NUR 305 EXAM 1 QUESTIONS AND ANSWERS
Which of the following patients undergoing surgery are considered to be at high risk for
venous thromboembolism (VTE)? Select all that apply.
A. Patient who underwent a prolonged surgical procedure
B. Morbidly obese patient
C. Patient with a humerus fracture
D. Wheelchair bound patient
E. Patient with severe heart failure - Answer -A, B, D, E
The Surgical Care Improvement Project (SCIP) goals focus on which of the following?
Select all that apply.
A. Thromboembolism
B. Serious cardiac events
C. Stroke
D. Hemorrhage
E. Infection - Answer -A, B, E
The preoperative assessment revealed that the patient's HR is 115. The surgeon
ordered a beta-blocker. Which of the following is a correct rationale for this prescription?
A. A rapid heart rate requires more effort by the heart.
B. The patient may have an undiagnosed heart condition
C. Anesthesia has bad effects if the patients is tachycardic
D. When the heart rate goes up, the blood pressure does too - Answer -A
Which of the following are correct examples of different types of surgery? Select all that
apply.
A. Hemicolectomy: diagnostic
B. Liver biopsy: diagnostic
C. Mastectomy: restorative
D. Total shoulder replacement: restorative
E. Decompression craniotomy: palliative - Answer -B, D, E
Which of the following preoperative lab values must be reported immediately to the
surgeon?
A. Hgb 14.8mg/dL (148 mmol/L)
B. Na 134 mEq/L
C. Creatinine 1.2 mg/dL
D. K 2.9 mEq/L - Answer -D
The preoperative assessment revealed that the patient has brittle nails and hair, dry
skin turgor, and muscle wasting. What is the best nurse's action?
A. Document the findings thoroughly in the chart
B. Consult the surgeon about a postoperative dietitian referral
C. Refer the patient to Meals on Wheels after discharge
,D. Encourage the patient to eat more after recovering from surgery - Answer -A
The PACU nurse is assessing a postsurgical patient. The patient had abdominal
surgery the previous day and has a nasogastric tube. Put in order the correct sequence
for performing an accurate assessment of the abdomen.
A. Gently palpate the abdomen
B. Ask the patient whether they have passed any flatus
C. Observe for abdominal distention.
D. Turn off suction to the nasogastric tube.
E. Auscultate for bowel sounds in all four quadrants. - Answer -D, C, E, A, B
The postoperative assessment revealed that the patient has respiratory depression after
receiving morphine for pain. Which medication does the nurse prepare to administer?
A. Vitamin K
B. Naloxone
C. Flumazenil
D. Protamine Sulfate - Answer -B
A postoperative patient has the following orders:
IV LR @ 125 ml/hr
NG to Low cont suction
Replace NG output every 4hrs with NS over 4hrs
Morphine sulfate 2mg IV push Q1 PRN
NPO
Up in chair at night
At 1600 te=he nurse measures NG output from 1200 to be 200ml. What is the patient's
total IV rate for the next 4 hrs? - Answer -175 ml/hr
A nurse student is changing the dressing and performing care around a T-tube drain.
Which of the following actions by the student should warrant intervention by the clinical
instructor?
A. Cleaning around the drain per agency protocol
B. Using sterile technique to empty the drain
C. Placing a new sterile gauze under the drain
D. Securing the drain's safety pin to the sheets. - Answer -D
A postoperative patient is not comfortable with the antiembolic stockings and asks the
nurse to remove them. What is the best response by the nurse?
A. Let me call the surgeon to see if you really need them
B. To prevent blood clots, you need them a few more hours
C. Okay, we can remove them since you are stable now
D. No, you have to use those for 24hrs after surgery - Answer -B
Which of the following assessment findings would indicate that a postoperative patient
is meeting the PACU discharge criteria? Select all that apply.
