Perioperative
The nurse requests the client to sign a surgical informed consent form for an emergency
appendectomy. Which statement by the client indicates further teaching is needed?
1. "I will be glad when this is over so I can go home today."
2. "I will not be able to eat or drink anything prior to my surgery."
3. "I can practice relaxing by listening to my favorite music."
4. "I will need to get up and walk as soon as possible." - answer1. "I will be glad when
this is over so I can go home today."
Rationale: the client will be in the hospital for a few days. This is not a day-surgery
procedure. The client needs more teaching.
The nurse in the holding area of the surgery department is interviewing a client who
requests to keep his religious medal on during surgery. Which intervention should the
nurse implement?
1. Notify the surgeon about the client's request to wear the medal.
2. Tape the medal to the client and allow the client to wear the medal.
3. Request the family member take the medal prior to surgery.
4. Explain taking the medal to surgery is against the policy. - answer2. Tape the medal
to the client and allow the client to wear the medal.
Rationale: the medal should be taped and the client should be allowed to wear the
medal because meeting spiritual needs is essential to the client's care.
The nurse must obtain surgical consent forms for the scheduled surgery. Which client
would not be able to consent legally to surgery?
1. The 65-year-old client who cannot read or write.
2. The 30-year-old client who does not understand English.
3. The 16-year-old client who has a fractured ankle.
,4. The 80-year-old client who is not oriented to the day. - answer3. The 16-year-old
client who has a fractured ankle.
Rationale: A 16-year-old client is not legally able to give permission for surgery unless
the adolescent has been given an emancipated status by a judge.
The nurse is preparing a client for surgery. Which intervention should the nurse
implement first?
1. Check the permit for the spouse's signature.
2. Take and document intake and output.
3. Administer the "on call" sedative.
4. Complete the preoperative checklist. - answer4. Complete the preoperative checklist.
Rationale: Completing the preoperative checklist has the highest priority to ensure all
details are completed without omissions.
The nurse is interviewing a surgical client in the holding area. Which information should
the nurse report to the anesthesiologist? (Select all that apply)
1. The client has loose, decayed teeth.
2. The client is experiencing anxiety.
3. The client smokes two (2) packs of cigarettes a day.
4. The client has had a chest x-ray which does not show infiltrates.
5. The client reports using herbs. - answer1. The client has loose, decayed teeth.
3. The client smokes two (2) packs of cigarettes a day.
5. the client reports using herbs.
Rationale: 1. loose teeth or caries need to be reported to the anesthesiologist so he or
she can make provisions to prevent breaking the teeth and causing the client to
possible aspirate pieces. 3. Smokers are at higher risk for complications from
anesthesia. 5. Herbs - for example, St. John's wort, licorice, and ginkgo - have serious
interactions with anesthis and with bodily functions such as coagulation.
Which task would be most appropriate for the nurse to delegate to the unlicensed
assistive personnel (UAP)?
, 1. Complete the preoperative checklist.
2. Assess the client's preoperative vital signs.
3. Teach the client about coughing and deep breathing.
4. Assist the client to remove clothing and jewelry. - answer4. Assist the client to
remove clothing and jewelry.
Rationale: The nurse cannot delegate assessing or teaching to a UAP. The UAP can
remove clothing and jewelry. The preoperative checklist requires analysis, which cannot
be delegated.
The nurse is assessing a client in the day surgery unit who states, "I am really afraid of
having this surgery. I'm afraid of what they will find." Which statement would be the best
therapeutic response by the nurse?
1. "Don't worry about your surgery. It is safe."
2. "Tell me why you're worried about your surgery."
3. "Tell me about your fears of having this surgery."
4. "I understand how you feel. Surgery is frightening." - answer3. "Tell me about your
fears of having this surgery."
Rationale: 1. giving false reassurance. 2. "Why" is never therapeutic. 3. This statement
focuses on the emotion which the client identified and is therapeutic. 4. This statement
belittles the client's fear, and no person understands how another person feels.
The 68-year-old client scheduled for intestinal surgery does not have clear fecal
contents after three (3) tap water enemas. Which intervention should the nurse
implement first?
1. Notify the surgeon of the client's status
2. Continue giving enemas until clear
3. Increase the client's IV fluid rate
4. Obtain STAT serum electrolytes - answer1. Notify the surgeon of the client's status
Rationale: 1. The nurse should contact the surgeon because the client is at risk for fluid
and electrolyte imbalance after three (3) enemas. Clients who are NPO, elderly clients,
and pediatric clients are more likely to have these imbalances. 2. Administering more
enemas will put the client at further risk for fluid volume deficit and electrolyte
The nurse requests the client to sign a surgical informed consent form for an emergency
appendectomy. Which statement by the client indicates further teaching is needed?
