Complete Solutions
1. A perioperative nurse is preparing a patient for surgery for
treatment of a ruptured spleen as the result of an automobile
crash. The nurse knows that this type of surgery belongs in what
category?
a. Minor, diagnostic
b. Minor, elective
c. Major, emergency
d. Major, palliative Correct Answers c.
This surgery would involve a major body organ, has the
potential for postoperative complications, requires
hospitalization, and must be done immediately to save the
patient's life. Elective surgery is a procedure that is preplanned
by essentially healthy people. Diagnostic surgery is performed
to confirm a diagnosis. Palliative surgery is not curative, rather it
is done to relieve or reduce the intensity of an illness.
10. A patient had a surgical procedure that necessitated a
thoracic incision. The nurse anticipates that he will have a
higher risk for postoperative complications involving which
body system?
a. Respiratory system
b. Circulatory system
c. Digestive system
d.Nervous system Correct Answers a.
,A thoracic incision makes it more painful for the patient to take
deep breaths or cough. Shallow respirations and ineffective
coughing increase the risk for respiratory complications.
11. While assessing a patient in the PACU, a nurse notes
increased wound drainage, restlessness, a decreasing blood
pressure, and an increase in the pulse rate. The nurse interprets
these findings as most likely indicating:
a. Thrombophlebitis
b. Atelectasis
c. Infection
d. Hemorrhage Correct Answers d.
Increased wound drainage, restlessness, decreasing blood
pressure, and increasing pulse rate are assessment findings that
indicate hemorrhage. Manifestations of thrombophlebitis are
pain and cramping in the calf or thigh of the involved extremity,
redness and swelling in the affected area, elevated temperature,
and an increase in the diameter of the involved extremity.
Manifestations of atelectasis include decreased lung sounds over
the affected area, dyspnea, cyanosis, crackles, restlessness, and
apprehension. Signs of infection include elevated white blood
count and fever.
12. A patient tells the nurse she is having pain in her right lower
leg. How does the nurse assess for the presence of
thrombophlebitis?
a. By palpating the skin over the tibia and fibula
b. By documenting daily calf circumference measurements
c. By recording vital signs obtained four times a day
,d. By noting difficulty with ambulation Correct Answers b.
Inflammation from thrombophlebitis increases the size of the
affected extremity and can be assessed by measuring
circumference on a regular basis.
13. A scrub nurse is assisting a surgeon with a kidney transplant.
What are the patient responsibilities of this surgical team
member? Select all that apply.
a. Maintaining sterile technique
b. Draping and handling instruments and supplies
c. Identifying and assessing the patient on admission
d. Integrating case management
e. Preparing the skin at the surgical site
f. Providing exposure of the operative area Correct Answers a,
b.
The scrub nurse is a member of the sterile team who maintains
sterile technique while draping and handling instruments and
supplies. Two duties of the circulating nurse are to identify and
assess the patient on admission to the operating room and
prepare the skin at the surgical site. The RNFA actively assists
the surgeon by providing exposure of the operative area. The
APRN coordinates care activities, collaborates with physicians
and nurses in all phases of perioperative and postanesthesia care,
and integrates case management, critical paths, and research into
care of the surgical patient.
14. Older adults often have reduced vital capacity as a result of
normal physiologic changes. Which nursing intervention would
be most important for the postoperative care of an older surgical
patient specific to this change?
, a. Take and record vital signs every shift.
b. Turn, cough, and deep breathe every 4 hours.
c. Encourage increased intake of oral fluids.
d. Assess bowel sounds daily. Correct Answers b.
Reduced vital capacity in older adults increases the risk for
respiratory complications, including pneumonia and atelectasis.
Having the patient turn, cough, and deep breathe every 4 hours
maintains respiratory function and helps to prevent
complications.
15. A nurse is explaining the rationale for performing leg
exercises after surgery. Which reason would the nurse include in
the explanation?
a. Promote respiratory function
b. Maintain functional abilities
c. Provide diversional activities
d. Increase venous return Correct Answers d.
Leg exercises in the postoperative period increase venous return.
As a result, the patient has a decreased risk for thrombophlebitis
and emboli.
2. A nurse is preparing a patient for a cesarean section and
teaches her the effects of the regional anesthesia she will be
receiving. Which effects would the nurse expect? Select all that
apply.
a. Loss of consciousness
b. Relaxation of skeletal muscles
c. Reduction or loss of reflex action