1.
The nurse is preparing a client for surgery. What is the most effective method for obtaining an accurate blood pressure reading from the client?
Correct Answer
C. Use a cuff that is wide enough to cover two-thirds of the client’s upper arm.
Explanation
To obtain an accurate blood pressure reading, it is crucial to use a cuff that covers two-thirds of the client's upper arm. Using an improperly sized cuff can lead to inaccurate readings. The width of the cuff should be sufficient to ensure accurate compression and measurement of blood pressure.
2.
Which of the following items on a client’s pre-surgery laboratory results would indicate a need to contact the surgeon?
Correct Answer
D. Hemoglobin 9.5 mg/dl.
Explanation
A hemoglobin level of 9.5 mg/dl indicates anemia, which may affect the patient's oxygen-carrying capacity. This is a concern for surgery as inadequate oxygenation can lead to complications. The nurse should contact the surgeon to discuss the need for potential interventions or adjustments to the surgical plan.
3.
To prevent complications of immobility, which activities would help the nurse plan for the first postoperative day after a colon resection?
Correct Answer
B. Get the client out of bed and ambulate to a bedside chair.
Explanation
Ambulation helps prevent complications of immobility after colon resection. Early mobilization aids in preventing postoperative complications such as atelectasis and deep vein thrombosis. It promotes circulation and respiratory function, contributing to a quicker recovery.
4.
In the recovery room, the postoperative client suddenly becomes cyanotic. What is the most appropriate nursing action?
Correct Answer
C. Reposition the head and determine patency of the airway.
Explanation
Cyanosis suggests inadequate oxygenation. The nurse should first reposition the client's head to open the airway, ensuring proper ventilation. If cyanosis persists, calling for assistance and administering oxygen may follow. Immediate assessment and intervention are crucial for the client's safety.
5.
A client is scheduled for surgery in the morning. Preoperative orders have been written. What is most important to do before surgery?
Correct Answer
A. Have all consent forms signed.
Explanation
Ensuring all laboratory work is complete is crucial before surgery to identify and address any potential issues. It helps the surgical team make informed decisions and ensures the patient's safety during the procedure.
6.
The nurse is caring for a first-day postoperative surgical client. Prioritize the patient’s desired dietary progression. Arrange in sequence the dietary progression from 1 to 4:
1. Full liquid;
2. NPO;
3. Clear liquid;
4. Soft
Correct Answer
B. 2, 3, 1, 4
Explanation
Initially, the patient is kept on NPO to allow the digestive system to rest. Once the patient’s condition stabilizes, they are gradually moved to a clear liquid diet, then to a full liquid diet, and finally to a soft diet as their tolerance improves. This progression helps to prevent complications and aids in the patient’s recovery. Always remember, the specific dietary progression can vary based on the patient’s individual health status and the nature of the surgery. It’s important to follow the healthcare provider’s instructions.
7.
A postoperative client receives a dinner tray with gelatin, pudding, and vanilla ice cream. Based on the foods on the client’s tray, what would the nurse anticipate the client’s current diet order to be:
Correct Answer
C. Full liquid diet
Explanation
Based on the provided food items (gelatin, pudding, and vanilla ice cream), the nurse would anticipate that the client's current diet order is a full liquid diet. A full liquid diet typically includes foods that are liquid at room temperature or turn into a liquid at body temperature. Gelatin, pudding, and liquid ice cream are consistent with the items allowed on a full liquid diet.
8.
The nurse is preparing the preoperative client for surgery. The following statements indicate the client is knowledgeable about his impending surgery, except:
Correct Answer
B. “The skin prep area is going to be longer and wider than the anticipated incision.”
Explanation
This statement indicates the client's understanding of the surgical preparation. Knowing the extent of the skin prep helps prevent infection and ensures a sterile environment during surgery.
9.
Which of the following is the primary purpose of maintaining NPO for 6 to 8 hours before surgery?
Correct Answer
C. To prevent aspiration pneumonia.
Explanation
Maintaining NPO status before surgery helps prevent aspiration pneumonia. With an empty stomach, the risk of regurgitated gastric contents entering the lungs during anesthesia induction is minimized.
10.
The nurse will provide preoperative teaching on deep breathing, coughing, and turning exercises. When is the best time to provide the preoperative teachings?
Correct Answer
A. Before administration of preoperative medications.
Explanation
Providing preoperative teaching on deep breathing, coughing, and turning exercises is most effective before administering preoperative medications. This ensures the patient is alert and can actively participate in learning essential postoperative care practices.
11.
Which of the following factors ensure the validity of informed written consent, except:
Correct Answer
D. If the patient is unable to write, the nurse signs the consent for the patient.
Explanation
The nurse should not sign the consent for the patient. Informed consent requires the patient's autonomous agreement. If the patient is unable to write, a witness may confirm that the patient provided verbal consent.
12.
