An older client is hospitalized after an operation. When assessing the client for
postoperative infection, the nurse places priority on which assessment?
a. Change in behavior
b. Daily white blood cell count
c. Presence of fever and chills
d. Tolerance of increasing activity
A
A preoperative nurse is assessing a client prior to surgery. Which information would be
most important for the nurse to relay to the surgical team?
a. Allergy to bee and wasp stings
b. History of lactose intolerance
c. No previous experience with surgery
d. Use of multiple herbs and supplements
D
A nurse works on the postoperative floor and has four clients who are being discharged
tomorrow. Which one has the greatest need for the nurse to consult other members of
the health care team for post-discharge care?
a. Married young adult who is the primary caregiver for children
b. Middle-aged client who is post knee replacement, needs physical therapy
c. Older adult who lives at home despite some memory loss
d. Young client who lives alone, has family and friends nearby
C
A clinic nurse is teaching a client prior to surgery. The client does not seem to
comprehend the teaching, forgets a lot of what is said, and asks the same questions
again and again. What action by the nurse is best?
a. Assess the client for anxiety.
b. Break the information into smaller bits.
c. Give the client written information.
d. Review the information again.
A
An inpatient nurse brings an informed consent form to a client for an operation
scheduled for tomorrow. The client asks about possible complications from the
operation. What response by the nurse is best?
a. Answer the questions and document that teaching was done.
b. Do not have the client sign the consent and call the surgeon.
c. Have the client sign the consent, then call the surgeon.
d. Remind the client of what teaching the surgeon has done.
, B
A client has a great deal of pain when coughing and deep breathing after abdominal
surgery despite having pain medication. What action by the nurse is best?
a. Call the provider to request more analgesia.
b. Demonstrate how to splint the incision.
c. Have the client take shallower breaths.
d. Tell the client a little pain is expected.
B
A nurse is giving a client instructions for showering with special antimicrobial soap the
night before surgery. What instruction is most appropriate?
a. "After you wash the surgical site, shave that area with your own razor."
b. "Be sure to wash the area where you will have surgery very thoroughly."
c. "Use a washcloth to wash the surgical site; do not take a full shower or bath."
d. "Wash the surgical site first, then shampoo and wash the rest of your body."
B
A postoperative client has an abdominal drain. What assessment by the nurse indicates
that goals for the priority client problems related to the drain are being met?
a. Drainage from the surgical site is 30 mL less than yesterday.
b. There is no redness, warmth, or drainage at the insertion site.
c. The client reports adequate pain control with medications.
d. Urine is clear yellow and urine output is greater than 40 mL/hr.
B
A client waiting for surgery is very anxious. What intervention can the nurse delegate to
the unlicensed assistive personnel (UAP)?
a. Assess the client's anxiety.
b. Give the client a back rub.
c. Remind the client to turn.
d. Teach about postoperative care.
B
A client in the preoperative holding room has received sedation and now needs to
urinate. What action by the nurse is best?
a. Allow the client to walk to the bathroom.
b. Delegate assisting the client to the nurse's aide.
c. Give the client a bedpan or urinal to use.
d. Insert a urinary catheter now instead of waiting.
postoperative infection, the nurse places priority on which assessment?
a. Change in behavior
b. Daily white blood cell count
c. Presence of fever and chills
d. Tolerance of increasing activity
A
A preoperative nurse is assessing a client prior to surgery. Which information would be
most important for the nurse to relay to the surgical team?
a. Allergy to bee and wasp stings
b. History of lactose intolerance
c. No previous experience with surgery
d. Use of multiple herbs and supplements
D
A nurse works on the postoperative floor and has four clients who are being discharged
tomorrow. Which one has the greatest need for the nurse to consult other members of
the health care team for post-discharge care?
a. Married young adult who is the primary caregiver for children
b. Middle-aged client who is post knee replacement, needs physical therapy
c. Older adult who lives at home despite some memory loss
d. Young client who lives alone, has family and friends nearby
C
A clinic nurse is teaching a client prior to surgery. The client does not seem to
comprehend the teaching, forgets a lot of what is said, and asks the same questions
again and again. What action by the nurse is best?
a. Assess the client for anxiety.
b. Break the information into smaller bits.
c. Give the client written information.
d. Review the information again.
A
An inpatient nurse brings an informed consent form to a client for an operation
scheduled for tomorrow. The client asks about possible complications from the
operation. What response by the nurse is best?
a. Answer the questions and document that teaching was done.
b. Do not have the client sign the consent and call the surgeon.
c. Have the client sign the consent, then call the surgeon.
d. Remind the client of what teaching the surgeon has done.
, B
A client has a great deal of pain when coughing and deep breathing after abdominal
surgery despite having pain medication. What action by the nurse is best?
a. Call the provider to request more analgesia.
b. Demonstrate how to splint the incision.
c. Have the client take shallower breaths.
d. Tell the client a little pain is expected.
B
A nurse is giving a client instructions for showering with special antimicrobial soap the
night before surgery. What instruction is most appropriate?
a. "After you wash the surgical site, shave that area with your own razor."
b. "Be sure to wash the area where you will have surgery very thoroughly."
c. "Use a washcloth to wash the surgical site; do not take a full shower or bath."
d. "Wash the surgical site first, then shampoo and wash the rest of your body."
B
A postoperative client has an abdominal drain. What assessment by the nurse indicates
that goals for the priority client problems related to the drain are being met?
a. Drainage from the surgical site is 30 mL less than yesterday.
b. There is no redness, warmth, or drainage at the insertion site.
c. The client reports adequate pain control with medications.
d. Urine is clear yellow and urine output is greater than 40 mL/hr.
B
A client waiting for surgery is very anxious. What intervention can the nurse delegate to
the unlicensed assistive personnel (UAP)?
a. Assess the client's anxiety.
b. Give the client a back rub.
c. Remind the client to turn.
d. Teach about postoperative care.
B
A client in the preoperative holding room has received sedation and now needs to
urinate. What action by the nurse is best?
a. Allow the client to walk to the bathroom.
b. Delegate assisting the client to the nurse's aide.
c. Give the client a bedpan or urinal to use.
d. Insert a urinary catheter now instead of waiting.
