EXAM 3 TEST BANK CLINICAL SKILLS
QUESTIONS AND ANSWERS 100%
PASS
A postoperative patient has not voided for 8 hours after return to the clinical unit.
Which action should the nurse take first?
a. Perform a bladder scan.
b. Encourage increased oral fluid intake.
c. Assist the patient to ambulate to the bathroom.
d. Insert a straight catheter as indicated on the PRN order. - Answer-A
The initial action should be to assess the bladder for distention. If the bladder is
distended, providing the patient with privacy (by walking with them to the bathroom)
will be helpful. Because of the risk for urinary tract infection, catheterization should
only be done after other measures have been tried without success. There is no
indication to notify the surgeon about this common postoperative problem unless all
measures to empty the bladder are unsuccessful
The nurse is caring for a patient the first postoperative day following a laparotomy for
a small bowel obstruction. The nurse notices new bright-red drainage about 5 cm in
diameter on the dressing. Which action should the nurse take first?
a. Reinforce the dressing.
b. Apply an abdominal binder.
c. Take the patients vital signs.
d. Recheck the dressing in 1 hour for increased drainage. - Answer-C
New bright-red drainage may indicate hemorrhage, and the nurse should initially
assess the patients vital signs for tachycardia and hypotension. The surgeon should
then be notified of the drainage and the vital signs. The dressing may be changed or
reinforced, based on the surgeons orders or institutional policy. The nurse should not
wait an hour to recheck the dressing.
When caring for a patient the second postoperative day after abdominal surgery for
removal of a large pancreatic cyst, the nurse obtains an oral temperature of 100.8 F.
Which action should the nurse take first?
a. Have the patient use the incentive spirometer.
b. Assess the surgical incision for redness and swelling.
c. Administer the ordered PRN acetaminophen (Tylenol).
d. Ask the health care provider to prescribe a different antibiotic. - Answer-A
A temperature of 100.8 F in the first 48 hours is usually caused by atelectasis, and
the nurse should have the patient cough and deep breathe.
,This problem may be resolved by nursing intervention, and therefore notifying the
health care provider is not necessary. Acetaminophen will reduce the temperature,
but it will not resolve the underlying respiratory congestion. Because a wound
infection does not usually occur before the third postoperative day, a wound infection
is not a likely source of the elevated temperature
The nurse assesses that the oxygen saturation is 89% in an unconscious patient
who was transferred from surgery to the postanesthesia care unit (PACU) 15
minutes ago. Which action should the nurse take first?
a. Elevate the patients head.
b. Suction the patients mouth.
c. Increase the oxygen flow rate.
d. Perform the jaw-thrust maneuver. - Answer-D
In an unconscious postoperative patient, a likely cause of hypoxemia is airway
obstruction by the tongue, and the first action is to clear the airway by maneuvers
such as the jaw thrust or chin lift. Increasing the oxygen flow rate and suctioning are
not helpful when the airway is obstructed by the tongue. Elevating the patients head
will not be effective in correcting the obstruction but may help with oxygenation after
the patient is awake.
The nurse assesses a patient who had a total abdominal hysterectomy 2 days ago.
Which information about the patient is most important to communicate to the health
care provider?
a. The right calf is swollen, warm, and painful.
b. The patients temperature is 100.3 F (37.9 C).
c. The 24-hour oral intake is 600 mL greater than the total output.
d. The patient complains of abdominal pain at level 6 (0 to 10 scale) when
ambulating. - Answer-A
The calf pain, swelling, and warmth suggest that the patient has a deep vein
thrombosis, which will require the health care provider to order diagnostic tests
and/or anticoagulants. Because the stress response causes fluid retention for the
first 2 to 5 days postoperatively, the difference between intake and output is
expected. A temperature elevation to 100.3 F on the second postoperative day
suggests atelectasis, and the nurse should have the patient deep breathe and
cough. Pain with ambulation is normal, and the nurse should administer the ordered
analgesic before patient activities
A patient who had knee surgery received intramuscular ketorolac (Toradol) 30
minutes ago and continues to complain of pain at a level of 7 (0 to 10 scale). Which
action is best for the nurse to take at this time?
a. Administer the prescribed PRN IV morphine sulfate.
b. Notify the health care provider about the ongoing knee pain.
c. Reassure the patient that postoperative pain is expected after knee surgery.
d. Teach the patient that the effects of ketorolac typically last about 6 to 8 hours -
Answer-A
,The priority at this time is pain relief. Concomitant use of opioids and nonsteroidal
antiinflammatory drugs (NSAIDs) improves pain control in postoperative patients.
