Test bank
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 - ANSa. Change in behavior
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 - ANSd. Use of multiple herbs and supplements
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 - ANSc. Older adult who lives at
home despite some memory loss
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. - ANSa. Assess the client for anxiety.
A preoperative nurse is reviewing morning laboratory values on four clients waiting for surgery.
Which result warrants immediate communication with the surgical team?
a. Creatinine: 1.2 mg/dL
b. Hemoglobin: 14.8 mg/dL
,c. Potassium: 2.9 mEq/L
d. Sodium: 134 mEq/L - ANSc. Potassium: 2.9 mEq/L
A potassium of 2.9 mEq/L is critically low and can affect cardiac and respiratory status.
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. - ANSb. Do not have the client sign
the consent and call the surgeon.
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. - ANSb. Demonstrate how to splint the incision.
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. - ANSb. Be sure to
wash the area where you will have surgery very thoroughly.
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. - ANSb. There is no redness,
warmth, or drainage at the insertion site.
A client waiting for surgery is very anxious. What intervention can the nurse delegate to the
unlicensed assistive personnel (UAP)?
, a. Assess the clients anxiety.
b. Give the client a back rub.
c. Remind the client to turn.
d. Teach about postoperative care. - ANSb. Give the client a back rub.
A client who collapsed during dinner in a restaurant arrives in the emergency department. The
client is going to surgery to repair an abdominal aortic aneurysm. What medication does the
nurse prepare to administer as a priority for this client?
a. Hydroxyzine (Atarax)
b. Lorazepam (Ativan)
c. Metoclopramide (Reglan)
d. Morphine sulfate - ANSc. Metoclopramide (Reglan)
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 nurses aide.
c. Give the client a bedpan or urinal to use.
d. Insert a urinary catheter now instead of waiting. - ANSc. Give the client a bedpan or urinal to
use.
A student is caring for clients in the preoperative area. The nurse contacts the surgeon about a
client whose heart rate is 120 beats/min. After consulting with the surgeon, the nurse
administers a beta blocker to the client. The student asks why this was needed. What response
by the nurse is best?
a. A rapid heart rate requires more effort by the heart.
b. Anesthesia has bad effects if the client is tachycardic.
c. The client may have an undiagnosed heart condition.
d. When the heart rate goes up, the blood pressure does too. - ANSa. A rapid heart rate
requires more effort by the heart.
The perioperative nurse manager and the postoperative unit manager are concerned about the
increasing number of surgical infections in their hospital. What action by the managers is best?
a. Audit charts to see if the Surgical Care Improvement Project (SCIP) outcomes were met.
b. Encourage staff on both units to provide peer pressure to adhere to hand hygiene policy.
c. Hold educational meetings with the nursing and surgical staff on infection prevention.
d. Monitor staff on both units for consistent adherence to established hand hygiene practices. -
ANSa. Audit charts to see if the Surgical Care Improvement Project (SCIP) outcomes were met.
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 - ANSa. Change in behavior
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 - ANSd. Use of multiple herbs and supplements
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 - ANSc. Older adult who lives at
home despite some memory loss
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. - ANSa. Assess the client for anxiety.
A preoperative nurse is reviewing morning laboratory values on four clients waiting for surgery.
Which result warrants immediate communication with the surgical team?
a. Creatinine: 1.2 mg/dL
b. Hemoglobin: 14.8 mg/dL
,c. Potassium: 2.9 mEq/L
d. Sodium: 134 mEq/L - ANSc. Potassium: 2.9 mEq/L
A potassium of 2.9 mEq/L is critically low and can affect cardiac and respiratory status.
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. - ANSb. Do not have the client sign
the consent and call the surgeon.
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. - ANSb. Demonstrate how to splint the incision.
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. - ANSb. Be sure to
wash the area where you will have surgery very thoroughly.
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. - ANSb. There is no redness,
warmth, or drainage at the insertion site.
A client waiting for surgery is very anxious. What intervention can the nurse delegate to the
unlicensed assistive personnel (UAP)?
, a. Assess the clients anxiety.
b. Give the client a back rub.
c. Remind the client to turn.
d. Teach about postoperative care. - ANSb. Give the client a back rub.
A client who collapsed during dinner in a restaurant arrives in the emergency department. The
client is going to surgery to repair an abdominal aortic aneurysm. What medication does the
nurse prepare to administer as a priority for this client?
a. Hydroxyzine (Atarax)
b. Lorazepam (Ativan)
c. Metoclopramide (Reglan)
d. Morphine sulfate - ANSc. Metoclopramide (Reglan)
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 nurses aide.
c. Give the client a bedpan or urinal to use.
d. Insert a urinary catheter now instead of waiting. - ANSc. Give the client a bedpan or urinal to
use.
A student is caring for clients in the preoperative area. The nurse contacts the surgeon about a
client whose heart rate is 120 beats/min. After consulting with the surgeon, the nurse
administers a beta blocker to the client. The student asks why this was needed. What response
by the nurse is best?
a. A rapid heart rate requires more effort by the heart.
b. Anesthesia has bad effects if the client is tachycardic.
c. The client may have an undiagnosed heart condition.
d. When the heart rate goes up, the blood pressure does too. - ANSa. A rapid heart rate
requires more effort by the heart.
The perioperative nurse manager and the postoperative unit manager are concerned about the
increasing number of surgical infections in their hospital. What action by the managers is best?
a. Audit charts to see if the Surgical Care Improvement Project (SCIP) outcomes were met.
b. Encourage staff on both units to provide peer pressure to adhere to hand hygiene policy.
c. Hold educational meetings with the nursing and surgical staff on infection prevention.
d. Monitor staff on both units for consistent adherence to established hand hygiene practices. -
ANSa. Audit charts to see if the Surgical Care Improvement Project (SCIP) outcomes were met.
