CHAPTER 12 EXAM QUESTIONS AND ANSWERS
100% VERIFIED
The nurse is caring for a client after a mammoplasty. The nurse understands that the
client had which procedure done? - answer Formation or repair of the breast
The nurse is caring for a client receiving a spinal block. Which symptom would most
concern the nurse? - answer Hypotension
RATIONALE: Hypotension after a spinal block is very concerning for decreased cardiac
output and vasodilation. This is the highest concern for the nurse.
The nurse is caring for a client with a surgical incision that is 18 days old. The nurse
understands that the wound is in which phase of wound healing? - answer Phase III
RATIONALE:
Phase III occurs from week 3 to week 6 postoperative. During this phase collagen is
forming
The nurse is caring for a client with an incision closed using staples. How long should
the nurse expect the staples to remain in the client? - answer 10 days
The nurse is assisting with the care of a malnourished client being prepared for surgery.
Which statement by the client regarding nutrition would indicate adequate teaching? -
answer "I should take a vitamin with zinc and vitamin C in it after surgery."
RATIONALE: Zinc has been shown to increase tissue growth, skin integrity, and
cell-mediated immunity. Vitamin C has been shown to help with collagen formation for
wounds. Both are good recommendations for clients who are potentially deficient in
them.
The nurse is caring for a client with urinary retention after a hysterectomy. Which
nursing intervention is appropriate when assisting this client? Select all that apply. -
answer - Place bedpan in warmer before use
- Record oral intake.
- Assist client to bedside toilet.
- Inform the surgeon if client has not voided in 4 to 6 hours.
- Pour warm water over the perineum.
RATIONALE:
, - Cold bedpans can cause reflexive sphincter tightening and inhibit emptying.
- Recording oral intake and any output will assist the nurse in detecting urinary retention
problems.
- Assisting a client to the bedside toilet or men to a standing position can ease voiding
rather than using a bedpan.
- The typical time frame for clients undergoing gynecological surgeries is 4 to 6 hours. If
the client has still not voided within the time frame then the surgeon should be informed.
- Pouring warm water over a female's perineum, turning on running water, or drinking
hot beverages are ways to stimulate voiding in clients.
The nurse is receiving a report on a team of four clients. Which client should the nurse
see first? - answer A client complaining of left leg pain and swelling
RATIONALE: This client should be seen first due to suspected deep vein thrombosis
(DVT). DVTs present as swelling, warmth, redness, and pain in an extremity.
The nurse is caring for a client in the postanesthesia care unit after an abdominal
surgery. Which nursing action is appropriate? - answer Document the surgical site
incision.
RATIONALE: Documentation of surgical incision sites is critical to the prevention of
complications. Hematoma formation and dressing status should be monitored.
The nurse is discharging a client after surgery. Which recommendation by the nurse to
the caregiver is appropriate for this client? Select all that apply. - answer - "A shower
stool can help the client bathe themselves easier."
- "Always wash your hands before and after wound care."
- "Place extra pillows and blankets on the bed."
- "Try to place the client on the first floor."
RATIONALE:
- Shower grab bars and stools can allow the client more independence when bathing
and reduce caregiver strain.
- Strict hand washing before and after wound care will help prevent infections.
- Placing extra blankets and pillows on the bed will assist in positioning and the comfort
of the client.
- Having the client in a bedroom on the first floor can be helpful when trying to get the
client to the bathroom and kitchen during the day.
The nurse is caring for a client undergoing surgery with the nursing diagnosis of
100% VERIFIED
The nurse is caring for a client after a mammoplasty. The nurse understands that the
client had which procedure done? - answer Formation or repair of the breast
The nurse is caring for a client receiving a spinal block. Which symptom would most
concern the nurse? - answer Hypotension
RATIONALE: Hypotension after a spinal block is very concerning for decreased cardiac
output and vasodilation. This is the highest concern for the nurse.
The nurse is caring for a client with a surgical incision that is 18 days old. The nurse
understands that the wound is in which phase of wound healing? - answer Phase III
RATIONALE:
Phase III occurs from week 3 to week 6 postoperative. During this phase collagen is
forming
The nurse is caring for a client with an incision closed using staples. How long should
the nurse expect the staples to remain in the client? - answer 10 days
The nurse is assisting with the care of a malnourished client being prepared for surgery.
Which statement by the client regarding nutrition would indicate adequate teaching? -
answer "I should take a vitamin with zinc and vitamin C in it after surgery."
RATIONALE: Zinc has been shown to increase tissue growth, skin integrity, and
cell-mediated immunity. Vitamin C has been shown to help with collagen formation for
wounds. Both are good recommendations for clients who are potentially deficient in
them.
The nurse is caring for a client with urinary retention after a hysterectomy. Which
nursing intervention is appropriate when assisting this client? Select all that apply. -
answer - Place bedpan in warmer before use
- Record oral intake.
- Assist client to bedside toilet.
- Inform the surgeon if client has not voided in 4 to 6 hours.
- Pour warm water over the perineum.
RATIONALE:
, - Cold bedpans can cause reflexive sphincter tightening and inhibit emptying.
- Recording oral intake and any output will assist the nurse in detecting urinary retention
problems.
- Assisting a client to the bedside toilet or men to a standing position can ease voiding
rather than using a bedpan.
- The typical time frame for clients undergoing gynecological surgeries is 4 to 6 hours. If
the client has still not voided within the time frame then the surgeon should be informed.
- Pouring warm water over a female's perineum, turning on running water, or drinking
hot beverages are ways to stimulate voiding in clients.
The nurse is receiving a report on a team of four clients. Which client should the nurse
see first? - answer A client complaining of left leg pain and swelling
RATIONALE: This client should be seen first due to suspected deep vein thrombosis
(DVT). DVTs present as swelling, warmth, redness, and pain in an extremity.
The nurse is caring for a client in the postanesthesia care unit after an abdominal
surgery. Which nursing action is appropriate? - answer Document the surgical site
incision.
RATIONALE: Documentation of surgical incision sites is critical to the prevention of
complications. Hematoma formation and dressing status should be monitored.
The nurse is discharging a client after surgery. Which recommendation by the nurse to
the caregiver is appropriate for this client? Select all that apply. - answer - "A shower
stool can help the client bathe themselves easier."
- "Always wash your hands before and after wound care."
- "Place extra pillows and blankets on the bed."
- "Try to place the client on the first floor."
RATIONALE:
- Shower grab bars and stools can allow the client more independence when bathing
and reduce caregiver strain.
- Strict hand washing before and after wound care will help prevent infections.
- Placing extra blankets and pillows on the bed will assist in positioning and the comfort
of the client.
- Having the client in a bedroom on the first floor can be helpful when trying to get the
client to the bathroom and kitchen during the day.
The nurse is caring for a client undergoing surgery with the nursing diagnosis of
