NCLEX PERI OP QUESTIONS AND ANSWERS /2020>2021 LATEST UPDATE/GUARANTEE OF AN A+

NCLEX PERI OP QUESTIONS AND ANSWERS The nurse has just reassessed the condition of a postoperative client who was admitted 1 hour ago to the surgical unit. The nurse plans to monitor which parameter most carefully during the next hour? 1. Urinary output of 20 mL/hour 2. Temperature of 37.6°C (99.6°F) 3. Blood pressure of 100/70 mm Hg 4. Serous drainage on the surgical dressing The nurse is teaching a client about coughing and deep-breathing techniques to prevent postoperative complications. Which statement is most appropriate for the nurse to make to the client at this time as it relates to these techniques? 1. "Use of an incentive spirometer will help prevent pneumonia." 2. "Close monitoring of your oxygen saturation will detect hypoxemia." 3. "Administration of intravenous fluids will prevent or treat fluid imbalance." 4. "Early ambulation and administration of blood thinners will prevent pulmonary embolism." The nurse is creating a plan of care for a client scheduled for surgery. The nurse should include which activity in the nursing care plan for the client on the day of surgery? 1. Avoid oral hygiene and rinsing with mouthwash. 2. Verify that the client has not eaten for the last 24 hours. 3. Have the client void immediately before going into surgery. 4. Report immediately any slight increase in blood pressure or pulse. A client with a gastric ulcer is scheduled for surgery. The client cannot sign the operative consent form because of sedation from opioid analgesics that have been administered. The nurse should take which most appropriate action in the care of this client? 1. Obtain a court order for the surgery. 2. Have the charge nurse sign the informed consent immediately. 3. Send the client to surgery without the consent form being signed. 4. Obtain a telephone consent from a family member, following agency policy. A preoperative client expresses anxiety to the nurse about upcoming surgery. Which response by the nurse is most likely to stimulate further discussion between the client and the nurse? 1. "If it's any help, everyone is nervous before surgery." 2. "I will be happy to explain the entire surgical procedure to you." 3. "Can you share with me what you've been told about your surgery?" 4. "Let me tell you about the care you'll receive after surgery and the amount of pain you can anticipate." The nurse is conducting preoperative teaching with a client about the use of an incentive spirometer. The nurse should include which piece of information in discussions with the client? 1. Inhale as rapidly as possible. 2. Keep a loose seal between the lips and the mouthpiece. 3. After maximum inspiration, hold the breath for 15 seconds and exhale. 4. The best results are achieved when sitting up or with the head of the bed elevated 45 to 90 degrees. The nurse has conducted preoperative teaching for a client scheduled for surgery in 1 week. The client has a history of arthritis and has been taking acetylsalicylic acid. The nurse determines that the client needs additional teaching if the client makes which statement? 1. "Aspirin can cause bleeding after surgery." 2. "Aspirin can cause my ability to clot blood to be abnormal." 3. "I need to continue to take the aspirin until the day of surgery." 4. "I need to check with my health care provider about the need to stop the aspirin before the scheduled surgery." The nurse assesses a client's surgical incision for signs of infection. Which finding by the nurse would be interpreted as a normal finding at the surgical site? 1. Red, hard skin 2. Serous drainage 3. Purulent drainage 4. Warm, tender skin The nurse is monitoring the status of a postoperative client in the immediate postoperative period. The nurse would become most concerned with which sign that could indicate an evolving complication? 1. Increasing restlessness 2. A pulse of 86 beats/minute 3. Blood pressure of 110/70 mm Hg 4. Hypoactive bowel sounds in all 4 quadrants Rationale: Increasing restlessness is a sign that requires continuous and close monitoring because it could indicate a potential complication, such as hemorrhage, shock, or pulmonary embolism. A blood pressure of 110/70 mm Hg with a pulse of 86 beats/minute is within normal limits. Hypoactive bowel sounds heard in all 4 quadrants are a normal occurrence in the immediate postoperative period. A client who has had abdominal surgery complains of feeling as though "something gave way" in the incisional site. The nurse removes the dressing and notes the presence of a loop of bowel protruding through the incision. Which interventions should the nurse take? Select all that apply. 1. Contact the surgeon. 2. Instruct the client to remain quiet. 3. Prepare the client for wound closure. 4. Document the findings and actions taken. 5. Place a sterile saline dressing and ice packs over the wound. 