Question 1

The nurse is aware that in both the very young and the elderly surgical patient, the risk is much higher for:

Accepted Answer

Both the very young and the elderly are at greater risk for dehydration or overhydration and alterations in body temperature control.

Question 2

A patient who had surgery earlier in the day using general anesthesia asks whether he can have something to eat. The diet order indicates clear liquids can be taken. Before giving a Jell-O to the patient, the nurse should check for the presence of:

Accepted Answer

Before allowing a patient to eat or drink after surgery, the nurse must ensure that bowel sounds are present in all four quadrants. This is because of the risk of paralytic ileus (lack of return of peristalsis) after surgery.

Question 3

In order for the anesthesiologist to accurately calculate the amount of anesthesia needed for an 82-year-old patient, the nurse should have data available on the chart, such as:

Accepted Answer

Accurate height and weight are significant for calculation of the anesthetic agents needed for elderly patients.

Question 4

A patient scheduled for surgery has an order for a preoperative surgical skin prep. The nurse may be required to:

Accepted Answer

The nurse may be required to instruct in the use of an antimicrobial soap in the shower. Although hair may be clipped away from the incision line, this is usually not done by the floor nurse but accomplished in the surgery suite.

Question 5

A patient undergoing preadmission testing before same-day surgery asks how long he will remain in the recovery area before being allowed to go home. The nurse's most informative response would be:

Accepted Answer

The usual recovery time in a same-day surgery recovery area is 1 to 3 hours.

Question 6

When the patient is ready to return from the post-anesthesia care unit (PACU), a minimal Aldrette score of _______ is an indicator that the patient is ready to return to the floor.

Accepted Answer

Using an Aldrette scoring system of activity, respiration, circulation, consciousness, and skin color being scored from 1 to 3, a score of 9 to 10 is the minimal indicator that the patient is ready to return to the floor.

Question 7

The nurse discovers that the signed operative permit has misspelled the patient's name. The nurse must:

Accepted Answer

A new consent form must be made, signed, and witnessed, provided the patient has not been sedated already.

Question 8

A post-operative surgical patient asks how the sequential pneumatic compression boots applied in the operating room will help lower the risk of blood clots forming in the legs. The nurse's most appropriate response would be that the boots:

Accepted Answer

Pneumatic boots alternately compress and release to squeeze the blood vessels and thus propel blood through the vessels back to the heart.

Question 9

The circulating nurse is responsible for:

Accepted Answer

Any break in sterile technique in the operating room should be immediately pointed out and remedied.

Question 10

A nurse is monitoring the urinary drainage from a patient who returned to the unit a few hours ago from the post-anesthesia care unit (PACU) following a surgical procedure. The urine total is 54 mL for the last 2 hours. The most appropriate nursing action is to:

Accepted Answer

If the urinary flow rate is lower than 60 mL for a 2-hour period, the surgeon is notified.

Question 11

A nurse is instructing a patient who had surgical removal of a brain tumor on how to prevent respiratory complications from surgery. The nurse would teach the patient to:

Accepted Answer

Coughing may be contraindicated for patients who have had hernia repair, eye, ear, or brain surgery. This is because the act of coughing could create increased pressure in the surgical area, which is contraindicated. Huffing or the use of an incentive spirometer is effective for post-surgical respiratory health.

Question 12

A 16-year-old boy injured in a motorcycle accident is unconscious and cannot sign the emergency surgical consent form; no family members can be located. The nurse anticipates that the:

Accepted Answer

If no family can be found to sign the permit for an unconscious person, a second surgeon can confirm the need for the immediate surgical intervention and the procedure will take place.

Question 13

A patient who has recently arrived on the surgical unit after being transferred from the post-anesthesia care unit asks for a drink. The nurse should first check the:

Accepted Answer

Before a post-surgical patient is offered anything to eat or drink, the ability of the patient to swallow should be assessed.

Question 14

The nurse is assessing the surgical dressing of a patient who arrived on the unit an hour ago. The surgical dressing has serosanguineous drainage on the dressing. The nurse should:

Accepted Answer

The area should be outlined, dated, and timed for future reference and comparisons.

Question 15

While completing the preoperative checklist, a patient who is almost ready for transport to the operating room states that he does not want to remove his wedding band. The nurse should:

Accepted Answer

A wedding band may be worn to surgery, but it must be taped to the finger in a manner that does not restrict circulation.

Question 16

The illiterate patient signs the surgical consent form with an "X." The nurse is aware that this "X" is:

Accepted Answer

An "X" is an acceptable signature if it is witnessed.

Question 17

A patient who has returned to the surgical nursing unit from the post-anesthesia care unit (PACU) is drowsy and requires verbal stimulation to remain aroused. The best position to maintain an airway for this patient is:

Accepted Answer

The patient should be positioned on the side or with the head turned to the side to prevent aspiration. Maintaining an open airway is a priority measure.

Question 18

To help prevent errors in the surgical procedure, the National Patient Safety Goal instituted a directive that prior to presurgical medication, each patient must:

Accepted Answer

Prior to presurgical medication, the conscious patient participates in a marking of the body part and site of the expected surgical procedure.

Question 19

The circulating nurse notes that the anesthetized patient has tensed muscles and irregular respirations. The nurse is aware that the patient has reached stage:

Accepted Answer

Quiet must be maintained while the patient is in stage II, because noise may cause the patient to become excited, resulting in instability of vital signs.

Question 20

A patient who had abdominal surgery is complaining of "gas pains" and has distention of the abdomen and flatus. To promote patient comfort, the nurse should advise:

Accepted Answer

Ambulation is helpful in expelling gas. Taking large amounts of food or liquid at a time, and drinking fluids that are either very hot or cold, can aggravate the symptoms.

Quiz 37: Care of the Surgical Patient