Patient teaching and reassurance are appropriate, but should be done after the
patients pain is relieved. If the patient continues to have pain after the morphine is
administered, the health care provider should be notified.
The nurse working in the postanesthesia care unit (PACU) notes that a patient who
has just been transported from the operating room is shivering and has a
temperature of 96.5 F (35.8 C). Which action should the nurse take?
a. Cover the patient with a warm blanket and put on socks.
b. Notify the anesthesia care provider about the temperature.
c. Avoid the use of opioid analgesics until the patient is warmer.
d. Administer acetaminophen (Tylenol) 650 mg suppository rectally. - Answer-A
The patient assessment indicates the need for active rewarming. There is no
indication of a need for acetaminophen. Opioid analgesics may help reduce
shivering. Because hypothermia is common in the immediate postoperative period,
there is no need to notify the anesthesia care provider, unless the patient continues
to be hypothermic after active rewarming.
The nurse reviews the laboratory results for a patient on the first postoperative day
after a hiatal hernia repair. Which finding would indicate to the nurse that the patient
is at increased risk for poor wound healing?
a. Potassium 3.5 mEq/L
b. Albumin level 2.2 g/dL
c. Hemoglobin 11.2 g/dL
d. White blood cells 11,900/L - Answer-B
Because proteins are needed for an appropriate inflammatory response and wound
healing, the low serum albumin level (normal level 3.5 to 5.0 g/dL) indicates a risk for
poor wound healing.
The potassium level is normal. Because a small amount of blood loss is expected
with surgery, the hemoglobin level is not indicative of an increased risk for wound
healing. WBC count is expected to increase after surgery as a part of the normal
inflammatory response.
The nurse assesses a patient on the second postoperative day after abdominal
surgery to repair a perforated duodenal ulcer. Which finding is most important for the
nurse to report to the surgeon?
a. Tympanic temperature 99.2 F (37.3 C)
b. Fine crackles audible at both lung bases
c. Redness and swelling along the suture line
d. 200 mL sanguineous fluid in the wound drain - Answer-D
, Wound drainage should decrease and change in color from sanguineous to
serosanguineous by the second postoperative day. The color and amount of
drainage for this patient are abnormal and should be reported.
Redness and swelling along the suture line and a slightly elevated temperature are
normal signs of postoperative inflammation. Atelectasis is common after surgery.
The nurse should have the patient cough and deep breathe, but there is no urgent
need to notify the surgeon.
After receiving change-of-shift report about these postoperative patients, which
patient should the nurse assess first?
a. Obese patient who had abdominal surgery 3 days ago and whose wound edges
are separating
b. Patient who has 30 mL of sanguineous drainage in the wound drain 10 hours after
hip replacement surgery
c. Patient who has bibasilar crackles and a temperature of 100F (37.8C) on the first
postoperative day after chest surgery
d. Patient who continues to have incisional pain 15 minutes after hydrocodone and
acetaminophen (Vicodin) administration - Answer-A
The patients history and assessment suggests possible wound dehiscence, which
should be reported immediately to the surgeon. Although the information about the
other patients indicates a need for ongoing assessment and/or possible intervention,
the data do not suggest any acute complications. Small amounts of red drainage are
common in the first postoperative hours. Bibasilar crackles and a slightly elevated
temperature are common after surgery, although the nurse will need to have the
patient cough and deep breathe. Oral medications typically take more than 15
minutes for effective pain relief.
While ambulating in the room, a patient complains of feeling dizzy. In what order will
the nurse accomplish the following activities?
a. Have the patient sit down in a chair.
b. Give the patient something to drink.
c. Take the patients blood pressure (BP).
d. Notify the patients health care provider. - Answer-A, C, B, D
The first priority for the patient with syncope is to prevent a fall, so the patient should
be assisted to a chair. Assessment of the BP will determine whether the dizziness is
due to orthostatic hypotension, which occurs because of hypovolemia. Increasing the
fluid intake will help prevent orthostatic dizziness. Because this is a common
postoperative problem that is usually resolved through nursing measures such as
increasing fluid intake and making position changes more slowly, there is no urgent
need to notify the health care provider.
The nurse is caring for a surgical patient, when the family member asks what
perioperative nursing means. How should the nurse respond?
a. Perioperative nursing occurs in preadmission testing.