6. Place the client in a supine position without a pillow under the head. Rationale: Wound dehiscence is the separation of the wound edges. Wound evisceration is protrusion of the internal organs through an incision. If wound dehiscence or evisceration occurs, the nurse should call for help, stay with the client, and ask another nurse to contact the surgeon and obtain needed supplies to care for the client. The nurse places the client in a low Fowler's position, and the client is kept quiet and instructed not to cough. Protruding organs are covered with a sterile saline dressing. Ice is not applied because of its vasoconstrictive effect. The treatment for evisceration is usually immediate wound closure under local or general anesthesia. The nurse also documents the findings and actions taken. A client who has undergone preadmission testing has had blood drawn for serum laboratory studies, including a complete blood count, coagulation studies, and electrolytes and creatinine levels. Which laboratory result should be reported to the surgeon's office by the nurse, knowing that it could cause surgery to be postponed? 1. Hemoglobin, 8.0 g/dL (80 mmol/L) 2. Sodium, 145 mEq/L (145 mmol/L) 3. Serum creatinine, 0.8 mg/dL (70.6 mmol/L) 4. Platelets, 210,000 mm3 (210 × 109/L) The nurse receives a telephone call from the post-anesthesia care unit stating that a client is being transferred to the surgical unit. The nurse plans to take which action first on arrival of the client? 1. Assess the patency of the airway. 2. Check tubes or drains for patency. 3. Check the dressing to assess for bleeding. 4. Assess the vital signs to compare with preoperative measurements. The nurse is reviewing a surgeon's prescription sheet for a preoperative client that states that the client must be nothing by mouth (NPO) after midnight. The nurse should call the surgeon to clarify that which medication should be given to the client and not withheld? 1. Prednisone 2. Ferrous sulfate 3. Cyclobenzaprine 4. Conjugated estrogen Rationale: Prednisone is a corticosteroid. With prolonged use, corticosteroids cause adrenal atrophy, which reduces the ability of the body to withstand stress. When stress is severe, corticosteroids are essential to life. Before and during surgery, dosages may be increased temporarily and may be given parenterally rather than orally. Ferrous sulfate is an oral iron preparation used to treat iron deficiency anemia. Cyclobenzaprine is a skeletal muscle relaxant. Conjugated estrogen is an estrogen used for hormone replacement therapy in postmenopausal women. These last 3 medications may be withheld before surgery without undue effects on the client. A client has just returned to a nursing unit after an above-knee amputation of the right leg. The nurse should place the client in which position? 1. Prone 2. Reverse Trendelenburg's 3. Supine, with the residual limb flat on the bed 4. Supine, with the residual limb supported with pillows The nurse is caring for a client with a severe burn who is scheduled for an autograft to be placed on the lower extremity. The nurse creates a postoperative plan of care for the client and should include which intervention in the plan? 1. Maintain the client in a prone position. 2. Elevate and immobilize the grafted extremity. 3. Maintain the grafted extremity in a flat position. 4. Keep the grafted extremity covered with a blanket. The nurse is caring for a client who is postoperative following a pelvic exenteration and the health care provider changes the client's diet from NPO (nothing by mouth) status to clear liquids. The nurse should check which priority item before administering the diet? 1. Bowel sounds 2. Ability to ambulate 3. Incision appearance 4. Urine specific gravity A gastrectomy is performed on a client with gastric cancer. In the immediate postoperative period, the nurse notes bloody drainage from the nasogastric tube. The nurse should take which most appropriate action? 1. Measure abdominal girth. 2. Irrigate the nasogastric tube. 3. Continue to monitor the drainage. 4. Notify the health care provider (HCP) The nurse is assessing the colostomy of a client who has had an abdominal perineal resection for a bowel tumor. Which assessment finding indicates that the colostomy is beginning to function? 1. The passage of flatus 2. Absent bowel sounds 3. The client's ability to tolerate food 4. Bloody drainage from the colostomy The nurse is reviewing the blood tests of a generally healthy client who is scheduled for orthopedic surgery under general anesthesia. Besides a complete blood count (CBC), what preadmission blood tests would the preoperative nurse expect to be prescribed? Select all that apply. 