Question 1

Which assessment findings indicate increased risk of infection following hip replacement surgery?&#10;A) The patient has been a type 2 diabetic for the last 5 years.&#10;B) The patient had an indwelling urinary catheter during surgery.&#10;C) The patient takes adalimumab for rheumatoid arthritis.&#10;D) The patient received two units of packed red blood cells after surgery.&#10;E) The patient's platelet count has been 300,000 to 350,000/mm&#179; after surgery

Accepted Answer

Diabetes,urinary catheterization,rheumatoid arthritis,and immunosuppressant medication all increase the risk of infection for the patient.Need for transfusion and normal platelet counts do not increase the risk of infection.

Question 2

Which is the most appropriate outcome for the postoperative patient with the nursing diagnosis ineffective breathing pattern related to side effects of pain medication?&#10;A) The patient will correctly demonstrate how to use pursed-lip breathing.&#10;B) The patient will report the ability to breathe comfortably without anxiety.&#10;C) The patient's pulse oximetry will stay greater than 94% with at least 12 breaths/minute.&#10;D) The patient will rest comfortably and rate pain no higher than 4 on 0-to-10 scale.

Accepted Answer

The appropriate outcome for ineffective breathing pattern is that the patient's pulse oximetry will stay greater than 94% with at least 12 breaths/minute.Pursed-lip breathing will not be of benefit for respiratory depression due to pain medication.Comfortable breathing is not as measurable as pulse oximetry and respiratory rate.Pain rating is not an appropriate outcome for ineffective breathing pattern.

Question 3

Which is the priority outcome for the patient with the nursing diagnosis fluid volume deficit related to ongoing postoperative bleeding?&#10;A) The patient's urine output will be at least 30 mL/hour.&#10;B) The patient's temperature will remain within normal limits.&#10;C) The patient's surgical incision will remain intact with sutures.&#10;D) The patient will verbalize measures to reduce fluid volume loss.

Accepted Answer

Urine output is a sensitive indicator of fluid volume.Urine output of at least 30 mL/hour is an indicator that the patient's fluid volume is not significantly low.Temperature and incision appearance are not appropriate outcomes for fluid volume deficit.It is not appropriate to expect the patient to verbalize measures to stop postoperative bleeding.

Question 4

Which nursing diagnosis is the highest priority for a patient who just underwent hip replacement surgery?&#10;A) Risk for perioperative positioning injury related to anesthesia,immobilization&#10;B) Dressing/grooming self-care deficit related to inability to bend over or cross legs&#10;C) Impaired walking related to toe-touch weight bearing to operative lower extremity&#10;D) Risk for injury related to dislodgement of prosthesis,unsteadiness with ambulation

Accepted Answer

Risk for injury is the highest priority nursing diagnosis for this patient as the patient could fall or damage the prosthesis.Impaired walking and dressing/grooming self-care deficit are lower-priority nursing diagnoses.Risk for perioperative positioning injury is not applicable as the surgery is complete.

Question 5

The postanesthesia care unit nurse receives a patient from the operating room.Which assessment will the nurse perform first?&#10;A) Foley catheter and surgical fluid intake&#10;B) Intravenous lines for patency or redness&#10;C) Airway,lung sounds,and pulse oximetry&#10;D) Nasogastric tube and presence of bowel sounds

Accepted Answer

The priority assessment is airway and oxygenation.Urinary output,intravenous lines,and bowel sounds may be assessed afterward.

Question 6

The nurse is caring for a patient with shallow respirations and diminished breath sounds following abdominal surgery yesterday.Which are the appropriate actions of the nurse?&#10;A) Assist the patient to sit up in the chair and ambulate in the hallway.&#10;B) Watch the patient use the incentive spirometer and ensure hourly usage.&#10;C) Teach the patient to splint the incision when coughing to minimize pain.&#10;D) Dim the lights,provide warm blankets,and maintain a quiet environment.&#10;E) Maintain patient privacy and use therapeutic touch as desired by the patient.

Accepted Answer

Assisting the patient to sit up in the chair and ambulate in the hallway will facilitate chest expansion for deeper breaths.Incentive spirometry is crucial for prevention of atelectasis and pneumonia.The patient should be taught to splint the incision when coughing to minimize pain.A peaceful environment,privacy,and therapeutic touch will not help prevent atelectasis or pneumonia.

Question 7

Four hours after major abdominal surgery,the nurse notes that the patient does not have any bowel sounds.What is the appropriate action of the nurse?&#10;A) Notify the surgeon immediately and prepare the patient for emergency surgery.&#10;B) Keep the patient NPO and document the finding in the patient's medical record.&#10;C) Allow the patient to have clear liquids as tolerated to help bowel function return.&#10;D) Provide meticulous oral care and allow the patient to have ice chips for dry mouth.

Accepted Answer

Absence of bowel sounds is common for the first few hours to days following major abdominal surgery.The nurse should keep the patient NPO as any oral intake will lead to nausea and vomiting.The surgeon does not need to be notified and the patient does not require emergency surgery.

Question 8

Which assessment finding indicates that the patient is at high risk for development of pulmonary embolism?&#10;A) The patient's platelet count was 45,000/mm&#179; this morning.&#10;B) The patient's last bowel movement was before surgery,4 days ago.&#10;C) The patient has refused enoxaparin injections after surgery.&#10;D) The patient required transfusion of two units of packed red blood cells.