Which of the following drugs is administered to minimize respiratory secretions preoperatively?
Correct Answer
C. Atropine sulfate
Explanation
Atropine sulfate is administered preoperatively to minimize respiratory secretions. This helps maintain a clear airway during surgery and reduces the risk of respiratory complications.
13.
Which of the following is experienced by the patient who is under general anesthesia?
Correct Answer
A. The patient is unconscious.
Explanation
Under general anesthesia, the patient is unconscious and completely unaware. General anesthesia induces a controlled state of unconsciousness to allow surgery without pain or awareness.
14.
Which of the following is the most dangerous complication during induction of spinal anesthesia?
Correct Answer
B. Hypotension
Explanation
Hypotension is a potentially dangerous complication during induction of spinal anesthesia. It can lead to inadequate perfusion and oxygenation of vital organs, requiring prompt intervention to stabilize the patient.
15.
Which of the following postoperative patients is at risk for respiratory complications?
Correct Answer
A. The obese patient with a long history of smoking who had undergone upper abdominal surgery.
Explanation
Obesity and long history of smoking pose a high risk for respiratory complications among postop clients. The upper abdominal incision is near the diaphragm. This usually inhibits deep breathing by the client due to the anticipation of pain. This factor further contributes to risk of respiratory complications.
16.
The patient had undergone spinal anesthesia for appendectomy. To prevent spinal headaches, the nurse should place the patient in which of the following positions?
Correct Answer
B. Flat on the bed for 6 to 8 hours.
Explanation
To prevent spinal headaches, the patient should lie flat for 6 to 8 hours after spinal anesthesia. This position allows the puncture site to seal properly, minimizing the risk of cerebrospinal fluid leakage and subsequent headaches.
17.
The nurse is admitting a patient to the operating room. Which of the following nursing actions should be given the highest priority by the nurse?
Correct Answer
C. Checking the patient’s identification and correct operative permit.
Explanation
Ensuring correct patient identification and a valid operative permit is the highest priority when admitting a patient to the operating room. This step helps prevent errors and ensures the right patient undergoes the correct procedure.
18.
Which of the following assessment data is most important to determine when caring for a patient who has received spinal anesthesia?
Correct Answer
B. The character of the patient’s respiration.
Explanation
Monitoring the character of respiration is crucial after spinal anesthesia to detect any respiratory distress or complications. Changes in respiratory patterns can indicate potential issues that require prompt intervention.
19.
The nurse is transferring the patient from the postanesthesia care unit to the surgical unit. Which of the following is the primary reason for the gradual change of position of the patient?
Correct Answer
C. To prevent respiratory distress.
Explanation
The gradual change of position during transfer helps prevent respiratory distress in postoperative patients. Sudden position changes may lead to respiratory compromise, particularly in those recovering from anesthesia.
20.
The nurse is caring for a patient who has undergone exploratory laparotomy. Which of the following postop findings should the nurse report to the physician?
Correct Answer
B. The patient’s urine output has been 20 ml/hr for the past 2 hours.
Explanation
A low urine output may indicate inadequate renal perfusion and potential renal impairment. This finding should be reported to the physician for further assessment and intervention.
21.
The patient had undergone a thyroidectomy. Which of the following are the earliest signs of poor tissue perfusion and poor respiratory function?
Correct Answer
A. Cyanosis, lethargy.
Explanation
Cyanosis and lethargy are early signs of poor tissue perfusion and respiratory function. These symptoms suggest inadequate oxygenation and require immediate attention to prevent further complications.
22.
The diabetic patient who had undergone abdominal surgery experienced wound evisceration. Which of the following is the most appropriate immediate nursing action?
Correct Answer
A. Cover the wound with sterile gauze moistened with sterile normal saline.
Explanation
Covering the wound with sterile gauze moistened with sterile normal saline helps maintain a moist environment and protects exposed tissues. It is crucial for preventing further tissue damage and promoting optimal wound healing.
23.
The patient had undergone a total hip replacement. He complains of pain in the operative site. Which of the following is the appropriate initial nursing action?
Correct Answer
C. Assess the patient’s pain level and vital signs.
Explanation
Assessing the patient's pain level and vital signs is the initial nursing action to determine the appropriate intervention for postoperative pain management. It helps tailor the pain relief plan to the patient's needs.
24.
Which of the following individuals is not typically considered a member of the sterile team in an operating room?
Correct Answer
C. Radiology technician
Explanation
Radiology technicians are not part of the sterile team in the operating room. Their role involves medical imaging, such as X-rays, CT scans, and MRIs, which are typically performed in specialized radiology suites or areas outside of the surgical environment. They do not work within the sterile field during surgery.
25.
The best position for kidney, chest, or hip surgery is:
Correct Answer
D. Lateral
Explanation
The lateral position is often the best for kidney, chest, or hip surgery. It provides optimal access to these areas while maintaining patient safety and comfort during the procedure.