1. D-dimer assay Clotting studies 3. Glucose fasting Electrolyte levels 5. Arterial blood gas (ABG) Serum creatinine and blood urea nitrogen (BUN) levels The nurse is discharging a client after an arthroscopy. The nurse needs to teach the client to watch for which potential complications? Select all that apply. 1. Backache Infection 3. Swelling Thrombophlebitis 5. Decreased appetite Increased joint pain related to mechanical injury The nurse in a surgical unit receives a postoperative client from the postanesthesia care unit. After the initial assessment of the client, the nurse should plan to continue with postoperative assessment activities how often? 1. Every hour for 2 hours and then every 4 hours as needed 2. Every 30 minutes for the first hour, every hour for 2 hours, and then every 4 hours as needed 3. Every 15 minutes for the first hour, every 30 minutes for 2 hours, every hour for 4 hours, and then every 4 hours as needed 4. Every 5 minutes for the first half-hour, every 15 minutes for 2 hours, every 30 minutes for 4 hours, and then every hour as needed A client is admitted to a surgical unit postoperatively with a wound drain in place. Which actions should the nurse take in the care of the drain? Select all that apply. Check the drain for patency. 2. Observe for bright red bloody drainage. 3. Clamp the drain for 15 minutes every hour. 4. Curl the drain tightly, and tape it firmly to the body. Maintain aseptic technique when emptying the drain. The nurse is developing a plan of care for a preoperative client who has a latex allergy. Which intervention should be included in the plan? 1. Avoid using medications from glass ampules. 2. Use medications that are from ampules with rubber stoppers. 3. Avoid using intravenous tubing that is made of polyvinyl chloride. 4. Apply a cloth barrier to the client's arm under a blood pressure cuff when taking the blood pressure. A client is admitted to the ambulatory surgery center for elective surgery. The nurse asks the client whether any food, fluid, or medication was taken today. Which medication, if taken by the client, should indicate to the nurse the need to contact the health care provider? 1. A beta-blocker 2. An antibiotic 3. An anticoagulant 4. A calcium-channel blocker The home care nurse visits a client to perform a dressing change on a leg ulcer. The client has diabetes mellitus and a history of cardiac disease and is taking one aspirin daily in addition to other medications as prescribed. The client tells the nurse that dental surgery is scheduled and asks the nurse whether the aspirin should be discontinued. The nurse should make which statement to the client? 1. "The pharmacist should be called." 2. "There is no risk to having such a minor surgery while taking aspirin." 3. "Aspirin has no effect on the surgical procedure and may minimize discomfort." 4. "Dental surgery can safely be done usually 10 days after stopping the aspirin, depending on the health care provider's preference." The nurse is providing preoperative teaching to a client scheduled for a cholecystectomy. Which intervention would be of highest priority in the preoperative teaching plan? 1. Teaching leg exercises 2. Teaching coughing and deep breathing exercises 3. Providing instructions regarding fluid restrictions 4. Assessing the client's understanding of the surgical procedure A client who has undergone radical neck dissection is experiencing problems with verbal communication related to postoperative hoarseness. The nurse should formulate which outcome as the most appropriate goal for this client problem? 1. Uses nonverbal communication only 2. Describes that hoarseness will be permanent 3. Initiates communication only when necessary 4. Incorporates nonverbal forms of communication as needed A preoperative client has received a dose of scopolamine as prescribed by the anesthesiologist. The nurse should assess the client for which anticipated side effect of this medication? 1. Diaphoresis 2. Pupillary constriction 3. Increased urinary output 4. Dry oral mucous membranes The nurse is caring for a postoperative client who has just returned from the post anesthesia care unit after having nasal surgery. What priority action is essential for the nurse to perform? 1. Assessing how often the client swallows 2. Checking vital signs per agency protocol 3. Viewing the external packing for bleeding 4. Determining if the client can breathe through the unaffected nostril Rationale: Assessing how often the client swallows after nasal surgery is a priority action because this is a sign of bleeding. Checking vital signs and looking at the external packing for bleeding are important but not a priority for nasal surgery clients. Determining if the client can breathe through the unaffected nostril is an essential reasonable postoperative assessment. A client scheduled for surgery receives a dose of scopolamine. The nurse expects to note which side effects of the medication? Select all that apply. 