Accepted Answer

Enoxaparin is a low-molecular-weight heparin used to prevent DVT and pulmonary embolism (PE).The refusal of enoxaparin significantly increases the patient's risk of developing DVT or PE.Normal platelet count is 150,000 to 400,000/mm³ so the patient with a 45,000/mm³ platelet count is at risk of hemorrhage.Bowel movement and transfusion do not increase risk of DVT or PE.

Question 9

Which is the priority nursing diagnosis for a patient with shallow respirations following abdominal surgery?&#10;A) Ineffective breathing pattern related to incisional pain and anesthesia&#10;B) Deficient diversional activity related to boredom from hospitalization&#10;C) Readiness for enhanced comfort related to desire for rest after surgery&#10;D) Risk for suffocation related to emotional and cognitive stress after surgery

Accepted Answer

Ineffective breathing pattern is the priority nursing diagnosis because the patient's respirations are shallow after surgery.The patient is at risk for developing pneumonia or atelectasis if the nurse does not encourage deep breathing.Deficient diversional activity and readiness for enhanced comfort are not priority diagnoses.Risk for suffocation is not applicable as stress after surgery would not lead to suffocation.

Question 10

Which surgical procedure may be performed using conscious sedation?&#10;A) Knee-replacement surgery&#10;B) Coronary artery bypass surgery&#10;C) Cataract removal with lens implant&#10;D) Modified radical mastectomy surgery

Accepted Answer

Conscious sedation may be used for minor surgical procedures such as endoscopy or cataract removal.Major surgeries such as joint replacement,heart bypass,and mastectomy require spinal or general anesthesia.

Question 11

Which assessment finding leads the nurse to question the order to remove the patient's indwelling urinary catheter?&#10;A) The patient does not wish to get out of bed and ambulate to the toilet.&#10;B) The patient just underwent radical prostatectomy surgery 2 days ago.&#10;C) The drainage bag contains 300 mL of clear yellow urine from the last 4 hours.&#10;D) The patient is to be discharged home after a final assessment by the surgeon.

Accepted Answer

The answer of Which assessment finding leads the nurse to...

Question 12

Which type of anesthesia will the patient receive during surgery on the cervical spine?&#10;A) Local&#10;B) Spinal&#10;C) General&#10;D) Epidural

Accepted Answer

The answer of Which type of anesthesia will the patient...

Question 13

Which surgery is classified as a palliative procedure?&#10;A) Release of bowel obstruction in a patient with end-stage colon cancer&#10;B) Thoracotomy to determine if a patient's lung nodule is cancerous or benign&#10;C) Tummy tuck and repair of umbilical hernia after the patient gave birth to triplets&#10;D) Removal of the donor's heart,lungs,and cornea for transplant in recipient patients

Accepted Answer

The answer of Which surgery is classified as a palliative...

Question 14

Which assessment finding leads the nurse to include risk for ineffective airway clearance to the surgical patient's care plan?&#10;A) The patient is extremely anxious about the upcoming surgery.&#10;B) The patient will be receiving a local anesthetic for the procedure.&#10;C) The patient sleeps poorly and wakes up every morning with a headache.&#10;D) The patient speaks no English and requires the services of an interpreter.

Accepted Answer

The answer of Which assessment finding leads the nurse to...

Question 15

Which nursing diagnosis is the highest priority for a patient who had spinal anesthesia for hysterectomy surgery?&#10;A) Nausea related to side effect of spinal anesthesia&#10;B) Constipation related to manipulation of bowel during surgery&#10;C) Risk for falls related to impaired motor function from anesthesia&#10;D) Impaired oral mucus membranes related to NPO status before surgery

Accepted Answer

The answer of Which nursing diagnosis is the highest priority...

Question 16

The nurse is teaching the patient about postoperative exercises including incentive spirometry.How can the nurse best determine that the teaching was effective?&#10;A) The patient states that the preoperative anxiety has decreased significantly.&#10;B) The patient correctly demonstrates the exercises and how to use the spirometer.&#10;C) The patient senses a caring presence of the nurse in the therapeutic relationship.&#10;D) The patient explains to the nurse why the exercises and spirometer are important.

Accepted Answer

The answer of The nurse is teaching the patient about...

Question 17

The nurse is caring for a patient undergoing a surgical procedure that will take 7 to 8 hours to complete.Which is the appropriate outcome for the diagnosis risk for perioperative positioning injury related to prolonged immobilization?

A) The patient's skin will be assessed prior to surgery to identify areas at risk.
B) The patient's privacy and dignity will be maintained throughout the procedure.
C) The patient's bony prominences will be padded with pressure-reducing cushions.
D) The patient's skin will be free of redness or breakdown when surgery is complete.

Accepted Answer

The answer of The nurse is caring for a patient...

Question 18

Which is the highest priority nursing diagnosis for the patient undergoing a lengthy surgery in the operating room?&#10;A) Powerlessness related to unconscious state from general anesthesia&#10;B) Hypothermia related to cool ambient temperature in the operating room&#10;C) Risk for impaired oral mucus membranes related to prolonged NPO status&#10;D) Risk for caregiver role strain related to lengthy waiting period for family members

Accepted Answer

The answer of Which is the highest priority nursing diagnosis...

Question 19

The nurse is caring for a patient who will be having emergency surgery in a few minutes for appendicitis.Which preoperative teaching is most important?&#10;A) What to expect when waking up in the postanesthesia care unit&#10;B) Interventions to minimize risk of postoperative wound infection&#10;C) Demonstration of incentive spirometer and deep-breathing exercises&#10;D) Importance of early ambulation to prevent pneumonia and atelectasis

Accepted Answer

The answer of The nurse is caring for a patient...

Deck 40: Surgical Patient