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A client is recovering well 24 hours after cranial surgery but is fatigued. The surgeon advances
the client from nothing-by-mouth (NPO) status to clear liquids. The nurse knows that which
information is least reliable in determining the client's readiness to take in fluids?
a. Presence of a swallow reflex
b. Appetite
c. Presence of bowel sounds
d. Absence of nausea - correct answer Appetite
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?
a. Have the client practice postoperative breathing exercises.
b. Verify that the client has not eaten for the past 24 hours.
c. Administer all the daily medications.
d. Ensure that the client has voided. - correct answer D. Ensure that the client has voided
What client teaching will the nurse provide regarding postoperative leg exercises, to minimize
the risk for development of deep vein thrombosis after surgery?
a. Begin exercises by sitting at a 90-degree angle on the side of the bed.
b. Point toes of one foot toward bottom of bed, then point toes of same leg toward their face.
Repeat several times, then switch legs.
c. Bend knee, and push heel of foot into the bed until the calf and thigh muscles contract.
Repeat several times, then switch legs.
d. Only perform each exercise one time to prevent overuse. - correct answer b. Point toes of
one foot toward bottom of bed, then point toes of same leg toward their face. Repeat several
times, then switch legs
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?
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a. A beta-blocker
b. An antibiotic
c. An anticoagulant
d. A calcium channel blocker - correct answer c. An anticoagulant
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?
a. Osteoporosis
b. Pacemaker
c. Alcohol Abuse
d. Peptic Ulcer Disease - correct answer C. Alcohol abuse
A client is scheduled for surgery at noon. The surgeon is delayed and the surgery is now
scheduled for 3:00 PM. How will the nurse plan to administer the preoperative prophylactic
antibiotic?
a.Give at noon as originally prescribed.
b.Adjust the administration time to be given within one hour prior to surgery.
c.Cancel orders; preoperative prophylactic antibiotics are given optionally.
d.Hold the preoperative antibiotic so it can be administered immediately following surgery. -
correct answer b.Adjust the administration time to be given within one hour prior to surgery.
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?
Select one:
a.Avoid oral hygiene and rinsing with mouthwash.
b.Verify that the client has not eaten for the last 24 hours.
c.Report immediately any slight increase in blood pressure or pulse.
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d.Have the client void immediately before going into surgery. - correct answer d.Have the client
void immediately before going into surgery.
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?
a. Keep a loose seal between the lips and the mouthpiece.
b. Inhale as rapidly as possible.
c. The best results are achieved when sitting up or with the head of the bed elevated 45 to 90
degrees.
d. After maximum inspiration, hold the breath for 15 seconds and exhale. - correct answer
c.The best results are achieved when sitting up or with the head of the bed elevated 45 to 90
degrees.
The PACU nurse caring for a client with a nasogastric (NG) tube notes 300 mL of bright red
blood has collected. What is the appropriate nursing action?
Select one:
a. Call the client's surgeon to report the drainage.
b. Document as a normal finding.
c. Place the client in Trendelenburg position.
d. Immediately remove the NG tube. - correct answer a.Call the client's surgeon to report the
drainage.
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?
Select one:
a. Blood pressure of 100/70 mm Hg
b. Serous drainage on the surgical dressing
c. Temperature of 37.6°C (99.6°F)
d. Urinary output of 20 mL/hour - correct answer d. Urinary output of 20 mL/hour
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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?
a. Apply a sterile dressing soaked with normal saline.
b. Apply a sterile dressing soaked in povidone-iodine.
c. Irrigate the wound and apply a sterile dry dressing.
d. Leave the incision open to the air to dry the area. - correct answer a. Apply a sterile dressing
soaked with normal saline.
The nurse is providing preoperative teaching to a client scheduled for a cholecystectomy (gall
bladder removal). Which intervention would be of highest priority in the preoperative teaching
plan?
a. Assessing the client's understanding of the surgical procedure
b. Teaching leg exercises
c. Providing instructions regarding fluid restrictions
d. Teaching coughing and deep breathing exercises - correct answer d. Teaching coughing and
deep breathing exercises
The nurse is caring for four clients who will undergo surgery today. Which client does the nurse
recognize as at highest risk for surgical complication?
Select one:
a. 64-year-old who has just received pre-surgical prophylactic antibiotics
b. 58-year-old who has well-controlled Type II diabetes
c. 52-year-old who takes aspirin daily
d. 69-year-old who will be discharged after surgery to an extended care facility - correct answer
c. 52-year-old who takes aspirin daily
When a client is transferred from the postanesthesia care unit and arrives on the surgical unit,
which should be the first action taken by the nurse?