm not sure what I will do if insurance doesn't cover this expensive hip replacement."
, D. "My sister had anesthesia a few months ago and she said she didn't like the way she felt." -
AnswerA
The nurse is caring for a client who has been readmitted to the medical-surgical unit following
surgery for a hernia repair completed under general anesthesia. What is the priority nursing
assessment?
A. Perform thorough auscultation of the lungs
B. Assess response to pinprick stimulation from feet to mid-chest level
C. Determine level of consciousness and response to environmental stimuli
D. Compare blood pressure findings from preoperative assessment to the present - AnswerA
In the early postoperative phase, which assessment finding in a client who had an epidural during
surgery requires immediate nursing intervention?
A. Blood pressure of 142/90 mm Hg
B. Headache of 4 on a 1-10 scale
C. Gradual return of motor function
D. Increase in back pain when coughing - AnswerA
The nurse is caring for a client who reports being fearful of becoming dependent on opioid pain
medication after surgery. What is the appropriate nursing response? Select all that apply.
A. "Why do you think you're going to get hooked?"
B. "Don't worry, I won't give you any opioid medications."
C. "Have you had concerns with drug dependence in the past?"
D. "Tell me what makes you most fearful about taking opioid medication."
E. "There are proper ways of taking opioids so you will not become dependent." - AnswerC,D,E
The nurse is completing a preoperative physical assessment for a client who will have surgery this
afternoon. Which assessment finding will the nurse report to the operative team? Select all that
apply.
A. Left arm prosthesis
B. Skin turgor <3 seconds
C. Blood pressure 160/100 mm Hg
D. Presence of chest rigidity
