Nursing 300 test 1
Which nursing intervention is the highest priority during the first 24 hours postoperatively for the client
who had a total laryngectomy due to cancer of the larynx? ANS: keep airway open
Upon waking up in the postanesthesia care unit and seeing a drain with bright red fluid in it exiting from
his total hip incision, a client asks the nurse, "Is this the way it's supposed to be?" What should the nurse
tell the client? ANS: drainage is what needs to be drained out for healing
When conducting the preoperative preparations, the nurse determines that the client does not speak
English, and the nurse does not speak the client's language. The surgeon needs to obtain the client's
informed consent. What is the best way for the nurse to obtain the client's informed consent? ANS: Call
the Spanish interpreter to translate the surgeon's explanation of the procedure, risks, and alternatives
to obtain the client's consent and to answer the client's questions.
A nurse is caring for a client who just had an appendectomy. The client is receiving opioid analgesics
routinely for pain. The nurse should focus the follow-up assessment on which complication? ANS:
constipation
After abdominal surgery, a client is reluctant to turn in bed. The nurse should: ANS: explain importance
of turning to patient
The expected outcome of withholding food and fluids from a client who will receive general anesthesia
is to help prevent: ANS: vomiting and potential aspiration during surgery
When the nurse asks the client who is having abdominal surgery today if the client understands the
procedure, the client replies, "No, not really; I talked about several different things with my surgeon,
and I'm just not sure." What should the nurse do next? ANS: notify the surgeon of the lack of
understanding
A client has undergone a left hemicolectomy for bowel cancer. Which activities prevent the occurrence
of postoperative pneumonia in this client? ANS: Coughing, breathing deeply, frequent repositioning, and
using an incentive spirometer
,The nurse administered morphine IV to a client after a cholecystectomy one hour ago. The nurse should
contact the healthcare provider based on what assessment finding? ANS: respiratory rate 8 breaths/min
As the nurse assists the postoperative client out of bed, the client reports having gas pains in the
abdomen. To reduce this discomfort, what should the nurse do? ANS: encourage the patient to
ambulate
A nurse is caring for a client with a postoperative wound evisceration. Which action should the nurse
perform first? ANS: Cover the protruding internal organs with sterile gauze, moistened with sterile saline
solution.
A client who had transurethral resection of the prostate has dribbling urine after his Foley catheter is
removed on the second postoperative day. The nurse notes that the client had 200 mL of urine output in
the last 8 hours with a 1,000-mL intake. What should the nurse do first? ANS: assess for bladder
distention
A client in a general hospital is to undergo surgery in 2 days and is experiencing moderate anxiety about
the procedure and its outcome. What should the nurse do to help the client reduce anxiety? ANS:
Explain the surgical procedure to the client and what happens before and after surgery.
The nurse is taking a nursing history from a client prior to surgery. Which information in the client's
history would have a significant impact on the client's recovery postoperatively? The client: ANS: has
smoked 1 pack of cigarettes a day for 12 years.
Which outcome is expected for a client who has undergone surgical repair of an inguinal hernia? ANS:
The client will verbalize understanding of instructions to avoid lifting for 2 to 6 weeks after surgery.
A client is scheduled to have surgery to relieve an intestinal obstruction. Prior to surgery, the nurse
should verify that the client has followed which preoperative instructions? ANS: discontinue use of
blood thinners
,A 7-year-old has had an appendectomy on November 12. He has had pain for the last 24 hours. There is
a prescription to administer acetaminophen with codeine every 3 to 4 hours as needed. The nurse is
beginning the shift, and the child is requesting pain medication. The nurse reviews the chart below for
pain history. Based on the information in the medical record, what should the nurse do next? ANS:
administer meds
Which finding is an example of a variance in the critical pathway of a client 3 days after an above-the-
knee amputation? ANS: • Temperature of 102° F (38.9°C)
The nurse is assessing a client's abdominal incision 48 hours after surgery. Which finding indicates that
the wound is inflamed? ANS: • Localized warmth over the incisional area.
A nurse completes preoperative teaching for a client scheduled for a cholecystectomy. The client states,
"If I lie still and avoid turning, I will avoid pain. Do you think this is a good idea?" What is the nurse's best
response? ANS: • "Turn from side to side every 2 hours, and the nurse will administer pain medication
to assist in movement."
A client who is 1 day postoperative is using a morphine patient-controlled analgesia (PCA) pump. The
client is confused and disoriented. What is the priority intervention by the nurse? ANS: • Check
respiratory rate and depth as well as oxygen saturation levels.
