Question 1

The postoperative care nurse is reviewing the documentation from the intraoperative phase of a client's surgical procedure. Which information should the nurse anticipate finding on the intraoperative documentation? Select all that apply.

A)Pain assessment
B)Start and stop times of anesthesia
C)Medication review
D)Antibiotic infusion times
E)Start and stop times of the procedure

Start and stop times of anesthesia
Antibiotic infusion times
Start and stop times of the procedure

Accepted Answer

A)Intraoperative documentation is to include documentation about specific times, such as the start and stop times of anesthesia, antibiotic infusion times, and start and stop times of the procedure. The pain assessment and medication review are documented during both the preoperative and postoperative assessments.
B)Intraoperative documentation is to include documentation about specific times, such as the start and stop times of anesthesia, antibiotic infusion times, and start and stop times of the procedure. The pain assessment and medication review are documented during both the preoperative and postoperative assessments.
C)Intraoperative documentation is to include documentation about specific times, such as the start and stop times of anesthesia, antibiotic infusion times, and start and stop times of the procedure. The pain assessment and medication review are documented during both the preoperative and postoperative assessments.
D)Intraoperative documentation is to include documentation about specific times, such as the start and stop times of anesthesia, antibiotic infusion times, and start and stop times of the procedure. The pain assessment and medication review are documented during both the preoperative and postoperative assessments.
E)Intraoperative documentation is to include documentation about specific times, such as the start and stop times of anesthesia, antibiotic infusion times, and start and stop times of the procedure. The pain assessment and medication review are documented during both the preoperative and postoperative assessments.

Question 2

The nurse is preparing a client for emergency surgery to repair liver and colon lacerations caused by a motor vehicle crash. Which information about this type of surgery will the nurse use to guide the client's care? Select all that apply.

A)An organ is going to be removed.
B)This is an emergency surgery.
C)The client will be hospitalized longer.
D)The client is at risk for blood loss.
E)The client is at risk for hypothermia.

This is an emergency surgery.
The client will be hospitalized longer.
The client is at risk for blood loss.
The client is at risk for hypothermia.

Accepted Answer

A)The client is having surgery to repair lacerations. No organ is identified for removal. Emergency surgery is performed when a condition is life threatening. Surgery to control internal hemorrhage from lacerations is an example of emergency surgery. An open procedure usually requires a longer hospital stay. Open procedures place the client at a higher risk for blood loss. Larger incisions place the client at a higher risk for complications, such as hypothermia and surgical site infections (SSIs).
B)The client is having surgery to repair lacerations. No organ is identified for removal. Emergency surgery is performed when a condition is life-threatening. Surgery to control internal hemorrhage from lacerations is an example of emergency surgery. An open procedure usually requires a longer hospital stay. Open procedures place the client at a higher risk for blood loss. Larger incisions place the client at a higher risk for complications, such as hypothermia and surgical site infections (SSIs).
C)The client is having surgery to repair lacerations. No organ is identified for removal. Emergency surgery is performed when a condition is life-threatening. Surgery to control internal hemorrhage from lacerations is an example of emergency surgery. An open procedure usually requires a longer hospital stay. Open procedures place the client at a higher risk for blood loss. Larger incisions place the client at a higher risk for complications, such as hypothermia and surgical site infections (SSIs).
D)The client is having surgery to repair lacerations. No organ is identified for removal. Emergency surgery is performed when a condition is life-threatening. Surgery to control internal hemorrhage from lacerations is an example of emergency surgery. An open procedure usually requires a longer hospital stay. Open procedures place the client at a higher risk for blood loss. Larger incisions place the client at a higher risk for complications, such as hypothermia and surgical site infections (SSIs).
E)The client is having surgery to repair lacerations. No organ is identified for removal. Emergency surgery is performed when a condition is life-threatening. Surgery to control internal hemorrhage from lacerations is an example of emergency surgery. An open procedure usually requires a longer hospital stay. Open procedures place the client at a higher risk for blood loss. Larger incisions place the client at a higher risk for complications, such as hypothermia and surgical site infections (SSIs).

Question 3

A nurse was involved in the perioperative care of a preterm infant requiring cardiothoracic surgery. The infant has now been moved to the NICU. How should the nurse change the focus of her assessment in the postoperative phase?

A)The nurse should assess the client as preterm.
B)The nurse should assess the client's respiratory status.
C)The nurse should assess the client's glucose levels.
D)The nurse should assess the parents' coping mechanisms.

