1. The nurse is performing presurgical assessment of multiple clients. The
nurse determines that which client has the greatest risk for developing an
infection postoperatively?
A. The client with new-onset neutropenia of unknown etiology
B. The client with thrombocytopenia secondary to taking aspirin
C. The child newly diagnosed with type 1 diabetes mellitus (DM)
D. The client who needs assistance with ambulation due to arthritis
ANSWER: A
A. Neutropenia is a reduction in neutrophils, the body’s first line of defense in phagocytosis
of invading microorganisms. Neutropenia predis- poses the client to infection with
nonpathogenic organisms that are present in normal body flora as well as opportunistic
pathogens.
B. Thrombocytopenia is a reduction in platelets. Thrombocytopenia predisposes the client
to bleeding.
C. The client with DM is more susceptible to infections because there is a defect in the
mobilization of inflammatory cells and an impairment of phagocytosis by neutrophils
and monocytes. Although at risk, the client with neutropenia has a greater risk.
D. If assistance is provided for activity, there should not be an increased risk.
2. The client being admitted for same-day surgery has inspiratory crackles and
bilateral wheezes, and reports shortness of breath for several days. Which
intervention should the nurse implement first?
A. Notify the surgeon of the findings.
B. Document the assessment findings.
C. Apply 4 liters oxygen by nasal cannula.
D. Instruct on using an incentive spirometer (IS).
ANSWER: A
A. The nurse should notify the surgeon of unanticipated changes in the health status of the
preoperative client. Surgery may need to be postponed.
B. The nurse should first notify the surgeon and then document the findings and the
notification.
, C. There are no objective data supporting the need for oxygen.
D. Although an IS may be prescribed, notifying the surgeon is the priority.
3. The nurse determines that all of the following must be completed for the
client being prepared for surgery. Which intervention should the nurse complete
first?
A. Complete the preoperative checklist
B. Assess the client’s preoperative vital signs
C. Remove the client’s rings, gold chain, and wristwatch
D. Give 10 mEq KCL IV for a serum potassium level Of 3.0 mEq/L
ANSWER: D
A. Completing the preoperative checklist ensures that all requirements are completed. This
would be the second intervention.
B. Although important, assessing the client’s preoperative VS is not the priority.
C. Although important, removing the client’s rings, gold chain, and wristwatch is not the
priority.
D. Giving KCL is priority. Abnormalities must be corrected before surgery. A low serum
potassium level can induce cardiac dysrhythmias and delay surgery.
4. The nurse is performing a presurgical admission assessment of the client.
Which client statement needs the most immediate follow-up?
A. “I feel very hungry; I haven’t eaten foods or had any fluids for the past 12 hours.”
B. “I donated my own blood in case I need a transfusion; the last donation was 4 days ago-”
C. “I took all my meds including warfarin and atenolol with a sip of water this morning.”
D. “I brought a copy of my health care directive in case my heart stops during surgery.”
ANSWER: C
A. The exact amount of time the client must be NPO before surgery is controversial. Older
adults may have imbalances of fluids, electrolytes, and blood glucose levels from fasting
longer. However, there is no indication in the question that this is a concern.
B. Blood can be donated up to 72 hours before the scheduled surgery.
C. Warfarin (Coumadin) is an anticoagulant. Usually this is stopped a few days before
, surgery due to the increased risk of bleeding. The nurse should immediately follow up by
notifying the HCP.
D. Clients should be encouraged to bring a copy of the HCD so others are aware of the
client’s wishes. The nurse may want to follow up regarding the client’s statement “in
case my heart stops during surgery,” but this is not the most immediate concern.
5. The nurse is to witness the signature of a surgical consent for multiple
clients scheduled for surgery the following day. After evaluating the health
history of each client, for which client should the nurse plan to obtain a
signature from the next of kin?
A. The 75-year-old client who is legally blind
B. The 60-year-old client who does not understand English
C. The 50-year—old client who is forgetful but fully oriented
D. The 16-year-old client who fully understands the surgery
ANSWER: D
A. The client who is legally blind may sign his or her signature with an “X” as long as the
client under- stands the nature and reason for surgery, who will perform the surgery,
available options, the benefits and risks of surgery, and the consent form that is read to
the client. Another person besides the nurse should witness the client’s “X” signature.
B. An interpreter should be available to read the consent in the client’s native language. The
client can then provide written consent in the presence of two witnesses.
C. The client is able to sign a consent form unless determined incompetent. If the client is
fully oriented, a signed consent can be obtained from the client.
D. The legal age for consent is 18 years unless the adolescent has emancipated status
granted by a judge.
6 . The nurse receives the written laboratory results of a positive pregnancy test
for the client scheduled for an emergency appendectomy. Which intervention
should the nurse implement first?
A. Call the laboratory to verify the test results.
B. Inform the client of the pregnancy test results-
C. Report the pregnancy test results to the surgeon.
D. Notify the client’s primary care provider of the results.
nurse determines that which client has the greatest risk for developing an
infection postoperatively?
