VERSIONS} 2024
1. The nurse is completing a medication history for the surgical patient
in preadmission testing. Which medication should the nurse instruct the
patient to hold (discontinue) in preparation for surgery according to
protocol?
a. Warfarin
b. Vitamin C
c. Prednisone
d. Acetaminophen
ANS: A
Medications such as warfarin or aspirin alter normal clotting factors and
thus increase the risk of hemorrhaging. Discontinue at least 48 hours before
surgery. Acetaminophen is a pain reliever that has no special implications
for surgery. Vitamin C actually assists in wound healing and has no special
implications for surgery. Prednisone is a corticosteroid, and dosages are
often temporarily increased rather than held.
2. The nurse is prescreening a surgical patient in the preadmission testing
unit. The medication history indicates that the patient is
currently taking an anticoagulant. Which action should the nurse take when
consulting with the health care provider?
a. Ask for a radiological examination of the chest.
b. Ask for an international normalized ratio (INR).
c. Ask for a blood urea nitrogen (BUN).
, d. Ask for a serum sodium (Na).
ANS: B
INR, PT (prothrombin time), APTT (activated partial thromboplastin time), and
platelet counts reveal the clotting ability of the blood. Anticoagulants can be
utilized for different conditions, but its action is to increase the time it takes
for the blood to clot. This action can put the surgical patient at risk for
bleeding tendencies.
Typically, if at all possible, this medication is held several days before a
surgical procedure to decrease this risk. Chest x-ray, BUN, and Na are
diagnostic screening tools for surgery but are not specific to anticoagulants.
3. The nurse is preparing a patient for surgery. Which goal is a
priority for assessing the patient before surgery?
a. Plan for care after the procedure.
b. Establish a patient’s baseline of normal function.
c. Educate the patient and family about the procedure.
d. Gather appropriate equipment for the patient’s needs.
ANS: B
The goal of the preoperative assessment is to identify a patient’s normal
preoperative function and the presence of any risks to recognize, prevent, and
minimize possible postoperative complications. Gathering appropriate
equipment, planning care, and educating the patient and family are all
important interventions that must be provided for the surgical patient; they
are part of the nursing process but are not the priority reason/goal for
completing an assessment of the surgical patient.
, 4. The11nurse11is11encouraging11the11postoperative11patient11to1
1utilize11diaphragmatic
breathing.11Which11priority11goal11is11the11nurse11trying11to11achieve?
a. Manage11pain
b. Prevent11atelectasis
c. Reduce11healing11time
d. Decrease11thrombus11formation
ANS:11B
After11surgery,11patients11may11have11reduced11lung11volume11and11may11req
uire11greater11effort11to11cough11and11deep11breathe;11inadequate11lung11exp
ansion11can11lead11to11atelectasis11and11pneumonia.11Purposely11utilizing11di
aphragmatic11breathing11can11decrease11this11risk.11During11general11anesthe
sia,11the11lungs11are11not11fully11inflated11during11surgery11and11the11cough11r
eflex11is11suppressed,11so11mucus11collects11within11airway11passages.11Diaph
ragmatic11breathing11does11not11manage11pain;11in11some11cases,11if11splintin
g11and11pain11medications11are11not11given,11it11can11cause11pain.11Diaphragm
atic11breathing11does11not11reduce11healing11time11or11decrease11thrombus11
formation.11Better,11more11effective11interventions11are11available11for11thes
e11situations.
5. The11nurse11is11caring11for11a11postoperative11patient11on11the11medical-
surgical
floor.11Which11activity11will11the11nurse11encourage11to11prevent11venous11sta
sis11and11the11formation11of11thrombus?
a. Diaphragmatic11breathing
b. Incentive11spirometry
c. Leg11exercises
d. Coughing