Accepted Answer

A)The postoperative infant client will most often be transferred to and cared for in the neonatal intensive care unit (NICU)at the facility at which the infant had the procedure. At this stage, the nurse should focus largely on support for the parents. Assessment of parents' grief, guilt, anxiety, and coping mechanisms is necessary so that the nurse may better assist the infant in receiving necessary care required from the parents. Assessing the client as preterm happens during preoperative care. Assessing the client's respiratory status is given special care during the transition into intraoperative care, and regulating the client's glucose levels happens during intraoperative care. Assessing the client in these areas would not be a change in focus for the nurse.
B)The postoperative infant client will most often be transferred to and cared for in the neonatal intensive care unit (NICU)at the facility at which the infant had the procedure. At this stage, the nurse should focus largely on support for the parents. Assessment of parents' grief, guilt, anxiety, and coping mechanisms is necessary so that the nurse may better assist the infant in receiving necessary care required from the parents. Assessing the client as preterm happens during preoperative care. Assessing the client's respiratory status is given special care during the transition into intraoperative care, and regulating the client's glucose levels happens during intraoperative care. Assessing the client in these areas would not be a change in focus for the nurse.
C)The postoperative infant client will most often be transferred to and cared for in the neonatal intensive care unit (NICU)at the facility at which the infant had the procedure. At this stage, the nurse should focus largely on support for the parents. Assessment of parents' grief, guilt, anxiety, and coping mechanisms is necessary so that the nurse may better assist the infant in receiving necessary care required from the parents. Assessing the client as preterm happens during preoperative care. Assessing the client's respiratory status is given special care during the transition into intraoperative care, and regulating the client's glucose levels happens during intraoperative care. Assessing the client in these areas would not be a change in focus for the nurse.
D)The postoperative infant client will most often be transferred to and cared for in the neonatal intensive care unit (NICU)at the facility at which the infant had the procedure. At this stage, the nurse should focus largely on support for the parents. Assessment of parents' grief, guilt, anxiety, and coping mechanisms is necessary so that the nurse may better assist the infant in receiving necessary care required from the parents. Assessing the client as preterm happens during preoperative care. Assessing the client's respiratory status is given special care during the transition into intraoperative care, and regulating the client's glucose levels happens during intraoperative care. Assessing the client in these areas would not be a change in focus for the nurse.

Question 4

While receiving report from the operating room, the nurse learns that a client's surgical wound after gallbladder removal is classified as III. What does this classification tell the nurse? Select all that apply.

A)The alimentary tract was not entered.
B)The wound is necrotic and infected.
C)Gallbladder contents spilled into the surgical site.
D)A break in sterility occurred during the surgery.
E)The alimentary, respiratory, genital, or urinary tract was entered.

Accepted Answer

A)An incision is classified as III-contaminated if gross spillage from the GI tract occurred. This classification is also identified if a major break in sterile technique occurred. An incision is classified as I-clean if the alimentary, respiratory, genital, and urinary tract are not entered. An incision is classified as IV-dirty, infected if the wound is necrotic and infected. An incision is classified as II-lean contaminated if there are no signs of infection but the alimentary, respiratory, genital, or urinary tracts were entered.
B)An incision is classified as III-contaminated if gross spillage from the GI tract occurred. This classification is also identified if a major break in sterile technique occurred. An incision is classified as I-clean if the alimentary, respiratory, genital, and urinary tract are not entered. An incision is classified as IV-dirty, infected if the wound is necrotic and infected. An incision is classified as II-lean contaminated if there are no signs of infection but the alimentary, respiratory, genital, or urinary tracts were entered.
C)An incision is classified as III-contaminated if gross spillage from the GI tract occurred. This classification is also identified if a major break in sterile technique occurred. An incision is classified as I-clean if the alimentary, respiratory, genital, and urinary tract are not entered. An incision is classified as IV-dirty, infected if the wound is necrotic and infected. An incision is classified as II-lean contaminated if there are no signs of infection but the alimentary, respiratory, genital, or urinary tracts were entered.
D)An incision is classified as III-contaminated if gross spillage from the GI tract occurred. This classification is also identified if a major break in sterile technique occurred. An incision is classified as I-clean if the alimentary, respiratory, genital, and urinary tract are not entered. An incision is classified as IV-dirty, infected if the wound is necrotic and infected. An incision is classified as II-lean contaminated if there are no signs of infection but the alimentary, respiratory, genital, or urinary tracts were entered.
E)An incision is classified as III-contaminated if gross spillage from the GI tract occurred. This classification is also identified if a major break in sterile technique occurred. An incision is classified as I-clean if the alimentary, respiratory, genital, and urinary tract are not entered. An incision is classified as IV-dirty, infected if the wound is necrotic and infected. An incision is classified as II-lean contaminated if there are no signs of infection but the alimentary, respiratory, genital, or urinary tracts were entered.