QUESTIONS AND ANSWERS 100%
PASS
A postoperative patient has not voided for 8 hours after return to the clinical unit.
Which action should the nurse take first?
a. Perform a bladder scan.
b. Encourage increased oral fluid intake.
c. Assist the patient to ambulate to the bathroom.
d. Insert a straight catheter as indicated on the PRN order. - Answer-A
The initial action should be to assess the bladder for distention. If the bladder is
distended, providing the patient with privacy (by walking with them to the bathroom)
will be helpful. Because of the risk for urinary tract infection, catheterization should
only be done after other measures have been tried without success. There is no
indication to notify the surgeon about this common postoperative problem unless all
measures to empty the bladder are unsuccessful
The nurse is caring for a patient the first postoperative day following a laparotomy for
a small bowel obstruction. The nurse notices new bright-red drainage about 5 cm in
diameter on the dressing. Which action should the nurse take first?
a. Reinforce the dressing.
b. Apply an abdominal binder.
c. Take the patients vital signs.
d. Recheck the dressing in 1 hour for increased drainage. - Answer-C
New bright-red drainage may indicate hemorrhage, and the nurse should initially
assess the patients vital signs for tachycardia and hypotension. The surgeon should
then be notified of the drainage and the vital signs. The dressing may be changed or
reinforced, based on the surgeons orders or institutional policy. The nurse should not
wait an hour to recheck the dressing.
When caring for a patient the second postoperative day after abdominal surgery for
removal of a large pancreatic cyst, the nurse obtains an oral temperature of 100.8 F.
Which action should the nurse take first?
a. Have the patient use the incentive spirometer.
b. Assess the surgical incision for redness and swelling.
c. Administer the ordered PRN acetaminophen (Tylenol).
d. Ask the health care provider to prescribe a different antibiotic. - Answer-A
A temperature of 100.8 F in the first 48 hours is usually caused by atelectasis, and
the nurse should have the patient cough and deep breathe.
,This problem may be resolved by nursing intervention, and therefore notifying the
health care provider is not necessary. Acetaminophen will reduce the temperature,
but it will not resolve the underlying respiratory congestion. Because a wound
infection does not usually occur before the third postoperative day, a wound infection
is not a likely source of the elevated temperature
The nurse assesses that the oxygen saturation is 89% in an unconscious patient
who was transferred from surgery to the postanesthesia care unit (PACU) 15
minutes ago. Which action should the nurse take first?
a. Elevate the patients head.
b. Suction the patients mouth.
c. Increase the oxygen flow rate.
d. Perform the jaw-thrust maneuver. - Answer-D
In an unconscious postoperative patient, a likely cause of hypoxemia is airway
obstruction by the tongue, and the first action is to clear the airway by maneuvers
such as the jaw thrust or chin lift. Increasing the oxygen flow rate and suctioning are
not helpful when the airway is obstructed by the tongue. Elevating the patients head
will not be effective in correcting the obstruction but may help with oxygenation after
the patient is awake.
The nurse assesses a patient who had a total abdominal hysterectomy 2 days ago.
Which information about the patient is most important to communicate to the health
care provider?
a. The right calf is swollen, warm, and painful.
b. The patients temperature is 100.3 F (37.9 C).
c. The 24-hour oral intake is 600 mL greater than the total output.
d. The patient complains of abdominal pain at level 6 (0 to 10 scale) when
ambulating. - Answer-A
The calf pain, swelling, and warmth suggest that the patient has a deep vein
thrombosis, which will require the health care provider to order diagnostic tests
and/or anticoagulants. Because the stress response causes fluid retention for the
first 2 to 5 days postoperatively, the difference between intake and output is
expected. A temperature elevation to 100.3 F on the second postoperative day
suggests atelectasis, and the nurse should have the patient deep breathe and
cough. Pain with ambulation is normal, and the nurse should administer the ordered
analgesic before patient activities
A patient who had knee surgery received intramuscular ketorolac (Toradol) 30
minutes ago and continues to complain of pain at a level of 7 (0 to 10 scale). Which
action is best for the nurse to take at this time?
a. Administer the prescribed PRN IV morphine sulfate.
b. Notify the health care provider about the ongoing knee pain.
c. Reassure the patient that postoperative pain is expected after knee surgery.
d. Teach the patient that the effects of ketorolac typically last about 6 to 8 hours -
Answer-A
,The priority at this time is pain relief. Concomitant use of opioids and nonsteroidal
antiinflammatory drugs (NSAIDs) improves pain control in postoperative patients.
