Question 1

The nurse is preparing the client for general anesthesia. The client asks what the desired effects of general anesthesia are. Select all that apply.

Accepted Answer

General anesthesia aims to provide analgesia (pain relief), amnesia (loss of memory of the surgery), and muscle relaxation to facilitate surgical procedures. Risk reduction and reduced infection are goals of overall surgical care, not specific effects of general anesthesia.

Question 2

The surgical nurse manager is preparing the schedule based on classification. Surgeries are commonly classified by which of the following? Select all that apply.

Accepted Answer

Surgeries are commonly classified by acuity (severity of the condition), level of urgency (emergency, urgent, elective), and body system (e.g., cardiovascular, gastrointestinal). Length of surgery and type of anesthesia are not standard classification criteria.

Question 3

The postoperative client is admitted to the postanesthesia care unit (PACU) with an oral airway in place, an indwelling urinary catheter, IV fluid infusing via two different sites, and a Jackson-Pratt drain pinned to the gown near the wound dressing. What is the nurse's priority action after the client is moved to the bed?

Accepted Answer

Turning the client's head to the side is the priority action to ensure the airway remains open and to prevent aspiration, especially with an oral airway in place.

Question 4

A client had a colon resection for removal of a cancerous tumor. Postoperatively, on the surgical floor, which of the following activities would the nurse perform for the purpose of decreasing the risk of postoperative complications? Select all that apply.

Accepted Answer

Assisting with turning, deep breathing, and coughing helps prevent respiratory complications. Assessing drainage and monitoring vital signs are crucial for detecting complications early.

Question 5

The nurse is caring for a client who is wearing antiembolism compression stockings. The client repeatedly complains of discomfort caused by the stockings. What actions will the nurse take to improve comfort? Select all that apply.

Accepted Answer

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

Question 6

The postoperative client returned to the surgical nursing unit at 1:30 p.m. The evening shift nurse receives the report and begins working at 3:30 p.m. How often will the evening shift nurse take this client's vital signs?

Accepted Answer

The correct answer is D because it follows the standard postoperative protocol of closely monitoring the patient's vital signs immediately after surgery and then gradually spacing out the intervals as the patient stabilizes. This approach ensures that any potential complications are identified and addressed promptly.

Question 7

The nurse is caring for a client who had abdominal surgery 3 days ago and will be discharged home later today. The nurse will know that teaching is effective if the client does which of the following? Select all that apply.

Accepted Answer

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

Question 8

The nurse admits a client who is scheduled for surgery tomorrow morning. The nursing admission assessment indicates that the client is mildly anxious about the procedure, does not drink alcohol or smoke, is married with two children, and is allergic to kiwi, avocados, and penicillin. The nurse identifies the priority nursing diagnosis for this client as:

Accepted Answer

The priority nursing diagnosis is "Risk for Latex Allergy Response" due to the client's allergies to kiwi and avocados, which are associated with a latex allergy. This poses a significant risk during surgery where latex products may be used.

Question 9

The perioperative nurse maintains the safety of the client during surgery with which of the following goals? Select all that apply.

Accepted Answer

The answer of The perioperative nurse maintains the safety of...

Question 10

In the emergency department (ED), the client is diagnosed with a dislocated humerus. What type of anesthesia would the nurse anticipate will be used to repair the dislocation in the ED?

Accepted Answer

Conscious sedation is commonly used in the emergency department for procedures like the reduction of a dislocated humerus. It allows the patient to be comfortable and pain-free while still maintaining their own airway and the ability to respond to verbal commands.

Question 11

Which of the following describes the Perioperative Nursing Data Set (PNDS)? Select all that apply.

Accepted Answer

The Perioperative Nursing Data Set (PNDS) is significant because it is the first specialized nursing language recognized by the American Nurses Association (ANA), designed specifically to describe the care of perioperative clients. This standardized language helps in documenting and communicating the care provided to patients undergoing surgical or other invasive procedures.

Question 12

The intraoperative nurse observes the anesthesiologist administer general anesthesia, insert the endotracheal tube, and take control of the airway. The nurse understands that the next important nursing intervention for this client is to:

Accepted Answer

Positioning the client is crucial after anesthesia induction to ensure access to the surgical site and prevent injury.

Question 13

The nurse is caring for a client with a Salem-sump double-lumen nasogastric (NG) tube to suction. The client complains of nausea and has mild abdominal distention. What is the nurse's priority action?

Accepted Answer

Checking the placement of the NG tube is the priority action to ensure it is properly positioned for effective suctioning and to address the client's symptoms of nausea and abdominal distention. Incorrect placement can lead to ineffective suctioning and worsening of symptoms.

Question 14

The circulating nurse is providing care to the surgical client during the interoperative phase. Which of the following are components of the circulating nurse's focus to prevent complications during the surgery? Select all that apply.

Accepted Answer

The answer of The circulating nurse is providing care to...

Question 15

The preoperative nurse is preparing a client for surgery. Identify the interventions the nurse will perform. Select all that apply.

Accepted Answer

The preoperative nurse's responsibilities include informing the family where to wait (A), ensuring the client is physically ready for surgery which includes removing dentures and contact lenses (C), and providing information about the surgery process, including who will be present in the operating suite (E). Preparing the surgical suite (B) is the responsibility of the surgical team, not the preoperative nurse. Assisting a client to complete a living will (D) is not typically a preoperative nursing responsibility; it should be done well in advance of surgery and involves legal advice.

Question 16

The nurse admits a client to the postoperative unit following gastric bypass surgery for weight loss. Based on the client's history, what is the priority nursing diagnosis for this client?

Accepted Answer

Risk for Infection is the priority nursing diagnosis for this client because gastric bypass surgery is a major surgery that involves creating a new stomach pouch and bypassing the majority of the stomach and small intestine. This can lead to an increased risk of infection due to the presence of a foreign body (the new stomach pouch) and the disruption of the normal digestive process.

Question 17

A client returns from surgery with a nasogastric tube and intermittent gastric suction to provide abdominal decompression. Which of the following are correct nursing activities for managing the equipment and drainage? Select all that apply.

Accepted Answer

A) Wearing nonsterile gloves is appropriate for emptying the drainage container as this is considered a clean but not sterile procedure. D) Applying water-soluble lubricant to the client's lips can help prevent dryness and cracking due to the presence of the nasogastric tube and is a correct nursing activity. E) Documenting the consistency and amount of drainage is essential for monitoring the patient's condition and the effectiveness of the gastric suction.

Quiz 39: Perioperative Care