Question 5

The postoperative nurse is planning care for a client recovering from major thoracic surgery. Which nursing diagnoses should the nurse select to plan for this client's immediate care needs? Select all that apply.

A)Risk for Impaired Gas Exchange
B)Risk for Decreased Cardiac Output
C)Deficient Knowledge
D)Risk for Imbalanced Nutrition: Less than Body Requirements
E)Risk for Imbalanced Fluid Volume

Accepted Answer

A)Nursing diagnoses appropriate for the immediate postoperative phase include the Risk for Impaired Gas Exchange because of anesthesia medications and hypothermia, the Risk for Decreased Cardiac Output because of anesthesia, and the Risk for Imbalanced Fluid Volume because of blood loss and nothing by mouth status. Deficient Knowledge is a diagnosis more appropriate to the preoperative phase before surgery. There is no Risk for Imbalanced Nutrition: Less than Body Requirements during the immediate postoperative phase.
B)Nursing diagnoses appropriate for the immediate postoperative phase include the Risk for Impaired Gas Exchange because of anesthesia medications and hypothermia, the Risk for Decreased Cardiac Output because of anesthesia, and the Risk for Imbalanced Fluid Volume because of blood loss and nothing by mouth status. Deficient Knowledge is a diagnosis more appropriate to the preoperative phase before surgery. There is no Risk for Imbalanced Nutrition: Less than Body Requirements during the immediate postoperative phase.
C)Nursing diagnoses appropriate for the immediate postoperative phase include the Risk for Impaired Gas Exchange because of anesthesia medications and hypothermia, the Risk for Decreased Cardiac Output because of anesthesia, and the Risk for Imbalanced Fluid Volume because of blood loss and nothing by mouth status. Deficient Knowledge is a diagnosis more appropriate to the preoperative phase before surgery. There is no Risk for Imbalanced Nutrition: Less than Body Requirements during the immediate postoperative phase.
D)Nursing diagnoses appropriate for the immediate postoperative phase include the Risk for Impaired Gas Exchange because of anesthesia medications and hypothermia, the Risk for Decreased Cardiac Output because of anesthesia, and the Risk for Imbalanced Fluid Volume because of blood loss and nothing by mouth status. Deficient Knowledge is a diagnosis more appropriate to the preoperative phase before surgery. There is no Risk for Imbalanced Nutrition: Less than Body Requirements during the immediate postoperative phase.
E)Nursing diagnoses appropriate for the immediate postoperative phase include the Risk for Impaired Gas Exchange because of anesthesia medications and hypothermia, the Risk for Decreased Cardiac Output because of anesthesia, and the Risk for Imbalanced Fluid Volume because of blood loss and nothing by mouth status. Deficient Knowledge is a diagnosis more appropriate to the preoperative phase before surgery. There is no Risk for Imbalanced Nutrition: Less than Body Requirements during the immediate postoperative phase.

Question 6

How often should a client be monitored during the intraoperative phase?&#10;A)Every 5 minutes&#10;B)Every 30 minutes&#10;C)Constantly&#10;D)Occasionally

Accepted Answer

A)Constant monitoring of both the surgical environment and the client is necessary to ensure client safety. Monitoring the client every 5 minutes, every 30 minutes, or just occasionally could miss an important change in the client's status that could result in client harm or adverse complications.
B)Constant monitoring of both the surgical environment and the client is necessary to ensure client safety. Monitoring the client every 5 minutes, every 30 minutes, or just occasionally could miss an important change in the client's status that could result in client harm or adverse complications.
C)Constant monitoring of both the surgical environment and the client is necessary to ensure client safety. Monitoring the client every 5 minutes, every 30 minutes, or just occasionally could miss an important change in the client's status that could result in client harm or adverse complications.
D)Constant monitoring of both the surgical environment and the client is necessary to ensure client safety. Monitoring the client every 5 minutes, every 30 minutes, or just occasionally could miss an important change in the client's status that could result in client harm or adverse complications.

Question 7

Which of the following statements best describes the vital signs the nurse collects during the preoperative phase?&#10;A)They are the only vital signs collected during the perioperative period.&#10;B)When later vital signs are taken, they are compared against the preoperative set.&#10;C)Generally preoperative vital signs are only relevant during the intraoperative process.&#10;D)These are not essential and may be omitted for emergency surgeries.

