Chapter 09: Concepts of Care for
Perioperative Patients
Ignatavicius: Medical-Surgical Nursing, 10th Edition
MULTIPLE CHOICE
1. A postoperative client has respiratory depression after receiving morphine for pain.
Which medication and dose does the nurse prepare to administer?
a. Flumazenil 0.2 to 1 mg
b. Flumazenil 2 to 10 mg
c. Naloxone 0.4 to 2 mg
d. Naloxone 4 to 20 mg
ANS: C
The nurse would prepare to administer naloxone, an opioid antagonist, at a dose of
between 0.04 and 0.05 mg up to 2 mg, depending on the client’s symptoms.
Flumazenil is a benzodiazepine antagonist.
DIF: Remembering TOP: Integrated Process: Nursing Process:
Implementation KEY: Perioperative nursing, Critical rescue
MSC: Client Needs Category: Physiological Integrity:
Pharmacological and Parenteral Therapies
2. A nurse on the postsurgical inpatient unit is observing a client perform leg exercises.
What action by the client indicates a need for further instruction?
a. Client states “This will help prevent blood clots in my legs.”
b. Bends both knees, pushes against the bed until calf and thigh muscles contract.
c. Dorsiflexes and plantar flexes each foot several times an hour.
, d. Makes several clockwise then counterclockwise ankle circles with each foot.
ANS: B
The client should perform this leg exercise one leg at a time. The other actions are
correct.
DIF: Analyzing TOP: Integrated Process: Teaching/Learning KEY:
Perioperative nursing, Health teaching MSC: Client Needs Category:
Physiological Integrity: Reduction of Risk Potential
3. A postoperative client vomited. After cleaning and comforting the client, which action
by the nurse is most important?
a. Allow the client to rest.
b. Auscultate lung sounds.
c. Document the episode.
d. Encourage the client to eat dry toast.
ANS: B
Vomiting after surgery has several complications, including aspiration. The nurse
would listen to the client’s lung sounds. The client should be allowed to rest after an
assessment. Documenting is important, but the nurse needs to be able to document
fully, including an assessment. The client should not eat until nausea has subsided.
DIF: Applying TOP: Integrated Process: Nursing Process: Assessment
KEY: Perioperative nursing, Nursing assessment MSC: Client
Needs Category: Physiological Integrity: Reduction of Risk Potential
4. A postoperative client has just been admitted to the postanesthesia care unit (PACU).
What assessment by the PACU nurse takes priority?
a. Airway
b. Bleeding
c. Breathing
, d. Cardiac rhythm
ANS: A
Assessing the airway always takes priority, followed by breathing and circulation.
Bleeding is part of the circulation assessment, as is cardiac rhythm.
DIF: Applying TOP: Integrated Process: Nursing Process: Assessment
KEY: Perioperative nursing, Nursing assessment MSC: Client
Needs Category: Safe and Effective Care Environment: Management
of Care
5. A registered nurse (RN) is watching a new nurse change a dressing and perform care
around a Penrose drain. What action by the new nurse warrants intervention?
a. Cleaning around the drain per agency protocol
b. Placing a new sterile gauze under the drain
c. Securing the drain’s safety pin to the sheets
d. Using sterile technique to empty the drain
ANS: C
The safety pin that prevents the drain from slipping back into the client’s body would
not be pinned to the client’s bedding. Pinning it to the sheets will cause it to pull out
when the client turns. The other actions are appropriate.
DIF: Analyzing TOP: Integrated Process: Nursing Process:
Implementation KEY: Postoperative nursing, Drains MSC:
Client Needs Category: Safe and Effective Care Environment: Safety and
Infection Control
6. A postoperative nurse is caring for a client who received a neuromuscular blocking
agent during surgery. On assessment the nurse notes the client has weak hand grasps.
What assessment does the nurse conduct next?
a. Ability to raise head off the bed
Perioperative Patients
Ignatavicius: Medical-Surgical Nursing, 10th Edition
MULTIPLE CHOICE
1. A postoperative client has respiratory depression after receiving morphine for pain.
Which medication and dose does the nurse prepare to administer?
a. Flumazenil 0.2 to 1 mg
b. Flumazenil 2 to 10 mg
c. Naloxone 0.4 to 2 mg
d. Naloxone 4 to 20 mg
ANS: C
The nurse would prepare to administer naloxone, an opioid antagonist, at a dose of
between 0.04 and 0.05 mg up to 2 mg, depending on the client’s symptoms.
Flumazenil is a benzodiazepine antagonist.
DIF: Remembering TOP: Integrated Process: Nursing Process:
Implementation KEY: Perioperative nursing, Critical rescue
MSC: Client Needs Category: Physiological Integrity:
Pharmacological and Parenteral Therapies
2. A nurse on the postsurgical inpatient unit is observing a client perform leg exercises.
What action by the client indicates a need for further instruction?
a. Client states “This will help prevent blood clots in my legs.”
b. Bends both knees, pushes against the bed until calf and thigh muscles contract.
c. Dorsiflexes and plantar flexes each foot several times an hour.
, d. Makes several clockwise then counterclockwise ankle circles with each foot.
ANS: B
The client should perform this leg exercise one leg at a time. The other actions are
correct.
DIF: Analyzing TOP: Integrated Process: Teaching/Learning KEY:
Perioperative nursing, Health teaching MSC: Client Needs Category:
Physiological Integrity: Reduction of Risk Potential
3. A postoperative client vomited. After cleaning and comforting the client, which action
by the nurse is most important?
a. Allow the client to rest.
b. Auscultate lung sounds.
c. Document the episode.
d. Encourage the client to eat dry toast.
ANS: B
Vomiting after surgery has several complications, including aspiration. The nurse
would listen to the client’s lung sounds. The client should be allowed to rest after an
assessment. Documenting is important, but the nurse needs to be able to document
fully, including an assessment. The client should not eat until nausea has subsided.
DIF: Applying TOP: Integrated Process: Nursing Process: Assessment
KEY: Perioperative nursing, Nursing assessment MSC: Client
Needs Category: Physiological Integrity: Reduction of Risk Potential
4. A postoperative client has just been admitted to the postanesthesia care unit (PACU).
What assessment by the PACU nurse takes priority?
a. Airway
b. Bleeding
c. Breathing
, d. Cardiac rhythm
ANS: A
Assessing the airway always takes priority, followed by breathing and circulation.
Bleeding is part of the circulation assessment, as is cardiac rhythm.
DIF: Applying TOP: Integrated Process: Nursing Process: Assessment
KEY: Perioperative nursing, Nursing assessment MSC: Client
Needs Category: Safe and Effective Care Environment: Management
of Care
5. A registered nurse (RN) is watching a new nurse change a dressing and perform care
around a Penrose drain. What action by the new nurse warrants intervention?
a. Cleaning around the drain per agency protocol
b. Placing a new sterile gauze under the drain
c. Securing the drain’s safety pin to the sheets
d. Using sterile technique to empty the drain
ANS: C
The safety pin that prevents the drain from slipping back into the client’s body would
not be pinned to the client’s bedding. Pinning it to the sheets will cause it to pull out
when the client turns. The other actions are appropriate.
DIF: Analyzing TOP: Integrated Process: Nursing Process:
Implementation KEY: Postoperative nursing, Drains MSC:
Client Needs Category: Safe and Effective Care Environment: Safety and
Infection Control
6. A postoperative nurse is caring for a client who received a neuromuscular blocking
agent during surgery. On assessment the nurse notes the client has weak hand grasps.
What assessment does the nurse conduct next?
a. Ability to raise head off the bed
