Actual Answers 2026 Updated.
Before the administration of preoperative medications, the nurse is preparing to witness the
patient signing the operative consent form when the patient says, "I do not really understand
what the doctor said." Which action is best for the nurse to take?
a. Provide an explanation of the planned
surgical procedure.
b. Notify the surgeon that the informed consent
process is not complete.
c. Administer the prescribed preoperative
antibiotics and withhold any ordered sedative
medications.
d. Notify the operating room staff that the
surgeon needs to give a more complete
explanation of the procedure. - Answer ANS: B
The surgeon is responsible for explaining the surgery to the patient, and the nurse should wait
until the surgeon has clarified the surgery before having the patient sign the consent form. The
nurse should communicate directly with the surgeon about the consent form rather than asking
other staff to pass on the message. It is not within the nurse's legal scope of practice to explain
the surgical procedure. No preoperative medications
2.) A patient has received atropine before surgery and complains of dry mouth. Which action by
the nurse is best?
a.Check for skin tenting.
b.Notify the health care provider.
c.Ask the patient about any dizziness.
d.Tell the patient dry mouth is an expected side effect. - Answer ANS: D
Anticholinergic medications decrease oral secretions, so the patient is taught that a dry mouth
is an expected side effect. The dry mouth is not a symptom of dehydration in this case.
Therefore there is no immediate need to check for skin tenting. The health care provider does
not need to be notified about an expected side effect. Weakness, forgetfulness, and dizziness
are side effects associated with other preoperative medications such as opioids and
benzodiazepines.
A patient who takes a diuretic and a -blocker to control blood pressure is scheduled for breast
reconstruction surgery. Which patient information is most important to communicate to the
health care provider before surgery?
,a. Hematocrit 36%
b. Blood pressure 144/82
c. Pulse rate 58 beats/minute
d. Serum potassium 3.2 mEq/L - Answer ANS: D
The low potassium level may increase the risk for intraoperative complications such as
dysrhythmias. Slightly elevated blood pressure is common before surgery because of anxiety.
The lower heart rate would be expected in a patient taking a -blocker. The hematocrit is in the
low normal range but does not require any intervention before surgery.
Hc: m 42-54%
Hc: f 38-46
K 3.5-5.5mEq/Lb
As the nurse is preparing a patient for surgery, the patient refuses to remove a wedding ring.
Which of the following is the most appropriate action by the nurse? - Answer Tape the ring
securely to the finger and document this on the preoperative checklist
When the nurse interviews a patient who is to have outpatient surgery using a general
anesthetic, which info is most important to communicate to the surgeon and anesthesiologist
before surgery?
a. The patient drinks 3 or 4 cups of coffee every morning before going to work.
b. The patient takes a baby aspirin daily but stopped taking aspirin 10 days ago.
c. The patient drank 4 ounces of apple juice 3 hours before coming to the hospital.
d. The patient's father died after receiving general anesthesia for abdominal surgery. - Answer
ANS: D
The information about the patient's father suggests that there may be a family history of
malignant hyperthermia and that precautions may need to be taken to prevent this
complication. Current research indicates that having clear liquids 3 hours before surgery does
not increase the risk for aspiration in most patients. Patients are instructed to discontinue
aspirin 1 to 2 weeks before surgery. The patient should be offered caffeinated beverages
postoperatively to prevent a caffeine-withdrawal headache, but this does not have preoperative
implications.
A nurse is caring for a patient who has a central venous access device in place. Which of the
following routine measures should the nurse use specifically to prevent lumen occlusion? -
Answer Clamping the extension tubing while removing a syringe from the injection cap
, The nurse is flushing a patient's implanted port and meets resistance. What would the nurse do
next? - Answer Check that the clamp is open, gently push down on needle, and attempt to
flush again.
The nurse is flushing a patient's peripherally inserted central catheter. Which of the following
would the nurse do first? - Answer Cap the infusion line
Lab Values - Answer K: 3.5-5.5 mEq
Ca: 8.4-10.2 mg/dL
Na: 135-145
PO4: 3.0 - 4.5 mg/dL
An older patient receiving iso-osmolar continuous tube feedings develops restlessness,
agitation, and weakness. Which laboratory result should the nurse report to the health care
provider immediately?
a. K+ 3.4 mEq/L (3.4 mmol/L)
b. Ca+2 7.8 mg/dL (1.95 mmol/L)
c. Na+ 154 mEq/L (154 mmol/L)
d. PO4-3 4.8 mg/dL (1.55 mmol/L) - Answer ANS: C
The elevated serum sodium level is consistent with the patient's neurologic symptoms and
indicates a need for immediate action to prevent further serious complications such as seizures.
The potassium and calcium levels vary slightly from normal but do not require immediate action
by the nurse. The phosphate level is normal.
Following a thyroidectomy, a patient complains of "a tingling feeling around my mouth." Which
assessment should the nurse complete immediately?
a. Presence of the Chvostek's sign
b. Abnormal serum potassium level
c. Decreased thyroid hormone level
d. Bleeding on the patient's dressing - Answer A
The patient's symptoms indicate possible hypocalcemia, which can occur secondary to
parathyroid injury/removal during thyroidectomy. There is no indication of a need to check the
potassium level, the thyroid hormone level, or for bleeding.
13. A patient is receiving 3% NaCl solution for correction of hyponatremia. During
administration of the solution, the most important assessment for the nurse to monitor is
a.lung sounds.
b.urinary output.