Accepted Answer

A)Vital signs, including blood pressure, pulse, respiration, and oxygen saturation, should be taken throughout the perioperative period, with the baseline vital signs being obtained during the preoperative phase. Later vital signs will be compared against this baseline. Preoperative vital signs are not the only vital signs collected during the perioperative period, they are relevant through the perioperative period as a baseline, and they are important to record for any client.
B)Vital signs, including blood pressure, pulse, respiration, and oxygen saturation, should be taken throughout the perioperative period, with the baseline vital signs being obtained during the preoperative phase. Later vital signs will be compared against this baseline. Preoperative vital signs are not the only vital signs collected during the perioperative period, they are relevant through the perioperative period as a baseline, and they are important to record for any client.
C)Vital signs, including blood pressure, pulse, respiration, and oxygen saturation, should be taken throughout the perioperative period, with the baseline vital signs being obtained during the preoperative phase. Later vital signs will be compared against this baseline. Preoperative vital signs are not the only vital signs collected during the perioperative period, they are relevant through the perioperative period as a baseline, and they are important to record for any client.
D)Vital signs, including blood pressure, pulse, respiration, and oxygen saturation, should be taken throughout the perioperative period, with the baseline vital signs being obtained during the preoperative phase. Later vital signs will be compared against this baseline. Preoperative vital signs are not the only vital signs collected during the perioperative period, they are relevant through the perioperative period as a baseline, and they are important to record for any client.

Question 8

The nurse is providing teaching to a client who is scheduled to undergo surgery in 2 weeks. Which topics should the nurse include that will prepare the client to help reduce complications during the postoperative phase? Select all that apply.

A)Maintaining a patent airway
B)Deep breathing and coughing
C)Caring for the surgical incision
D)Managing constipation
E)Managing pain

Accepted Answer

A)Maintaining a patent airway is a nursing action that is performed during and after surgery; the client would not need client teaching about how to maintain a patent airway. In the preoperative phase, when the client is alert and oriented, the nurse should focus teaching on deep breathing and coughing exercises, care of the surgical incision, managing constipation, and managing pain. This knowledge will help the client reduce complications after the surgery.
B)Maintaining a patent airway is a nursing action that is performed during and after surgery; the client would not need client teaching about how to maintain a patent airway. In the preoperative phase, when the client is alert and oriented, the nurse should focus teaching on deep breathing and coughing exercises, care of the surgical incision, managing constipation, and managing pain. This knowledge will help the client reduce complications after the surgery.
C)Maintaining a patent airway is a nursing action that is performed during and after surgery; the client would not need client teaching about how to maintain a patent airway. In the preoperative phase, when the client is alert and oriented, the nurse should focus teaching on deep breathing and coughing exercises, care of the surgical incision, managing constipation, and managing pain. This knowledge will help the client reduce complications after the surgery.
D)Maintaining a patent airway is a nursing action that is performed during and after surgery; the client would not need client teaching about how to maintain a patent airway. In the preoperative phase, when the client is alert and oriented, the nurse should focus teaching on deep breathing and coughing exercises, care of the surgical incision, managing constipation, and managing pain. This knowledge will help the client reduce complications after the surgery.
E)Maintaining a patent airway is a nursing action that is performed during and after surgery; the client would not need client teaching about how to maintain a patent airway. In the preoperative phase, when the client is alert and oriented, the nurse should focus teaching on deep breathing and coughing exercises, care of the surgical incision, managing constipation, and managing pain. This knowledge will help the client reduce complications after the surgery.

Question 9

The nurse is providing teaching to a client who is about to undergo surgery. When discussing whom the client can expect to see in the operating room suite, which individuals should the nurse include? Select all that apply.

A)Surgeon
B)Postoperative nurse
C)Circulating nurse
D)Anesthesiologist
E)Social worker

Accepted Answer

A)The surgeon performs the procedure. The postoperative nurse will provide care to the client after the surgery is completed. The circulating nurse is a perioperative registered nurse who cares for the client during the surgical procedure. The anesthesiologist provides the anesthesia during the surgery and continually monitors the client's physiologic status. The social worker will not be in attendance during the procedure but may become involved in the client's care during the preoperative and postoperative phases.
B)The surgeon performs the procedure. The postoperative nurse will provide care to the client after the surgery is completed. The circulating nurse is a perioperative registered nurse who cares for the client during the surgical procedure. The anesthesiologist provides the anesthesia during the surgery and continually monitors the client's physiologic status. The social worker will not be in attendance during the procedure but may become involved in the client's care during the preoperative and postoperative phases.
C)The surgeon performs the procedure. The postoperative nurse will provide care to the client after the surgery is completed. The circulating nurse is a perioperative registered nurse who cares for the client during the surgical procedure. The anesthesiologist provides the anesthesia during the surgery and continually monitors the client's physiologic status. The social worker will not be in attendance during the procedure but may become involved in the client's care during the preoperative and postoperative phases.
D)The surgeon performs the procedure. The postoperative nurse will provide care to the client after the surgery is completed. The circulating nurse is a perioperative registered nurse who cares for the client during the surgical procedure. The anesthesiologist provides the anesthesia during the surgery and continually monitors the client's physiologic status. The social worker will not be in attendance during the procedure but may become involved in the client's care during the preoperative and postoperative phases.
E)The surgeon performs the procedure. The postoperative nurse will provide care to the client after the surgery is completed. The circulating nurse is a perioperative registered nurse who cares for the client during the surgical procedure. The anesthesiologist provides the anesthesia during the surgery and continually monitors the client's physiologic status. The social worker will not be in attendance during the procedure but may become involved in the client's care during the preoperative and postoperative phases.