A. The client with new-onset neutropenia of unknown etiology
B. The client with thrombocytopenia secondary to taking aspirin
C. The child newly diagnosed with type 1 diabetes mellitus (DM)
D. The client who needs assistance with ambulation due to arthritis
ANSWER: A
A. Neutropenia is a reduction in neutrophils, the body’s first line of defense in phagocytosis
of invading microorganisms. Neutropenia predis- poses the client to infection with
nonpathogenic organisms that are present in normal body flora as well as opportunistic
pathogens.
B. Thrombocytopenia is a reduction in platelets. Thrombocytopenia predisposes the client
to bleeding.
C. The client with DM is more susceptible to infections because there is a defect in the
mobilization of inflammatory cells and an impairment of phagocytosis by neutrophils
and monocytes. Although at risk, the client with neutropenia has a greater risk.
D. If assistance is provided for activity, there should not be an increased risk.
2. The client being admitted for same-day surgery has inspiratory crackles and
bilateral wheezes, and reports shortness of breath for several days. Which
intervention should the nurse implement first?
A. Notify the surgeon of the findings.
B. Document the assessment findings.
C. Apply 4 liters oxygen by nasal cannula.
D. Instruct on using an incentive spirometer (IS).
ANSWER: A
A. The nurse should notify the surgeon of unanticipated changes in the health status of the
preoperative client. Surgery may need to be postponed.
B. The nurse should first notify the surgeon and then document the findings and the
notification.
, C. There are no objective data supporting the need for oxygen.
D. Although an IS may be prescribed, notifying the surgeon is the priority.
3. The nurse determines that all of the following must be completed for the
client being prepared for surgery. Which intervention should the nurse complete
first?
A. Complete the preoperative checklist
B. Assess the client’s preoperative vital signs
C. Remove the client’s rings, gold chain, and wristwatch
D. Give 10 mEq KCL IV for a serum potassium level Of 3.0 mEq/L
ANSWER: D
A. Completing the preoperative checklist ensures that all requirements are completed. This
would be the second intervention.
B. Although important, assessing the client’s preoperative VS is not the priority.
C. Although important, removing the client’s rings, gold chain, and wristwatch is not the
priority.
D. Giving KCL is priority. Abnormalities must be corrected before surgery. A low serum
potassium level can induce cardiac dysrhythmias and delay surgery.
4. The nurse is performing a presurgical admission assessment of the client.
Which client statement needs the most immediate follow-up?
A. “I feel very hungry; I haven’t eaten foods or had any fluids for the past 12 hours.”
B. “I donated my own blood in case I need a transfusion; the last donation was 4 days ago-”
C. “I took all my meds including warfarin and atenolol with a sip of water this morning.”
D. “I brought a copy of my health care directive in case my heart stops during surgery.”
ANSWER: C
A. The exact amount of time the client must be NPO before surgery is controversial. Older
adults may have imbalances of fluids, electrolytes, and blood glucose levels from fasting
longer. However, there is no indication in the question that this is a concern.
B. Blood can be donated up to 72 hours before the scheduled surgery.
C. Warfarin (Coumadin) is an anticoagulant. Usually this is stopped a few days before
, surgery due to the increased risk of bleeding. The nurse should immediately follow up by
notifying the HCP.
D. Clients should be encouraged to bring a copy of the HCD so others are aware of the
client’s wishes. The nurse may want to follow up regarding the client’s statement “in
case my heart stops during surgery,” but this is not the most immediate concern.
5. The nurse is to witness the signature of a surgical consent for multiple
clients scheduled for surgery the following day. After evaluating the health
history of each client, for which client should the nurse plan to obtain a
signature from the next of kin?
A. The 75-year-old client who is legally blind
B. The 60-year-old client who does not understand English
C. The 50-year—old client who is forgetful but fully oriented
D. The 16-year-old client who fully understands the surgery
ANSWER: D
A. The client who is legally blind may sign his or her signature with an “X” as long as the
client under- stands the nature and reason for surgery, who will perform the surgery,
available options, the benefits and risks of surgery, and the consent form that is read to
the client. Another person besides the nurse should witness the client’s “X” signature.
B. An interpreter should be available to read the consent in the client’s native language. The
client can then provide written consent in the presence of two witnesses.
C. The client is able to sign a consent form unless determined incompetent. If the client is
fully oriented, a signed consent can be obtained from the client.
D. The legal age for consent is 18 years unless the adolescent has emancipated status
granted by a judge.
6 . The nurse receives the written laboratory results of a positive pregnancy test
for the client scheduled for an emergency appendectomy. Which intervention
should the nurse implement first?
A. Call the laboratory to verify the test results.
B. Inform the client of the pregnancy test results-
C. Report the pregnancy test results to the surgeon.
D. Notify the client’s primary care provider of the results.