Patient teaching and reassurance are appropriate, but should be done after the
patients pain is relieved. If the patient continues to have pain after the morphine is
administered, the health care provider should be notified.
The nurse working in the postanesthesia care unit (PACU) notes that a patient who
has just been transported from the operating room is shivering and has a
temperature of 96.5 F (35.8 C). Which action should the nurse take?
a. Cover the patient with a warm blanket and put on socks.
b. Notify the anesthesia care provider about the temperature.
c. Avoid the use of opioid analgesics until the patient is warmer.
d. Administer acetaminophen (Tylenol) 650 mg suppository rectally. - Answer-A
The patient assessment indicates the need for active rewarming. There is no
indication of a need for acetaminophen. Opioid analgesics may help reduce
shivering. Because hypothermia is common in the immediate postoperative period,
there is no need to notify the anesthesia care provider, unless the patient continues
to be hypothermic after active rewarming.
The nurse reviews the laboratory results for a patient on the first postoperative day
after a hiatal hernia repair. Which finding would indicate to the nurse that the patient
is at increased risk for poor wound healing?
a. Potassium 3.5 mEq/L
b. Albumin level 2.2 g/dL
c. Hemoglobin 11.2 g/dL
d. White blood cells 11,900/L - Answer-B
Because proteins are needed for an appropriate inflammatory response and wound
healing, the low serum albumin level (normal level 3.5 to 5.0 g/dL) indicates a risk for
poor wound healing.
The potassium level is normal. Because a small amount of blood loss is expected
with surgery, the hemoglobin level is not indicative of an increased risk for wound
healing. WBC count is expected to increase after surgery as a part of the normal
inflammatory response.
The nurse assesses a patient on the second postoperative day after abdominal
surgery to repair a perforated duodenal ulcer. Which finding is most important for the
nurse to report to the surgeon?
a. Tympanic temperature 99.2 F (37.3 C)
b. Fine crackles audible at both lung bases
c. Redness and swelling along the suture line
d. 200 mL sanguineous fluid in the wound drain - Answer-D
, Wound drainage should decrease and change in color from sanguineous to
serosanguineous by the second postoperative day. The color and amount of
drainage for this patient are abnormal and should be reported.
Redness and swelling along the suture line and a slightly elevated temperature are
normal signs of postoperative inflammation. Atelectasis is common after surgery.
The nurse should have the patient cough and deep breathe, but there is no urgent
need to notify the surgeon.
After receiving change-of-shift report about these postoperative patients, which
patient should the nurse assess first?
a. Obese patient who had abdominal surgery 3 days ago and whose wound edges
are separating
b. Patient who has 30 mL of sanguineous drainage in the wound drain 10 hours after
hip replacement surgery
c. Patient who has bibasilar crackles and a temperature of 100F (37.8C) on the first
postoperative day after chest surgery
d. Patient who continues to have incisional pain 15 minutes after hydrocodone and
acetaminophen (Vicodin) administration - Answer-A
The patients history and assessment suggests possible wound dehiscence, which
should be reported immediately to the surgeon. Although the information about the
other patients indicates a need for ongoing assessment and/or possible intervention,
the data do not suggest any acute complications. Small amounts of red drainage are
common in the first postoperative hours. Bibasilar crackles and a slightly elevated
temperature are common after surgery, although the nurse will need to have the
patient cough and deep breathe. Oral medications typically take more than 15
minutes for effective pain relief.
While ambulating in the room, a patient complains of feeling dizzy. In what order will
the nurse accomplish the following activities?
a. Have the patient sit down in a chair.
b. Give the patient something to drink.
c. Take the patients blood pressure (BP).
d. Notify the patients health care provider. - Answer-A, C, B, D
The first priority for the patient with syncope is to prevent a fall, so the patient should
be assisted to a chair. Assessment of the BP will determine whether the dizziness is
due to orthostatic hypotension, which occurs because of hypovolemia. Increasing the
fluid intake will help prevent orthostatic dizziness. Because this is a common
postoperative problem that is usually resolved through nursing measures such as
increasing fluid intake and making position changes more slowly, there is no urgent
need to notify the health care provider.
The nurse is caring for a surgical patient, when the family member asks what
perioperative nursing means. How should the nurse respond?
a. Perioperative nursing occurs in preadmission testing.