Question 10

The postoperative recovery room nurse determines that a client in the postoperative phase of care can be transitioned to phase 2 of recovery. The client is able to take deep breaths and cough, is using oxygen to maintain a saturation of greater than 90%, is fully awake, has a systolic blood pressure that is 130 mmHg now but the preoperative systolic blood pressure was 100 mmHg, and is able to move all four extremities independently. Using the following scale, this client's Aldrete score is ________.
The Aldrete score:
Respiration
2 = Able to take deep breath and cough
1 = Dyspnea/shallow breathing
0 = Apnea
O₂ Saturation
2 = Maintains >92% on room air
1 = Needs O2 inhalation to maintain O₂ saturation >90%
0 = Saturation <90% even with supplemental oxygen
Consciousness
2 = Fully awake
1 = Arousable on calling
0 = Not responding
Circulation
2 = BP 20% preop
1 = BP 20-49% preop
0 = BP 50% preop
Activity
2 = Able to move 4 extremities
1 = Able to move 2 extremities
0 = Able to move 0 extremities

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افتح القفل للوصول البطاقات البالغ عددها 17 في هذه المجموعة.

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k this deck

Accepted Answer

The answer of The postoperative recovery room nurse determines that...

Question 11

The nurse is preparing an older adult client for surgery. On which topics should the nurse focus when preparing this client's preoperative teaching? Select all that apply.&#10;A)Level of hearing&#10;B)Amount of anesthesia needed during surgery&#10;C)Teaching on deep breathing and coughing&#10;D)Plans for discharge care&#10;E)Actions to prevent pressure ulcers

Accepted Answer

The answer of The nurse is preparing an older adult...

Question 12

What drug may be used to treat nausea and vomiting associated with operative procedures?&#10;A)Metoclopramide&#10;B)Acetaminophen&#10;C)Midazolam&#10;D)Fentanyl

Accepted Answer

The answer of What drug may be used to treat...

Question 13

Which of the following situations demands that all perioperative staff cover their bodies with lead shields?&#10;A)The surgical team uses a bipolar handpiece to cauterize a client's tissue.&#10;B)The surgical team uses a class 3 laser to cut a client's kidney stone.&#10;C)The surgical team uses a pneumatic tourniquet to cut off circulation to a client's hand.&#10;D)The surgical team uses radiology to take intraoperative photos.

Accepted Answer

The answer of Which of the following situations demands that...

Question 14

A prothrombin time (PT)test measures which of the following?&#10;A)Time required for the client's blood to clot&#10;B)Time required for the client's plasma to clot&#10;C)Time required for platelets to effectively stop bleeding&#10;D)Time required for a surgical procedure

Accepted Answer

The answer of A prothrombin time (PT)test measures which of...

Question 15

A client with terminal cancer is undergoing surgery to partially remove a tumor that is pressing on a nerve and causing pain. This is classified as what type of surgery?&#10;A)Reconstructive&#10;B)Diagnostic&#10;C)Palliative&#10;D)Emergency

Accepted Answer

The answer of A client with terminal cancer is undergoing...

Question 16

A client presents with decreased blood volume, hypotension, tachycardia, and tachypnea during surgery. Which of the following intraoperative complications is most likely?&#10;A)Hypovolemia&#10;B)Hypervolemia&#10;C)Hypokalemia&#10;D)Hypernatremia

Accepted Answer

The answer of A client presents with decreased blood volume,...

Question 17

What is characteristic of assessment in perioperative care?&#10;A)It is primarily a component of preoperative care.&#10;B)It is used most often during the intraoperative process.&#10;C)It primarily is involved in evaluating clients during postoperative care.&#10;D)It is involved in every part of the perioperative process.

Accepted Answer

The answer of What is characteristic of assessment in perioperative...

Deck 17: Perioperative Care