Question 1

Before placing antiembolism stockings on a patient for the first time, a nurse should

Accepted Answer

Having the patient lie supine for 15 minutes allows blood to redistribute, providing a more accurate assessment of the need for antiembolism stockings and ensuring they are fitted correctly.

Question 2

The wife of a patient who recently returned from a radical neck dissection asks a nurse why her husband was given scopolamine. The best response by the nurse is:

Accepted Answer

Scopolamine is an anticholinergic medication that decreases the production of saliva, which can help prevent aspiration of saliva into the lungs. This is important in patients who have undergone a radical neck dissection, as it can cause swelling and difficulty swallowing. Option A is incorrect because drying secretions does not necessarily reduce bacteria in the saliva. Option B is incorrect because scopolamine does not specifically prevent drooling. Option C is incorrect because scopolamine does not directly reduce swelling in the lips and tongue.

Question 3

A nurse recognizes that which of the following patients may receive spinal anesthesia?

Accepted Answer

Spinal anesthesia is commonly used for surgeries below the waist, such as a hemorrhoidectomy. It is generally not used for surgeries above the waist, such as a pulmonary wedge resection or a torn rotator cuff repair. While a bone marrow biopsy can be done with spinal anesthesia, it is less commonly used for this procedure.

Question 4

A nurse is providing care to a 32-year-old who returned from a thyroidectomy 6 hours ago. The nurse notes that the patient's temperature is 99.5°F and that the patient has been taking sips of clear liquids, reports mild nausea, and is using patient-controlled anesthesia to manage pain, which is 3/10. The nurse should

Accepted Answer

The nurse should document the findings, as they are within normal limits for a post-thyroidectomy patient. The patient's temperature is only slightly elevated and the mild nausea and 3/10 pain can be expected after surgery. There is no indication for a low-salt diet or assessing the back of the patient's throat, and contacting the physician is not necessary at this time.

Question 5

Which of the following members of the surgical team is responsible for monitoring a patient's vital signs during surgery?

Accepted Answer

The person responsible for monitoring a patient's vital signs during surgery is the anesthesiologist. This is because they are trained in administering and managing anesthesia, as well as monitoring the patient's vital signs and overall condition throughout the surgery. The surgeon is focused on the actual procedure being performed, the circulating nurse assists with preparing the surgical room and ensuring proper equipment is available, and the first surgical assistant assists the surgeon during the procedure.

Question 6

A nurse who is caring for a male patient after a left-side total hip replacement recognizes that further teaching is required when

Accepted Answer

This activity can put strain on the newly replaced hip joint and may cause dislocation. The other activities listed are appropriate for a patient recovering from a hip replacement surgery.

Question 7

A nurse is providing care for a patient who is wearing antiembolism hose following a colectomy. The patient's plan of care should include:

Accepted Answer

Antiembolism stockings are designed to promote circulation and prevent blood clots in patients who are at risk, such as those recovering from surgery like a colectomy. It is important to remove these stockings twice daily to allow the skin to breathe, maintain skin integrity, and perform necessary hygiene. This helps prevent skin breakdown and allows for inspection of the skin for any signs of compromise. Rolling the stockings down or leaving them off for extended periods could counteract their purpose or cause other complications.

Question 8

When determining the appropriate size of thigh-high antiembolism hose, a nurse would obtain which of the following measurements?

Accepted Answer

The correct measurement for thigh-high antiembolism hose is the length from the gluteal fold to the bottom of the heel. This ensures the hose fits properly and provides the intended therapeutic compression to prevent deep vein thrombosis.

Question 9

Which of the following is most commonly taught to help prevent postsurgical respiratory complications?

Accepted Answer

Turning, coughing, and deep breathing exercises are the most commonly taught interventions to prevent postsurgical respiratory complications such as atelectasis and pneumonia. These exercises promote lung expansion, prevent mucus from accumulating, and improve oxygenation. Splinting incisions can reduce pain and discomfort but does not directly prevent respiratory complications. The use of postsurgical compression stockings is mainly to prevent deep vein thrombosis. Measuring intake and output is important to monitor hydration status but does not prevent respiratory complications.

Question 10

A nurse is caring for a patient who received spinal anesthesia. The patient reports having a bad headache later that day. The nurse's best response is:

Accepted Answer

A headache after spinal anesthesia is a common side effect and is usually due to loss of spinal fluid. The nurse should reassure the patient and provide interventions such as encouraging fluids and bed rest. Option A is incorrect as an allergy to the anesthetic would present with symptoms such as rash, itching, and difficulty breathing. Option C may be necessary if the headache is severe, but it is not the initial best response. Option D is irrelevant to the situation.

