Question 1

The client is scheduled for surgery tomorrow.The nurse begins what type of teaching?

Accepted Answer

Preoperative teaching involves educating and preparing the patient for surgery, including instructions regarding the procedure, preoperative testing, anesthesia, and postoperative care.

Question 2

Upon receiving the client from the postanesthesia care unit,which nursing action is the priority?

Accepted Answer

Assessing the client is the priority as it helps identify any immediate concerns or changes in the client’s condition that may require prompt attention. Applying clean linens, assembling equipment, and notifying the family can be done after the client has been assessed.

Question 3

The nurse is preparing to don sterile gloves using the closed procedure.Place the steps the nurse will take in the correct order in which they should occur.

Accepted Answer

The correct order for donning sterile gloves using the closed procedure is: B) Open the sterile glove wrapper while the hands are still covered by the sleeves, C) Use the nondominant hand to grasp the cuff of the glove through the gown cuff, and firmly anchor it, A) With the dominant hand, pick up the opposite glove with the thumb and index finger, handling it through the sleeve, E) Place the fingers of the gloved hand under the cuff of the remaining glove, D) Extend the fingers into the glove as you pull the glove up over the cuff. This sequence ensures sterility is maintained throughout the process.

Question 4

The nurse administers the preoperative medication to the client 1 hour before elective surgery,and then discovers the preoperative consent is not signed.Which action by the nurse is the most appropriate?

Accepted Answer

The most appropriate action is to notify the health care provider that surgery will need to be canceled because the client has already been medicated and may not be able to give informed consent. Consent obtained after administering preoperative medication could be considered invalid due to impaired judgment.

Question 5

The postoperative client displays sudden chest pain,shortness of breath,cyanosis,tachycardia,and low blood pressure.The nurse suspects which postoperative complication?

Accepted Answer

Sudden chest pain, shortness of breath, cyanosis, tachycardia, and hypotension are all common signs of a pulmonary embolism. It is important for the nurse to recognize these symptoms and immediately notify the healthcare provider for prompt intervention. Pneumonia and atelectasis may cause shortness of breath and hypoxia, but not the sudden chest pain and tachycardia. Hypovolemia may cause low blood pressure, but not the sudden onset of chest pain and respiratory distress.

Question 6

Which tasks can the nurse assign to the unlicensed assistive personnel (UAP)who is assisting with providing care on a medical-surgical unit?

Accepted Answer

The tasks that can be delegated to the UAP include tasks that do not require nursing judgment or assessment skills, and that the UAP has been trained to perform. Reinforcing teaching previously provided by the nurse, assisting with client exercises, and reporting when a client cannot complete exercises are tasks that the UAP can perform. However, documenting assessments completed by the nurse and conducting discharge teaching require nursing judgment and assessment skills, which are outside the scope of practice of the UAP.

Question 7

The nurse works in a facility whose policy requires an antiseptic hand rub instead of a surgical scrub when performing surgical hand asepsis.Which are known advantages of the hand rub over the scrub?

Accepted Answer

Antiseptic hand rubs are less harmful to the skin than surgical scrubs because they do not require the use of a brush which can be abrasive to the skin. Hand rubs also contain ingredients that help to protect the skin, such as emollients and moisturizers. Contrarily, scrubbing can result in dryness and skin irritation. Another advantage of hand rubs is that they take less time to perform.

Question 8

The client arrives at the surgeon's office 1 week after surgery to have the sutures removed.Which classification would the nurse use when documenting care for this client?

Accepted Answer

The client has already undergone surgery and is returning for a postoperative visit to have sutures removed, making this care postoperative. Preoperative care refers to care provided before surgery, perioperative care includes care provided before and after surgery, and intraoperative care refers specifically to care provided during the surgical procedure.

Question 9

In the ongoing postoperative period,the nurse independently determines,within the protocols of the hospital,the need for which provision of care?

Accepted Answer

Assessment intervals are an important provision of care that the nurse can independently determine within hospital protocols. This includes monitoring the patient's vital signs, level of consciousness, pain level, dressing changes, and any other relevant assessments. The nurse can make adjustments to the frequency of assessments based on the patient's condition and as per hospital policies. The other options (A, B, and D) may require a physician's order or may have already been determined by the physician preoperatively.

Question 10

The nurse is assessing a client's postoperative wound and finds it has separated from the suture line with extrusion of the bowel through the opening.When documenting this finding,which term will the nurse use?

Accepted Answer

Wound evisceration is the protrusion of an internal organ through an incision or wound opening. It is a serious medical emergency that requires immediate intervention to prevent infection and further injury to the affected person.

Question 11

The nurse is caring for a client with a drain connected to a portable drainage suction device shaped like a grenade made of plastic.Which term will the nurse use when describing this system during end-of-shift report?

Accepted Answer

The portable drainage suction device described, which is shaped like a grenade and made of plastic, is known as a Jackson-Pratt drain. This is a type of closed wound drainage system that uses gentle suction to remove fluids from a surgical site.

Question 12

The nurse performs preoperative teaching for a client requiring a surgical intervention.Which actions by the client indicate appropriate understanding of the information provided?

Accepted Answer

Demonstrating proper coughing, deep breathing, leg exercises, and how to turn and get out of bed, as well as asking questions and voicing understanding, indicate the client has understood the preoperative teaching. Having no anxiety is not necessarily an indicator of understanding the information provided.

Question 13

The nurse is performing a surgical hand scrub,and holds the hands in which position when rinsing?

Accepted Answer

The hands should be held higher than the elbows when rinsing during a surgical hand scrub to prevent contamination from the arms to the hands.

Question 14

The nurse is completing the preoperative checklist on the night shift in preparation for the client's surgery,scheduled for 0800.Which tasks could the nurse complete at this time?

Accepted Answer

The nurse can check the medical record for the history, physical, and signed informed consent at any time, including during the night shift. However, administering preoperative medication and removing the prosthesis should only be done closer to the time of the surgery. Documenting the time of last voiding may also be done closer to the time of the surgery, as the client may void again before then.

Question 15

When providing preoperative teaching for the client who is scheduled for coronary artery bypass surgery in the morning,the nurse would include which dimensions?

Accepted Answer

The answer of When providing preoperative teaching for the client...

Quiz 33: Performing Perioperative Care