, A. Return of gag, cough, and swallow reflexes
B. No overt bleeding
C. Ability to move 2 extremities voluntarily
D. Blood pressure within 30 points of preanesthetic level
E. Oxygen saturation of >95% on RA - Answer -A, B, E
The PACU nurse notes VS on the following postoperative patients. Which of the
following patients should the nurse assess first?
A. Pt with pulse of 118 bpm
B. Pt with respiratory rate of 6 breaths/min
C. Pt with BP of 100/50mmHg
D. Pt with a temperature of 96F (35.6C) - Answer -B
Which of the following assessment findings would indicate an effect of hypothermia in
an elderly postoperative patient?
A. Hypotension
B. Tachycardia
C. Rapid, shallow respirations
D. Bradycardia - Answer -D
What should you communicate to Mrs. Taylor about the specific benefits of deep
breathing and coughing after surgery? Select all that apply.
A. Deep breathing exercises hyperventilate the alveoli and prevent them from collapsing
B. Coughing helps strengthen any compromised abdominal muscles
C. Deep breathing is helpful for relaxation after surgery
D. Coughing helps remove retained mucus from the respiratory tract
E.Deep breathing improves the oxygenation of body tissues
F. Deep breathing speeds the healing process
G. Deep breathing improves lung expansion and volume
H. Deep breathing helps expel anesthetic gases and mucus from the airway - Answer -
A, D, E, G, H
A PACU nurse is caring for multiple postoperatuve clients who are at risk for shock.
Which of the following lab values necessitate that the nurse contact the PCP?
A. Sodium: 150 mEq/L (150 mmol/L)
B. Creatinine: 0.9 mg/dL (68.6 mcmol/L)
C. White blood cell count: 11,000/mm3 (11 × 109/L)
D. Lactate: 54 mg/dL (6 mmol/L) - Answer -D
A postoperative client is receiving dopamine for the treatment of shock. Which of the
following assessment findings necessitate that the nurse contacts the PCP
immediately?
A. Blood pressure of 98/68 mm Hg
B. Report of chest heaviness
C. Urine output of 32 mL/hr
D. Pedal pulses 1+/4+ bilaterally - Answer -B
Which of the following patients undergoing surgery are considered to be at high risk for
venous thromboembolism (VTE)? Select all that apply.
A. Patient who underwent a prolonged surgical procedure
B. Morbidly obese patient
C. Patient with a humerus fracture
D. Wheelchair bound patient
E. Patient with severe heart failure - Answer -A, B, D, E
The Surgical Care Improvement Project (SCIP) goals focus on which of the following?
Select all that apply.
A. Thromboembolism
B. Serious cardiac events
C. Stroke
D. Hemorrhage
E. Infection - Answer -A, B, E
The preoperative assessment revealed that the patient's HR is 115. The surgeon
ordered a beta-blocker. Which of the following is a correct rationale for this prescription?
A. A rapid heart rate requires more effort by the heart.
B. The patient may have an undiagnosed heart condition
C. Anesthesia has bad effects if the patients is tachycardic
D. When the heart rate goes up, the blood pressure does too - Answer -A
Which of the following are correct examples of different types of surgery? Select all that
apply.
A. Hemicolectomy: diagnostic
B. Liver biopsy: diagnostic
C. Mastectomy: restorative
D. Total shoulder replacement: restorative
E. Decompression craniotomy: palliative - Answer -B, D, E
Which of the following preoperative lab values must be reported immediately to the
surgeon?
A. Hgb 14.8mg/dL (148 mmol/L)
B. Na 134 mEq/L
C. Creatinine 1.2 mg/dL
D. K 2.9 mEq/L - Answer -D
The preoperative assessment revealed that the patient has brittle nails and hair, dry
skin turgor, and muscle wasting. What is the best nurse's action?
A. Document the findings thoroughly in the chart
B. Consult the surgeon about a postoperative dietitian referral
C. Refer the patient to Meals on Wheels after discharge
,D. Encourage the patient to eat more after recovering from surgery - Answer -A
The PACU nurse is assessing a postsurgical patient. The patient had abdominal
surgery the previous day and has a nasogastric tube. Put in order the correct sequence
for performing an accurate assessment of the abdomen.