Which of the following statements heard during shift report identifies an important priority for action?
ANS: • A postoperative client's pulse has been increasing, and the blood pressure is decreasing.
The nurse is working with a licensed practical nurse (LPN) and delegating the taking of vital signs for a
preoperative client. Upon review of the chart as the client is leaving for the operating room, the nurse
notes that the temperature is 101.1°F (38.4°C) and the pulse is 110 bpm. What are the nurse's initial
actions? ANS: • Notify the surgeon and await the surgeon's decision; reinforce with the LPN the
importance of reporting abnormal preoperative vital signs.
, The surgeon prescribes cefazolin 1 g to be given IV at 0730 when the client's surgery is scheduled at
0800. What is the primary reason to start the antibiotic exactly at 0730? ANS: • The antibiotic is most
effective in preventing infection if it is given 30 to 60 minutes before the operative incision is made.
The nurse is providing preoperative instructions to a client who is deaf. Which strategy is most effective
in assuring that the client understands the information? ANS: • Give the client written material to read,
and follow up with time for questions.
A complete blood count is commonly performed before a client goes into surgery. What does this test
seek to identify? ANS: • Abnormally low hematocrit (HCT) and hemoglobin (Hb) levels
A client is to have a below-the-knee amputation. Prior to the surgery, what should the circulating nurse
in the operating room do? ANS: initiate time out
A client is in the operating room having surgery to replace a hip. Prior to starting the surgery, there is
confusion about the view of the hip on the X-ray The surgical team requests a "time out" and stops the
surgery. When can surgery continue? Select all that apply. ANS: • The surgeon verifies the correct
procedure.
• The surgeon verifies correct surgical site.
• The surgical team identifies the client using two sources of identification.
A client is admitted on the day of surgery for an arthroscopy of the left knee. Which nursing activities
should be completed prior to administering anesthesia to the client to avoid wrong-site surgery? Select
all that apply. ANS: • Verify that the surgeon has marked with a permanent marker the correct knee for
the surgical site.
• Verbally ask the client to state his or her name, surgical site, and procedure.
• Verify the correct client with the correct operative site from medical records and diagnostic reports.
• Call a "time-out" in the operating room to have the surgeon verify the correct knee before making the
incision.
Which nursing intervention is the highest priority during the first 24 hours postoperatively for the client
who had a total laryngectomy due to cancer of the larynx? ANS: keep airway open
Upon waking up in the postanesthesia care unit and seeing a drain with bright red fluid in it exiting from
his total hip incision, a client asks the nurse, "Is this the way it's supposed to be?" What should the nurse
tell the client? ANS: drainage is what needs to be drained out for healing
When conducting the preoperative preparations, the nurse determines that the client does not speak
English, and the nurse does not speak the client's language. The surgeon needs to obtain the client's
informed consent. What is the best way for the nurse to obtain the client's informed consent? ANS: Call
the Spanish interpreter to translate the surgeon's explanation of the procedure, risks, and alternatives
to obtain the client's consent and to answer the client's questions.
A nurse is caring for a client who just had an appendectomy. The client is receiving opioid analgesics
routinely for pain. The nurse should focus the follow-up assessment on which complication? ANS:
constipation
After abdominal surgery, a client is reluctant to turn in bed. The nurse should: ANS: explain importance
of turning to patient
The expected outcome of withholding food and fluids from a client who will receive general anesthesia
is to help prevent: ANS: vomiting and potential aspiration during surgery
When the nurse asks the client who is having abdominal surgery today if the client understands the
procedure, the client replies, "No, not really; I talked about several different things with my surgeon,
and I'm just not sure." What should the nurse do next? ANS: notify the surgeon of the lack of
understanding
A client has undergone a left hemicolectomy for bowel cancer. Which activities prevent the occurrence
of postoperative pneumonia in this client? ANS: Coughing, breathing deeply, frequent repositioning, and
using an incentive spirometer
,The nurse administered morphine IV to a client after a cholecystectomy one hour ago. The nurse should
contact the healthcare provider based on what assessment finding? ANS: respiratory rate 8 breaths/min
As the nurse assists the postoperative client out of bed, the client reports having gas pains in the
abdomen. To reduce this discomfort, what should the nurse do? ANS: encourage the patient to
ambulate
A nurse is caring for a client with a postoperative wound evisceration. Which action should the nurse
perform first? ANS: Cover the protruding internal organs with sterile gauze, moistened with sterile saline
solution.
