Question 1

The home health nurse is visiting a patient recovering after an abdominal hysterectomy. Which of these actions should the home health nurse take before promoting patient intake of oral fluids?

Accepted Answer

The answer of The home health nurse is visiting a...

Question 2

The nurse is assisting a postoperative patient to use an incentive spirometer. Which of these patient instructions are appropriate?

Accepted Answer

Incentive spirometry is used to encourage deep breathing to prevent pulmonary complications after surgery. Instructing the patient to inhale deeply until the target is reached is the correct use of the device, as it promotes lung expansion and prevents atelectasis.

Question 3

The nurse is reviewing the medication history of a preoperative patient who is NPO. The patient is noted to have been on long-term oral steroid therapy. What action should the nurse take?

Accepted Answer

The nurse should ensure that the physician is informed of the patient's history of steroid use as the physician may need to adjust the patient's medication regimen accordingly based on the individual patient's needs and the surgery being performed. Holding the medication without physician orders or administering it topically are not appropriate actions without further clarification from the physician. Monitoring vital signs and documenting is important but does not address the specific concern related to the long-term steroid use.

Question 4

The nurse is caring for a postoperative patient at risk for deep vein thrombosis. Which of the following actions should the nurse recommend be included in the patient's plan of care? (Select all that apply.?

Accepted Answer

The nurse should recommend ambulation, antiembolic stockings, and leg exercises to promote venous blood flow and decrease the risk of deep vein thrombosis. Massaging the patient's legs could actually increase the risk of dislodging a blood clot and should not be recommended. Placing a pillow under the patient's knees may provide comfort but does not directly address the risk for deep vein thrombosis.

Question 5

The nurse is assisting in the surgical holding area. The nurse understands that which of the following schedules are recommended for prophylactic antibiotics?

Accepted Answer

Prophylactic antibiotics are recommended to be administered within 1 hour prior to surgical incision to ensure adequate tissue levels of the antibiotic at the time of surgery, reducing the risk of postoperative infections. This timing is based on clinical guidelines to maximize the effectiveness of the antibiotics and minimize the risk of surgical site infections.

Question 6

The nurse is caring for a patient in the perianesthesia unit. What is the nurse's priority responsibility for the patient while in this unit?

Accepted Answer

Maintaining a patent airway is the nurse's top priority in the perianesthesia unit, as patients may still be under the effects of anesthesia and at risk for airway obstruction or respiratory depression. While the other options are important aspects of perianesthesia care, they are lower priorities than ensuring the patient has a clear airway.

Question 7

The nurse is collecting data for a patient who had an epidural anesthetic during surgery. What finding by the nurse is a priority to report?

Accepted Answer

Hypotension is a common side effect of epidural anesthesia and can be a sign of impaired blood flow to vital organs. Therefore, it is a priority finding to report to the healthcare provider. The other choices are expected side effects of epidural anesthesia and should still be documented, but they are not as urgent as hypotension.

Question 8

The nurse is caring for a postoperative patient who 30 minutes prior to transfer from the perianesthesia unit (PACU) received an intravenous analgesic. Pain medication orders are for morphine 10 mg IM every 3 hours PRN. An hour after arrival on the nursing unit, the patient reports pain of 8 on a 0 to 10 pain scale. What action should the nurse take?

Accepted Answer

The nurse should administer the intramuscular medication as ordered for pain management, considering the patient's report of significant pain. The time since the last analgesic dose in the PACU and the different route of administration (intravenous to intramuscular) allow for this action.

Question 9

The nurse recommends early ambulation as ordered be included in the patient's plan of care. Which of the following can be prevented by early ambulation?

Accepted Answer

Early ambulation can prevent thrombophlebitis by improving blood flow and preventing blood clots from forming in the legs. It may also help promote healing and prevent complications such as pneumonia and urinary tract infections. However, it may not necessarily prevent increased peristalsis, coughing or impaired wound healing.

Question 10

The nurse is caring for a preoperative patient. The patient asks the nurse what types of anesthesia cause a loss of sensation in a specific area of the body while the patient remains alert. Which of these responses should the nurse give? (Select all that apply.?

Accepted Answer

Epidural, local, and spinal anesthesia are types of anesthesia that cause loss of sensation in specific areas of the body while the patient remains alert. General anesthesia, on the other hand, affects the entire body, causing loss of consciousness.

Question 11

The practical/vocational nurse is preparing a patient for surgery who has asthma and is hard of hearing. Which of the following are within the scope of practice for the nurse? (Select all that apply.?

Accepted Answer

The practical/vocational nurse can provide emotional support, apply antiembolism devices, assist with hearing aids, reinforce instructions, and ensure the inhaler goes with the patient. However, providing information for informed consent is outside their scope.

