NUR 155 Test 2
1. The nurse has just reassessed the condition of a post- A. Urine output of
operative client who was admitted 1 hour ago to the 20ml/hour
surgical unit. The nurse plans to monitor which para-
meter most carefully during the next hour? Rationale:
A. Urine output of 20ml/hour Urine output should be
B. Temperature of 37.6 C maintained at a minimum
C. Blood pressure of 114/70 of 30mL/hour for an adult.
D. Serous drainage on the surgical dressing An output of less than that
for each of 2 consecutive
hours should be reported
to the health care provider.
2. A postoperative client asks the nurse why it is so impor- A. Pneumonia
tant to deep-breathe and cough after surgery. When
formulating a response, the nurse incorporates the Rationale:
understanding that retained pulmonary secretions in Postoperative respiratory
a postoperative client can lead to which condition? problems are atelecta-
A. Pneumonia sis, pneumonia and pul-
B. Hypoxemia monary emboli. Pneumo-
C. Fluid imbalance nia is the inflammation
D. Pulmonary embolism of lung tissue that caus-
es productive cough, dys-
pnea, and lung crackles
and can be caused by the
retention of pulmonary se-
cretions.
3. The nurse is developing a plan of care for a client C. Have the client void
scheduled for surgery. The nurse should include which immediately before going
activity in the nursing care plan for the client on the into surgery
day of surgery?
A. Avoid oral hygiene and rinsing with mouthwash Rationale:
, NUR 155 Test 2
B. Verify that the client has not eaten for the last 24 The nurse would assist the
hours client to void immediately
C. Have the client void immediately before going into before surgery so that the
surgery bladder will be empty. Oral
D. Report immediately any slight increase in BP or hygiene is allowed, but the
pulse client should not swallow
any water. The client usual-
ly has a restriction of food
and fluids for 6 to 8 hours
before surgery instead of
24 hours. A slight increase
in BP and pulse is com-
mon during the preopera-
tive period due to anxiety.
4. A client with a perforated gastric ulcer is scheduled for D. Obtain a telephone con-
surgery. The client cannot sign the operative consent sent from a family mem-
form because of sedation from opioid analgesics that ber, following agency pol-
have been administered. The nurse should take which icy
most appropriate action in the care of this client?
A. Obtain a court order for the surgery. Rationale:
B. Have the charge nurse sign the informed consent Every effort should be
immediately made to obtain permis-
C. Send the client to surgery without the consent form sion from a responsible
being signed family member to perform
D. Obtain a telephone consent from a family member, surgery if the client is un-
following agency policy able to sign the consent
form. A telephone con-
sent must be witnessed
by two persons who hear
the family member's oral
consent. The two witness-
, NUR 155 Test 2
es then sign the consent
with the name of the fam-
ily member, noting that
an oral consent was ob-
tained. Consent is not in-
formed if it is obtained
from a client who is con-
fused, unconscious, men-
tally incompetent, or un-
der the influence of seda-
tives. In an emergency the
client may not be able
to sign and family mem-
bers may not be available.
In this situation, a health
care provider is permitted
legally to perform surgery
without consent, but tin
this case it is not an emer-
gency. Agency policies re-
garding informed consent
should always be followed.
5. A preoperative client expresses anxiety to the nurse C. "Can you share with
about upcoming surgery. Which response by the nurse me what you've been told
is most likely to stimulate further discussion between about your surgery?"
the client and the nurse?
A. "If it's any help, everyone is nervous before Rationale:
surgery." Explanations should begin
B. "I will be happy to explain the entire surgical proce- with the information that
dure with you." the client knows. By pro-
C. "Can you share with me what you've been told about viding the client with in-
, NUR 155 Test 2
your surgery?" dividualized explanations
D. "Let me tell you about the care you'll receive after of care and procedures,
surgery and the amount of pain you can anticipate". the nurse can assist the
client in handling anxi-
ety and fear for a smooth
preoperative experience.
Clients who are calm and
emotionally prepared for
surgery withstand anes-
thesia better and experi-
ence fewer postoperative
complications.
6. The nurse is conducting preoperative teaching with a D. The best results are
client about the use of an incentive spirometer. The achieved when sitting up
nurse should include which piece of information in or with the head of the bed
discussions with the client? elevated 45 to 90 degrees
A. Inhale as rapidly as possible
B. Keep a loose seal between the lips and the mouth- Rationale:
piece For optimal lung ex-
C. After maximum inspiration, hold the breath for 15 pansion with the in-
seconds and exhale. centive spirometer, the
D. The best results are achieved when sitting up or with client should assume the
the head of the bed elevated 45 to 90 degrees semi-Fowlers or high
fowler's position. The
mouthpiece should be
covered completely and
tightly while the client in-
hales slowly, with a con-
stant flow through the unit.