1. Dry mouth 2. Diaphoresis 3. Profuse diarrhea 4. Pupillary dilation 5. Excessive urination Rationale: Scopolamine is an anticholinergic medication that causes frequent side effects of dry mouth, urinary retention, decreased sweating, and dilation of the pupils. The other options are incorrect and are not side effects of this medication. The nurse is providing discharge instructions to the client who has had a pneumonectomy and prepares a list of postoperative instructions for the client. Which intervention should the nurse include in the list? 1. Report any signs of respiratory infection to the health care provider. 2. Avoid breathing exercises to allow the diaphragm to strengthen. 3. Avoid lifting any objects greater than 30 pounds for at least 3 weeks. 4. Contact the health care provider if any feelings of weakness and fatigue occur. A postoperative client with a large abdominal wound requiring frequent dressing changes is starting to develop skin irritation in the area where the dressing tape is applied to the skin. The nurse determines that the client would benefit most from which measure? 1. Obtaining a wound culture 2. The use of Montgomery straps 3. The use of hypoallergenic tape 4. Cleansing the irritated area with povidone-iodine 1. Appetite 2. Absence of nausea 3. Presence of bowel sounds 4. Presence of a swallow reflex Rationale: To begin to tolerate oral intake after cranial or any other type of surgery, the client must have bowel sounds. The client also must have intact swallow and gag reflexes and should be free of nausea and vomiting. The client is likely to be easily fatigued, which may decrease appetite. Thus, appetite is the least reliable indicator regarding when intake should be started. The nurse is caring for a 25-year-old client who will undergo bilateral orchidectomy for testicular cancer. Which statement by the nurse would be helpful in exploring the client's concerns about loss of reproductive ability? 1. "You must be sad that you won't be able to have children after surgery." 2. "Has the health care provider told you that you will not be able to have children?" 3. "Can you share with me any concerns about how this surgery will affect you in the future?" 4. "Do you feel that the health care provider has told you all you need to know about the upcoming surgery?" The nurse has a prescription to remove the nasogastric (NG) tube from a client on the first post-operative day after cardiac surgery. The nurse should question the prescription if which finding was noted on assessment of the client? 1. The client is drowsy. 2. Bowel sounds are absent. 3. The abdomen is slightly distended. 4. NG tube drainage is Hema-test negative. The nurse has provided discharge instructions to a client after radical vulvectomy. Which statement by the client indicates a need for further instruction? 1. "I should avoid sexual activity for 4 to 6 weeks." 2. "I should wash the perineum after each voiding." 3. "It is all right to ride in a car as much as I want, as long as I am not driving the car." 4. "I need to report any redness, swelling, or drainage to the health care provider." The nurse is assigned to change the surgical dressing on a client who has undergone abdominal surgery. After removing the old dressing, the nurse assesses the surgical site. Which should be the nurse's initial action if the appearance shown in the figure is observed? Refer to Figure. 1. Document the findings. 2. Apply a sterile nonadherent dressing. 3. Redress the wound with a dry sterile dressing. 4. Ask the client to cough to assess for protrusion of the internal structures. A client arrives at the surgical unit after undergoing rhinoplasty and has a nose splint and gauze drip (moustache dressing) in place. The nurse reviews the health care provider's prescriptions and anticipates that which client position will be prescribed? 1. Sims' 2. Prone 3. Supine 4. Semi Fowler's The nurse has instructed a preoperative client using an incentive spirometer to sustain the inhaled breath for 3 seconds. When the client asks about the rationale for this action, the nurse explains that this action achieves which function? 1. Dilates the major bronchi 2. Increases surfactant production 3. Maintains inflation of the alveoli 4. Enhances ciliary action in the tracheobronchial tree A client has a risk for infection following radical vulvectomy. Therefore, the nurse should avoid which action when giving perineal care to this client? 1. Cleansing with warm tap water 2. Intermittently exposing the wound to air 3. Providing prescribed sitz-baths after the sutures are removed 4. Providing perineal care after each voiding and bowel movement Rationale: A sterile solution such as normal saline should be used for perineal care using an aseptic syringe. This should be done regularly at least twice a day and after each voiding and bowel movement. The wound is intermittently exposed to air to permit drying and to prevent maceration. Once sutures are removed, sitz baths may be prescribed to stimulate healing and for the soothing effect. In preparation for ambulation, the nurse is planning to assist a postoperative client to progress from a lying position to a sitting position. Which nursing action is appropriate to maintain the safety of the client? 