Question 11

A nurse who is working in the post-anesthesia care unit (PACU) recognizes that a patient is most likely to experience which of the following complications while in the unit?

Accepted Answer

The answer of A nurse who is working in the...

Question 12

A nurse is caring for a female patient who is scheduled for an abdominal hysterectomy. The nurse obtains the patient's signature on the consent form and then signs the form himself. The nurse's signature indicates that

Accepted Answer

The nurse's signature on the consent form indicates that they verified that it was the patient who signed the form, not that the patient understands the risks of the procedure or that the nurse has provided information about the surgical procedure. The patient's signature indicates that they have consented to the surgery and understand the risks and benefits. The fact that the nurse signed the form does not indicate that the patient has no questions about the surgery.

Question 13

A nurse is caring for a patient who returned from abdominal surgery 6 hours ago. The nurse notes that the abdominal dressing is nearly saturated with serosanguineous drainage and that a small amount of drainage is leaking from the lower edge of the dressing. The nurse's best action is to

Accepted Answer

Reinforcing the dressing with additional gauze pads is the best immediate action to manage increased drainage and prevent contamination of the surgical site. Removing or replacing the dressing entirely may not be appropriate without specific orders, as it could risk infection or disrupt the healing process. Reinforcing the tape edges does not address the issue of the saturated dressing.

Question 14

After assisting with the transfer of a patient from the post-anesthesia care unit into a bed on the unit, a nurse should first

Accepted Answer

After transferring a patient from the post-anesthesia care unit, the nurse should perform a physical assessment to ensure that the patient is stable and there are no immediate concerns that need to be addressed. Reviewing the physician's orders and determining the type and amount of intravenous fluid hanging are important tasks, but should be done after the physical assessment. Reassuring the patient is also important, but should not be the first priority.

Question 15

A nursing instructor teaches a group of students the differences between conscious sedation and general anesthesia. According to the instructor, which of the following is a primary benefit of conscious sedation?

Accepted Answer

Conscious sedation allows the patient to remain awake and respond to verbal cues, while also providing pain relief and anxiety reduction. Unlike general anesthesia, the patient can maintain their own airway and breathing without assistance.

Question 16

A nurse would expect an International Normalized Ratio (INR) to be ordered for which of the following patients?

Accepted Answer

INR is a blood test that measures clotting time and is used to monitor blood thinners such as warfarin. Patients with liver disease such as cirrhosis are at increased risk for bleeding and may be prescribed blood thinners, making INR monitoring necessary. The other patients listed do not have conditions that typically require INR monitoring.

Question 17

A nurse who is providing care for a patient with a large abdominal wound removes the dressing and notes that the wound has dehisced. The nurse should

Accepted Answer

The nurse should cover the wound with a large sterile dressing to protect it from contamination and prevent further injury.

Question 18

A nurse is caring for a 28-year-old man who returned from the repair of a broken jaw 3 hours earlier. The patient reports an urge to urinate and tried to use the urinal in the bed without success. The best action by the nurse is to

Accepted Answer

Using a bladder scanner to determine the degree of distention is the best initial action. It is non-invasive and provides immediate information about bladder fullness, which can guide further interventions.

Question 19

A nurse who is caring for patients on a surgical unit recognizes that the individual having corrective surgery is the

Accepted Answer

Corrective surgery is aimed at fixing a specific physical problem or defect. A cleft lip repair in a 4-month-old is a classic example of corrective surgery, as it aims to correct the congenital defect of the lip.

Question 20

A nurse is providing care for a patient with a nasogastric (NG) tube in place 10 hours after removal of a portion of the stomach. The patient's plan of care would include

Accepted Answer

Providing mouth care every 4 hours would be appropriate to prevent dry mouth, reduce the risk of infection, and improve comfort for the patient. Keeping the NG to continuous high suction is not necessary or appropriate in this case, as suction may damage the healing surgical site. Draping the NG tubing over the patient's shoulder is not appropriate or safe, as it may cause kinks in the tubing or dislodgement. Providing tube feeding every 3 hours may not be appropriate immediately after surgery, as the digestive system may need time to recover and start functioning properly.

Quiz 33: Care of the Surgical Patient