A client who had transurethral resection of the prostate has dribbling urine after his Foley catheter is
removed on the second postoperative day. The nurse notes that the client had 200 mL of urine output in
the last 8 hours with a 1,000-mL intake. What should the nurse do first? ANS: assess for bladder
distention
A client in a general hospital is to undergo surgery in 2 days and is experiencing moderate anxiety about
the procedure and its outcome. What should the nurse do to help the client reduce anxiety? ANS:
Explain the surgical procedure to the client and what happens before and after surgery.
The nurse is taking a nursing history from a client prior to surgery. Which information in the client's
history would have a significant impact on the client's recovery postoperatively? The client: ANS: has
smoked 1 pack of cigarettes a day for 12 years.
Which outcome is expected for a client who has undergone surgical repair of an inguinal hernia? ANS:
The client will verbalize understanding of instructions to avoid lifting for 2 to 6 weeks after surgery.
A client is scheduled to have surgery to relieve an intestinal obstruction. Prior to surgery, the nurse
should verify that the client has followed which preoperative instructions? ANS: discontinue use of
blood thinners
,A 7-year-old has had an appendectomy on November 12. He has had pain for the last 24 hours. There is
a prescription to administer acetaminophen with codeine every 3 to 4 hours as needed. The nurse is
beginning the shift, and the child is requesting pain medication. The nurse reviews the chart below for
pain history. Based on the information in the medical record, what should the nurse do next? ANS:
administer meds
Which finding is an example of a variance in the critical pathway of a client 3 days after an above-the-
knee amputation? ANS: • Temperature of 102° F (38.9°C)
The nurse is assessing a client's abdominal incision 48 hours after surgery. Which finding indicates that
the wound is inflamed? ANS: • Localized warmth over the incisional area.
A nurse completes preoperative teaching for a client scheduled for a cholecystectomy. The client states,
"If I lie still and avoid turning, I will avoid pain. Do you think this is a good idea?" What is the nurse's best
response? ANS: • "Turn from side to side every 2 hours, and the nurse will administer pain medication
to assist in movement."
A client who is 1 day postoperative is using a morphine patient-controlled analgesia (PCA) pump. The
client is confused and disoriented. What is the priority intervention by the nurse? ANS: • Check
respiratory rate and depth as well as oxygen saturation levels.
Which of the following statements heard during shift report identifies an important priority for action?
ANS: • A postoperative client's pulse has been increasing, and the blood pressure is decreasing.
The nurse is working with a licensed practical nurse (LPN) and delegating the taking of vital signs for a
preoperative client. Upon review of the chart as the client is leaving for the operating room, the nurse
notes that the temperature is 101.1°F (38.4°C) and the pulse is 110 bpm. What are the nurse's initial
actions? ANS: • Notify the surgeon and await the surgeon's decision; reinforce with the LPN the
importance of reporting abnormal preoperative vital signs.
, The surgeon prescribes cefazolin 1 g to be given IV at 0730 when the client's surgery is scheduled at
0800. What is the primary reason to start the antibiotic exactly at 0730? ANS: • The antibiotic is most
effective in preventing infection if it is given 30 to 60 minutes before the operative incision is made.
The nurse is providing preoperative instructions to a client who is deaf. Which strategy is most effective
in assuring that the client understands the information? ANS: • Give the client written material to read,
and follow up with time for questions.
A complete blood count is commonly performed before a client goes into surgery. What does this test
seek to identify? ANS: • Abnormally low hematocrit (HCT) and hemoglobin (Hb) levels
A client is to have a below-the-knee amputation. Prior to the surgery, what should the circulating nurse
in the operating room do? ANS: initiate time out
A client is in the operating room having surgery to replace a hip. Prior to starting the surgery, there is
confusion about the view of the hip on the X-ray The surgical team requests a "time out" and stops the
surgery. When can surgery continue? Select all that apply. ANS: • The surgeon verifies the correct
procedure.
• The surgeon verifies correct surgical site.
• The surgical team identifies the client using two sources of identification.
A client is admitted on the day of surgery for an arthroscopy of the left knee. Which nursing activities
should be completed prior to administering anesthesia to the client to avoid wrong-site surgery? Select
all that apply. ANS: • Verify that the surgeon has marked with a permanent marker the correct knee for
the surgical site.
• Verbally ask the client to state his or her name, surgical site, and procedure.
• Verify the correct client with the correct operative site from medical records and diagnostic reports.
• Call a "time-out" in the operating room to have the surgeon verify the correct knee before making the
incision.