1. Assess the client for signs of dizziness and hypotension. 2. Allow the client to rise from the bed to a standing position unassisted. 3. Elevate the head of the bed quickly to assist the client to a sitting position. 4. Assist the client to move quickly from the lying position to the sitting position. A client has returned to the nursing unit after an abdominal hysterectomy. The client is lying supine. To thoroughly assess the client for postoperative bleeding, what is the primary nursing action? 1. Check the heart rate. 2. Check the blood pressure. 3. Roll the client to one side and check her perineal pad. 4. Ask the client about sensation of moistness on her perineal pad. A client has received atropine sulfate intravenously during a surgical procedure. The nurse should monitor the client for which side effect of the medication in the immediate postoperative period? 1. Diarrhea 2. Bradycardia 3. Urinary retention 4. Excessive salivation The nurse is providing home care instructions to the parents of an infant who had a surgical repair of an inguinal hernia. What instruction should the nurse include to prevent infection at the surgical site? 1. Report a fever immediately. 2. Restrict the infant's physical activity. 3. Change the diapers as soon as they become damp. 4. Soak the infant in a tub bath twice a day for the next 5 days. The nurse is assessing a client who had abdominal surgery earlier in the day. Which preexisting medical condition would place the client at most risk for postoperative complications? 1. Pacemaker 4. Peptic ulcer disease 2. Osteoporosis 3. Alcohol abuse Rationale: A client with a history of alcohol abuse is at risk for liver disease, including altered metabolism and elimination of medications, impaired wound healing, and clotting and bleeding abnormalities. A client with this risk factor also would be at risk for experiencing alcohol withdrawal during the postoperative period. Clients with a pacemaker, osteoporosis, and peptic ulcer disease need to be monitored closely but are not at risk for major complications, as is the client with alcohol abuse and liver disease. An 85-year-old client is hospitalized for a fractured right hip. During the postoperative period, the client's appetite is poor and the client refuses to get out of bed. Which nursing statement would be most appropriate to make to the client? 1. "We need to give you iodine to help in hemoglobin synthesis." 2. "It is important for you to get out of bed so that calcium will go back into the bone." 3. "We need to increase your calcium intake because you are spending too much time in bed." 4. "You need to remember to turn yourself in bed every 2 hours to keep from getting so stiff." The nurse is obtaining a pulse oximetry reading from a postoperative client who appears short of breath. The client has dark fingernail polish on top of artificial nails. What is the most appropriate action? 1. Take the pulse oximetry reading from any finger. 2. Remove one of the artificial nails and then obtain the reading from the finger. 3. Obtain a pulse oximetry reading from another appropriate area, such as an earlobe. 4. Obtain fingernail polish remover, remove the polish, and then obtain the pulse oximetry reading from a finger. A client returns to the nursing unit following a pyelolithotomy for removal of a kidney stone. A Penrose drain is in place. Which action should the nurse include in the client's postoperative plan of care? 1. Positioning the client on the affected side 2. Irrigating the Penrose drain using sterile procedure 3. Changing dressings frequently around the Penrose drain 4. Weighing dressings and adding the amount to the output Which assessment finding indicates that a client who had a mastectomy is experiencing a complication related to the surgery? 1. Pain at the incisional site 2. Arm edema on the operative side 3. Sanguineous drainage in the Jackson-Pratt drain 4. Complaints of decreased sensation near the operative site An operating room nurse is positioning a client on the operating room table to prevent the client's extremities from dangling over the sides of the table. A nursing student who is observing for the day asks the nurse why this is so important. The nurse responds that this is done primarily to prevent which condition? 1. An increase in pulse rate 2. A drop in blood pressure 3. Nerve and muscle damage 4. Muscle fatigue in the extremities The nurse is preparing a preoperative client for transfer to the operating room. The nurse should take which action in the care of this client at this time? 1. Ensure that the client has voided. 