1. "I will be glad when this is over so I can go home today."
2. "I will not be able to eat or drink anything prior to my surgery."
3. "I can practice relaxing by listening to my favorite music."
4. "I will need to get up and walk as soon as possible." - answer1. "I will be glad when
this is over so I can go home today."
Rationale: the client will be in the hospital for a few days. This is not a day-surgery
procedure. The client needs more teaching.
The nurse in the holding area of the surgery department is interviewing a client who
requests to keep his religious medal on during surgery. Which intervention should the
nurse implement?
1. Notify the surgeon about the client's request to wear the medal.
2. Tape the medal to the client and allow the client to wear the medal.
3. Request the family member take the medal prior to surgery.
4. Explain taking the medal to surgery is against the policy. - answer2. Tape the medal
to the client and allow the client to wear the medal.
Rationale: the medal should be taped and the client should be allowed to wear the
medal because meeting spiritual needs is essential to the client's care.
The nurse must obtain surgical consent forms for the scheduled surgery. Which client
would not be able to consent legally to surgery?
1. The 65-year-old client who cannot read or write.
2. The 30-year-old client who does not understand English.
3. The 16-year-old client who has a fractured ankle.
,4. The 80-year-old client who is not oriented to the day. - answer3. The 16-year-old
client who has a fractured ankle.
Rationale: A 16-year-old client is not legally able to give permission for surgery unless
the adolescent has been given an emancipated status by a judge.
The nurse is preparing a client for surgery. Which intervention should the nurse
implement first?
1. Check the permit for the spouse's signature.
2. Take and document intake and output.
3. Administer the "on call" sedative.
4. Complete the preoperative checklist. - answer4. Complete the preoperative checklist.
Rationale: Completing the preoperative checklist has the highest priority to ensure all
details are completed without omissions.
The nurse is interviewing a surgical client in the holding area. Which information should
the nurse report to the anesthesiologist? (Select all that apply)
1. The client has loose, decayed teeth.
2. The client is experiencing anxiety.
3. The client smokes two (2) packs of cigarettes a day.
4. The client has had a chest x-ray which does not show infiltrates.
5. The client reports using herbs. - answer1. The client has loose, decayed teeth.
3. The client smokes two (2) packs of cigarettes a day.
5. the client reports using herbs.
Rationale: 1. loose teeth or caries need to be reported to the anesthesiologist so he or
she can make provisions to prevent breaking the teeth and causing the client to
possible aspirate pieces. 3. Smokers are at higher risk for complications from
anesthesia. 5. Herbs - for example, St. John's wort, licorice, and ginkgo - have serious
interactions with anesthis and with bodily functions such as coagulation.
Which task would be most appropriate for the nurse to delegate to the unlicensed
assistive personnel (UAP)?
, 1. Complete the preoperative checklist.
2. Assess the client's preoperative vital signs.
3. Teach the client about coughing and deep breathing.
4. Assist the client to remove clothing and jewelry. - answer4. Assist the client to
remove clothing and jewelry.
Rationale: The nurse cannot delegate assessing or teaching to a UAP. The UAP can
remove clothing and jewelry. The preoperative checklist requires analysis, which cannot
be delegated.
The nurse is assessing a client in the day surgery unit who states, "I am really afraid of
having this surgery. I'm afraid of what they will find." Which statement would be the best
therapeutic response by the nurse?
1. "Don't worry about your surgery. It is safe."
2. "Tell me why you're worried about your surgery."
3. "Tell me about your fears of having this surgery."
4. "I understand how you feel. Surgery is frightening." - answer3. "Tell me about your
fears of having this surgery."
Rationale: 1. giving false reassurance. 2. "Why" is never therapeutic. 3. This statement
focuses on the emotion which the client identified and is therapeutic. 4. This statement
belittles the client's fear, and no person understands how another person feels.
The 68-year-old client scheduled for intestinal surgery does not have clear fecal
contents after three (3) tap water enemas. Which intervention should the nurse
implement first?
1. Notify the surgeon of the client's status
2. Continue giving enemas until clear
3. Increase the client's IV fluid rate
4. Obtain STAT serum electrolytes - answer1. Notify the surgeon of the client's status
Rationale: 1. The nurse should contact the surgeon because the client is at risk for fluid
and electrolyte imbalance after three (3) enemas. Clients who are NPO, elderly clients,
and pediatric clients are more likely to have these imbalances. 2. Administering more
enemas will put the client at further risk for fluid volume deficit and electrolyte