A. Gently palpate the abdomen
B. Ask the patient whether they have passed any flatus
C. Observe for abdominal distention.
D. Turn off suction to the nasogastric tube.
E. Auscultate for bowel sounds in all four quadrants. - Answer -D, C, E, A, B
The postoperative assessment revealed that the patient has respiratory depression after
receiving morphine for pain. Which medication does the nurse prepare to administer?
A. Vitamin K
B. Naloxone
C. Flumazenil
D. Protamine Sulfate - Answer -B
A postoperative patient has the following orders:
IV LR @ 125 ml/hr
NG to Low cont suction
Replace NG output every 4hrs with NS over 4hrs
Morphine sulfate 2mg IV push Q1 PRN
NPO
Up in chair at night
At 1600 te=he nurse measures NG output from 1200 to be 200ml. What is the patient's
total IV rate for the next 4 hrs? - Answer -175 ml/hr
A nurse student is changing the dressing and performing care around a T-tube drain.
Which of the following actions by the student should warrant intervention by the clinical
instructor?
A. Cleaning around the drain per agency protocol
B. Using sterile technique to empty the drain
C. Placing a new sterile gauze under the drain
D. Securing the drain's safety pin to the sheets. - Answer -D
A postoperative patient is not comfortable with the antiembolic stockings and asks the
nurse to remove them. What is the best response by the nurse?
A. Let me call the surgeon to see if you really need them
B. To prevent blood clots, you need them a few more hours
C. Okay, we can remove them since you are stable now
D. No, you have to use those for 24hrs after surgery - Answer -B
Which of the following assessment findings would indicate that a postoperative patient
is meeting the PACU discharge criteria? Select all that apply.
, A. Return of gag, cough, and swallow reflexes
B. No overt bleeding
C. Ability to move 2 extremities voluntarily
D. Blood pressure within 30 points of preanesthetic level
E. Oxygen saturation of >95% on RA - Answer -A, B, E
The PACU nurse notes VS on the following postoperative patients. Which of the
following patients should the nurse assess first?
A. Pt with pulse of 118 bpm
B. Pt with respiratory rate of 6 breaths/min
C. Pt with BP of 100/50mmHg
D. Pt with a temperature of 96F (35.6C) - Answer -B
Which of the following assessment findings would indicate an effect of hypothermia in
an elderly postoperative patient?
A. Hypotension
B. Tachycardia
C. Rapid, shallow respirations
D. Bradycardia - Answer -D
What should you communicate to Mrs. Taylor about the specific benefits of deep
breathing and coughing after surgery? Select all that apply.
A. Deep breathing exercises hyperventilate the alveoli and prevent them from collapsing
B. Coughing helps strengthen any compromised abdominal muscles
C. Deep breathing is helpful for relaxation after surgery
D. Coughing helps remove retained mucus from the respiratory tract
E.Deep breathing improves the oxygenation of body tissues
F. Deep breathing speeds the healing process
G. Deep breathing improves lung expansion and volume
H. Deep breathing helps expel anesthetic gases and mucus from the airway - Answer -
A, D, E, G, H
A PACU nurse is caring for multiple postoperatuve clients who are at risk for shock.
Which of the following lab values necessitate that the nurse contact the PCP?
A. Sodium: 150 mEq/L (150 mmol/L)
B. Creatinine: 0.9 mg/dL (68.6 mcmol/L)
C. White blood cell count: 11,000/mm3 (11 × 109/L)
D. Lactate: 54 mg/dL (6 mmol/L) - Answer -D
A postoperative client is receiving dopamine for the treatment of shock. Which of the
following assessment findings necessitate that the nurse contacts the PCP
immediately?
A. Blood pressure of 98/68 mm Hg
B. Report of chest heaviness
C. Urine output of 32 mL/hr
D. Pedal pulses 1+/4+ bilaterally - Answer -B