2. Administer all the daily medications. 3. Verify that the client has not eaten for the past 24 hours. 4. Have the client practice postoperative breathing exercises. When performing a surgical dressing change on a client's abdominal dressing, the nurse notes an increased amount of drainage and separation of the incision line. The underlying tissue is visible to the nurse. The nurse should take which action in the initial care of this wound? 1. Leave the incision open to the air to dry the area. 2. Irrigate the wound and apply a sterile dry dressing. 3. Apply a sterile dressing soaked with normal saline. 4. Apply a sterile dressing soaked in povidone-iodine The nurse is developing a list of home care instructions for a client being discharged after a laparoscopic cholecystectomy. Which instructions should the nurse include include in the postoperative discharge plan of care? Select all that apply. 1. Wound care 2. Follow-up care 3. Activity restrictions 4. Dietary instructions 5. Deep-breathing exercises Rational: Deep-breathing exercises are taught in the preoperative period. A client has had an invasive abdominal surgery to relieve an obstruction of the common bile duct. The client's surgery is completed, and the client has been transferred to the post-anesthesia care unit (PACU). The PACU nurse observes that the client suddenly appears red in the face and appears to be coughing despite the presence of an endotracheal tube and ventilator support. What action should the PACU nurse take first? 1. Suction the client through the endotracheal tube. 2. Instruct the client in the use of an incentive spirometer. 3. Turn the client from a 30-degree lateral position to a supine position. 4. Instruct the client to use a communication board to tell the nurse what is wrong. When a client is transferred from the post-anesthesia care unit and arrives on the surgical unit, which should be the first action taken by the nurse? 1. Assess the client's pain. 2. Obtain the client's vital signs. 3. Administer oxygen to the client. 4. Check the rate of the intravenous infusion. The nurse provides instructions to a preoperative client about the use of an incentive spirometer. The nurse determines that the client needs further instruction if the client indicates that he or she will take which action? 1. Sit upright when using the device. 2. Inhale slowly, maintaining a constant flow. 3. Place the lips completely over the mouthpiece. 4. After maximal inspiration, hold the breath for 10 seconds and then exhale. A client has a prescription for continuous monitoring of oxygen saturation by pulse oximetry for a preoperative client. The nurse should perform which best action to ensure accurate readings on the oximeter? 1. Apply the sensor to a finger that is cool to the touch. 2. Apply the sensor to a finger with very dark nail polish. 3. Ask the client to limit motion in the hand attached to the pulse oximeter. 4. Place the sensor distal to an intravenous (IV) site with a continuous IV infusion. The nurse is preparing a client for surgery scheduled in two hours. Which interventions are appropriate in the preoperative period? Select all that apply. 1. Assist the client to void before transfer to the operating room. 2. Check all surgeon's prescriptions to ensure they have been carried out. 3. Teach postoperative breathing exercises before the client is premedicated. 4. Review the client's record for a history and physical report and laboratory reports. 5. Administer all the daily medications 2 hours before the scheduled time of the surgery. Rationale: Two hours before the scheduled surgery time is not the time to teach breathing exercises. This should have been accomplished earlier. The nurse does not administer all daily medications. Rather, the health care provider writes a specific prescription outlining which medications may be given with a sip of water. The nurse is caring for a client who recently returned from the operating room. On data collection, the nurse notes that the client's vital signs are blood pressure (BP), 118/70 mm Hg; pulse, 91 beats/minute; and respirations, 16 breaths/minute. Preoperative vital signs were BP, 132/88 mm Hg; pulse, 74 beats/minute; and respirations, 20 breaths/minute. Which action should the nurse plan to take first? 1. Call the surgeon immediately. 2. Shake the client gently to arouse. 3. Cover the client with a warm blanket. 4. Recheck the vital signs in 15 minutes. Which finding in a postoperative client would be of concern to the nurse? 1. Urinary output of 40 mL/hr 2. Temperature of 37.6°C (99.6°F) 3. Blood pressure of 88/52 mm Hg 4. Moderate drainage on the surgical dressing The nurse is caring for an abdominal surgical client who has a Jackson-Pratt drain in place. Which interventions should the nurse include in the plan of care for this drain? Select all that apply. 