The breath should be held
1. The nurse has just reassessed the condition of a post- A. Urine output of
operative client who was admitted 1 hour ago to the 20ml/hour
surgical unit. The nurse plans to monitor which para-
meter most carefully during the next hour? Rationale:
A. Urine output of 20ml/hour Urine output should be
B. Temperature of 37.6 C maintained at a minimum
C. Blood pressure of 114/70 of 30mL/hour for an adult.
D. Serous drainage on the surgical dressing An output of less than that
for each of 2 consecutive
hours should be reported
to the health care provider.
2. A postoperative client asks the nurse why it is so impor- A. Pneumonia
tant to deep-breathe and cough after surgery. When
formulating a response, the nurse incorporates the Rationale:
understanding that retained pulmonary secretions in Postoperative respiratory
a postoperative client can lead to which condition? problems are atelecta-
A. Pneumonia sis, pneumonia and pul-
B. Hypoxemia monary emboli. Pneumo-
C. Fluid imbalance nia is the inflammation
D. Pulmonary embolism of lung tissue that caus-
es productive cough, dys-
pnea, and lung crackles
and can be caused by the
retention of pulmonary se-
cretions.
3. The nurse is developing a plan of care for a client C. Have the client void
scheduled for surgery. The nurse should include which immediately before going
activity in the nursing care plan for the client on the into surgery
day of surgery?
A. Avoid oral hygiene and rinsing with mouthwash Rationale:
, NUR 155 Test 2
B. Verify that the client has not eaten for the last 24 The nurse would assist the
hours client to void immediately
C. Have the client void immediately before going into before surgery so that the
surgery bladder will be empty. Oral
D. Report immediately any slight increase in BP or hygiene is allowed, but the
pulse client should not swallow
any water. The client usual-
ly has a restriction of food
and fluids for 6 to 8 hours
before surgery instead of
24 hours. A slight increase
in BP and pulse is com-
mon during the preopera-
tive period due to anxiety.
4. A client with a perforated gastric ulcer is scheduled for D. Obtain a telephone con-
surgery. The client cannot sign the operative consent sent from a family mem-
form because of sedation from opioid analgesics that ber, following agency pol-
have been administered. The nurse should take which icy
most appropriate action in the care of this client?
A. Obtain a court order for the surgery. Rationale:
B. Have the charge nurse sign the informed consent Every effort should be
immediately made to obtain permis-
C. Send the client to surgery without the consent form sion from a responsible
being signed family member to perform
D. Obtain a telephone consent from a family member, surgery if the client is un-
following agency policy able to sign the consent
form. A telephone con-
sent must be witnessed
by two persons who hear
the family member's oral
consent. The two witness-
, NUR 155 Test 2
es then sign the consent
with the name of the fam-
ily member, noting that
an oral consent was ob-
tained. Consent is not in-
formed if it is obtained
from a client who is con-
fused, unconscious, men-
tally incompetent, or un-
der the influence of seda-
tives. In an emergency the
client may not be able
to sign and family mem-
bers may not be available.
In this situation, a health
care provider is permitted
legally to perform surgery
without consent, but tin
this case it is not an emer-
gency. Agency policies re-
garding informed consent
should always be followed.
5. A preoperative client expresses anxiety to the nurse C. "Can you share with
about upcoming surgery. Which response by the nurse me what you've been told
is most likely to stimulate further discussion between about your surgery?"
the client and the nurse?
A. "If it's any help, everyone is nervous before Rationale:
surgery." Explanations should begin
B. "I will be happy to explain the entire surgical proce- with the information that
dure with you." the client knows. By pro-
C. "Can you share with me what you've been told about viding the client with in-
, NUR 155 Test 2
your surgery?" dividualized explanations
D. "Let me tell you about the care you'll receive after of care and procedures,
surgery and the amount of pain you can anticipate". the nurse can assist the
client in handling anxi-
ety and fear for a smooth
preoperative experience.
Clients who are calm and
emotionally prepared for
surgery withstand anes-
thesia better and experi-
ence fewer postoperative
complications.
6. The nurse is conducting preoperative teaching with a D. The best results are
client about the use of an incentive spirometer. The achieved when sitting up
nurse should include which piece of information in or with the head of the bed
discussions with the client? elevated 45 to 90 degrees
A. Inhale as rapidly as possible
B. Keep a loose seal between the lips and the mouth- Rationale:
piece For optimal lung ex-
C. After maximum inspiration, hold the breath for 15 pansion with the in-
seconds and exhale. centive spirometer, the
D. The best results are achieved when sitting up or with client should assume the
the head of the bed elevated 45 to 90 degrees semi-Fowlers or high
fowler's position. The
mouthpiece should be
covered completely and
tightly while the client in-
hales slowly, with a con-
stant flow through the unit.
The breath should be held