Question 12

The nurse is assisting during surgery when a patient develops malignant hyperthermia. Which of the following protocols would the nurse be prepared to assist with as directed?

Accepted Answer

Malignant hyperthermia (MH) is a life-threatening hypermetabolic reaction to certain anesthetic agents, most commonly seen with inhaled anesthetics and succinylcholine. The immediate priority in treating MH is to stop the triggering agents (anesthetics and muscle relaxants), cool the patient (with ice and/or a cooling blanket), administer dantrolene sodium (a medication that reduces muscle contractions by inhibiting calcium release from the sarcoplasmic reticulum), and provide supportive care such as oxygenation and hydration. The surgery should not continue until the patient's condition has stabilized. Switching to a different anesthetic agent is not recommended because many different agents can trigger MH. Warming the patient is not appropriate as MH leads to hyperthermia.

Question 13

The nurse is contributing to the intraoperative plan of care for a patient undergoing an appendectomy. Which of these would be an intraoperative outcome for this patient?

Accepted Answer

Remaining free from injury is an intraoperative outcome and is important during a surgical procedure. Verbalizing fears, demonstrating leg exercises, and stating understanding of discharge instructions are postoperative outcomes.

Question 14

The nurse works on a preoperative unit. For which of the following conditions does the nurse recognize urgent surgery is needed?

Accepted Answer

The answer of The nurse works on a preoperative unit....

Question 15

The nurse is dangling a patient with an abdominal incision, when the incision suddenly eviscerates. What action should the nurse take after positioning the patient supine with flexed knees?

Accepted Answer

The nurse should immediately cover the exposed organs with sterile saline-moistened dressings to prevent infection and cover them until surgery can be performed. Applying an abdominal binder or administering pain medication would not address the evisceration and could even exacerbate it, and cleansing the abdomen could introduce further contaminants.

Question 16

The nurse is caring for a patient after ambulatory surgery. The patient's oxygen saturation must be above what level for the nurse to consider readiness for discharge?

Accepted Answer

Oxygen saturation should be above 90% for the patient to be considered ready for discharge. A saturation level lower than 90% indicates a potential respiratory compromise and therefore, closer monitoring and intervention is required before discharge.

Question 17

The nurse has reinforced preoperative teaching with a patient about coughing and deep breathing techniques. Which of the following statements by the client would indicate a correct understanding of the teaching? (Select all that apply.?

Accepted Answer

The correct understanding of coughing and deep breathing techniques includes the understanding that they should be done frequently (every hour while awake), should be started immediately after surgery (not delayed 2 days), and are important for preventing respiratory problems. Choice B is incorrect because deep breathing should be encouraged after surgery to prevent respiratory complications, and choice C is incorrect because shallow breathing can lead to respiratory complications and should be avoided.

Question 18

The intraoperative practical/vocational nurse is caring for a patient who is undergoing abdominal surgery with general anesthesia. What interventions should the nurse implement? (Select all that apply.?

Accepted Answer

The intraoperative practical/vocational nurse's role during surgery is to assist the physician as directed, assist with patient positioning, and participate in a time out before surgery begins to ensure accuracy in the procedure. Encouraging leg exercises and monitoring for unilateral swelling of the calf are interventions typically implemented by postoperative nurses to prevent complications such as deep vein thrombosis (DVT). The intervention of assisting the patient to change position in bed every 4 hours is also a postoperative intervention.

Question 19

The nurse is caring for a patient after a hernia repair who reports pain of 4 on a 0 to 10 scale. The patient's orders include ibuprofen (Motrin) 400 mg orally every 6 hours prn for pain. Which of the following actions should the nurse take?

Accepted Answer

The patient is experiencing pain and has been ordered ibuprofen for pain relief. The nurse should administer the medication as ordered to manage the patient's pain. Holding the medication or delaying its administration could result in inadequate pain relief and poor patient outcomes. It is not necessary to consult the physician for a stronger analgesic at this point, as the patient's pain level is currently at a 4 on a 0 to 10 scale, and ibuprofen is an appropriate first-line analgesic for mild to moderate pain.

Question 20

The nurse is caring for a preoperative patient who expresses a fear of dying. What action should the nurse take?

Accepted Answer

Allowing the patient time to express concerns is the best action to take as it acknowledges the patient's anxiety and provides an opportunity for the nurse to address the patient's fears and provide reassurance. Telling the patient everything will be all right may come across as dismissive and not address the patient's concerns. Explaining national death rates may further increase the patient's anxiety. Asking the family to comfort the patient is not necessarily the best action as the patient may prefer to discuss their fears with the healthcare provider.

Quiz 12: Nursing Care of Patients Having Surgery