Meds-surg Perioperative Nursing care Chp 16 - 18
NCLEX® Examination Challenges and Decision-Making Challenges
- 1.On admission to the preoperative area, the client scheduled for a hip replacement tells the nurse that three autologous blood donations for this surgery have been made in the past 3 weeks. What is the nurse’s best action?
- A.
A. Check the client’s international normalized ratio (INR).
- B.
B. Call the laboratory to ensure that the blood is physically at the operating facility.
- C.
C. Ensure that the client has given consent to receive blood if a transfusion is necessary.
- D.
D. Inform the client that an autologous transfusion does not eliminate the risk for development of bloodborne diseases.
- 2.The client scheduled for knee replacement surgery today performed all of the following actions yesterday. Which action is most important for the nurse to report to the surgeon?
- A.
A. Took 50 mg of diphenhydramine (Benadryl) at bedtime
- B.
B. Smoked one pack of cigarettes instead of two
- C.
C. Drank two 12-ounce glasses of beer
- D.
D. Took two aspirins three times
- 3.For which client preadmission testing laboratory result does the nurse take immediate action?
- A.
A. International normalized ratio 0.9
- B.
B. White blood cell count 8500/mm3
- C.
C. Serum potassium level 2.8 mEq/L
- D.
D. Serum sodium level 132 mEq/L
- 4.The client scheduled to have surgery today cannot read or write. The surgeon obtaining the consent wants to have the client’s spouse sign the consent instead. What is the nurse’s best action?
- A.
A. Nothing; a signed informed consent statement does not need to be obtained from this client.
- B.
B. Locate the spouse because the informed consent statement must be signed by the client’s closest relative.
- C.
C. Remind the surgeon that the client may sign the informed consent statement with an X in front of two witnesses.
- D.
D. Notify the administration because the court must appoint a legal guardian to represent the client’s best interests and give consent for all surgical procedures.
- 5.The client is NPO for surgery scheduled to occur in 4 hours. It is now 9 am, and the client’s regularly prescribed oral drugs (digoxin 0.125 mg, docusate [Colace] 300 mg, and ferrous fumarate [Feostat] 325 mg) are due to be administered. The physician will not be available until the time of surgery. What is the nurse’s best action?
- A.
A. Administer digoxin with minimal water and hold the other drugs.
- B.
B. Administer all medications parenterally.
- C.
C. Administer all medications orally.
- D.
D. Hold all medications.
- 6.The client brought to the holding area before surgery tells the nurse he has never had surgery before and is afraid of anything “medical.” Which nursing action is most likely to reduce this client’s anxiety?
- A.
A. Administering the preoperative medication as soon as possible.
- B.
B. Assuring the client that his scheduled surgery is routine and that nothing will go wrong.
- C.
C. Determining whether the client wants family members to be with him in the holding area.
- D.
D. Explaining to the client that this hospital’s surgical area is the most technologically advanced in the city.
- 7.The circulating nurse sees that a sponge is dropped onto the floor from the instrument table after the first surgical incision is opened. What is this nurse’s best action?
- A.
A. Obtain an additional sterile sponge to replace the contaminated one and place it on the instrument table.
- B.
B. Place the sponge in the circulating area to include in the final count before incision closure.
- C.
C. Pick up the sponge and throw it out so no one slips on it.
- D.
D. Hand the sponge back to the scrub nurse.
- 8.The client undergoing induction of anesthesia with succinylcholine, a depolarizing blocker agent, begins to experience generalized muscle twitching. What the circulating nurse’s best response?
- A.
A. Call the anesthesia provider’s attention to this response.
- B.
B. Ensure the client is secured to the table.
- C.
C. Cover the client with a warm blanket.
- D.
D. Document this expected response.
- 9.The postanesthesia recovery unit nurse is receiving a hand-off report from the nurse anesthetist and the circulating nurse for an 82-year-old client who had a 2-hour open reduction of a fractured elbow. For which reported information about the client or surgery does the receiving nurse ask the reporting team for more details?
- A.
A. The client is Jewish.
- B.
B. The estimated blood loss is 150 mL.
- C.
C. The client reported an allergy to codeine.
- D.
D. The total intraoperative urine output is 25 mL.
- 10.A postoperative client’s arterial blood gas (ABG) values are pH 7.36, HCO3 21 mEq/L, Paco2 35 mm Hg, Pao2 98 mm Hg. What is the nurse’s priority action?
- A.
A. Compare these values with the client’s preoperative ABG values.
- B.
B. Assess the airway and notify the physician.
- C.
C. Document the values as the only action.
- D.
D. Increase the oxygen flow rate.
- 11.The client who had neck surgery to remove the entire thyroid gland is transferred to the medical-surgical unit after 4 hours in the PACU. The client reports difficulty swallowing. What is the nurse’s priority action?
- A.
A. Assess the client’s respiratory status.
- B.
B. Inspect the client’s throat with a penlight.
- C.
C. Adjust the position of the drain in the incision.
- D.
D. Reassure the client that this is a normal and common problem after anesthesia.
- 12.When changing the client’s abdominal dressing on the second postoperative day, the nurse observes crusting on about half of the suture line and oozing of a small amount of serosanguineous drainage. What is the nurse’s best action?
- A.
A. Loosen the sutures or staples in the area where crusts have formed.
- B.
B. Clean the suture line with sterile saline and apply new dressings.
- C.
C. Gently remove the crusts and culture the material beneath.
- D.
D. Apply pressure over the incision and notify the surgeon.
Questions: 70 | Attempts: 52751 | Last updated: Jul 28, 2020
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