1. Secure the drain to the sheet. 2. Make sure suction is maintained. 3. Check that the drains are sutured in place. 4. Use clean technique to empty the reservoir. 5. Compress the reservoir to restore suction after emptying. 6. Record the amount and color of drainage according to agency protocol or health care provider's orders. The nurse is reviewing the health care provider's prescription sheet for a preoperative client, which states that the client must be NPO (nothing by mouth) after midnight. Which medication should the nurse clarify to be given and not withheld? 1. Atenolol 2. Atorvastatin 3. Cyclobenzaprine 4. Conjugated estrogen The nurse cares for a client who is at risk for wound dehiscence after abdominal surgery. Which action is the priority to minimize this risk? 1. Administer prescribed antibiotics. 2. Use sterile technique for dressing changes. 3. Keep sterile saline and sterile dressings at the bedside. 4. Place a pillow over the incision site during deep breathing and coughing. The nurse is caring for a client the day after a left total knee arthroplasty surgery. In reviewing the client's past medical history, the nurse notes that the client has a history of urinary incontinence and heart failure, which is managed with a potassium-retaining diuretic and a beta-adrenergic blocker. Which prescription, if not already prescribed, should the nurse contact the health care provider to obtain? 1. Daily electrolytes 2. A 12-lead electrocardiogram 3. Resume the client's dose of metoprolol 4. Insertion of an indwelling urinary catheter Rationale: According to The Joint Commission's Surgical Care Improvement Program's core measures, surgery clients on beta- blocker therapy prior to surgery should receive a beta blocker within 24 hours of surgery. Thus, option 3 is the correct option. Beta blockers have been found to decrease the risk for mortality associated with noncardiac surgery in high-risk clients. However, for treatment to be both safe and effective, dosing should begin before surgery and continue for at least 1 month after surgery. In this case, the client was already on the beta-blocker therapy prior to surgery, but it needs to be resumed postoperatively. Option 1 is incorrect, as the client is on a potassium-retaining diuretic, so hypokalemia is unlikely to occur. Option 2 is incorrect, as a 12-lead electrocardiogram would have been done prior to surgery and there is no indication that another one is needed. Option 4 is incorrect, as there is nothing that indicates an indwelling urinary catheter is necessary (history of incontinence and diuretic therapy do not necessitate an indwelling urinary catheter) and it should be avoided to prevent developing a catheter- associated urinary tract infection. The nurse cares for a client prior to surgery. The client asks the nurse, "What is the advantage of spinal anesthesia over general anesthesia for controlling my pain?" Which is the best response by the nurse? 1. "There is less risk of developing a low blood pressure." 2. "Itching, a side effect of the morphine, will be minimized." 3. "Your pain can be managed without making you as sleepy." 4. "You will be able to maintain control of your bladder function." The nurse is teaching a graduate nurse in the operating room about the components of Universal Protocol, one of The Joint Commission's National Patient Safety Goals. What specific component should the nurse include in the instructions? 1. Surgical site should be marked preoperatively. 2. Surgical sponges should be counted at the end of the surgery. 3. A time-out should be performed in the operating room before the procedure. 4. Preoperative antibiotic should be administered within 1 hour of the incision. The nurse prepares a client 1 hour prior to surgery. Which assessment finding does the nurse need to communicate to the health care provider (HCP) at this time? 1. Allergy to peanuts 2. Potassium is 3.6 mEq/L (3.6 mmol/L) 3. History of obstructive sleep apnea 4. Daily garlic capsules, last dose yesterday morning Rationale: Option 4 is the correct answer, as garlic can increase bleeding and should be discontinued for 2 to 3 weeks before surgery. Options 1 and 3 are incorrect, as they are not findings that the HCP needs to be immediately notified of because neither warrants a delay or cancellation of the surgery. Option 2 is incorrect because it is a normal potassium level. A client preparing to go home 2 days following a right mastectomy with dissection of axillary lymph nodes asks the nurse, "What should I do to minimize my chance for complications from this surgery?" Which response should the nurse make? 1. "Try to minimize moving your right arm." 2. "Examine the surgical incision once a week." 3. "Be sure to carry your purse over your right shoulder." 4. "Avoid having blood pressures taken on your right arm."