Perioperative – Intro Med Surg – Flashcards
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A client had an open transverse colectomy 5 days ago. The nurse enters the client's room and recognizes that the wound has eviscerated. After covering the wound with a sterile, saline-soaked dressing, which of the following actions should the nurse take? A. Go to nurses' station to seek assistance B. Reinsert the organs into the abdominal cavity. C. Place client in reverse Trendelenburg position D. Obtain V/S to assess for shock.
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D. Obtain V/S to assess for shock. Rationale: Nurse should obtain V/S to assess pts current status.
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A nurse is caring for a client who is postoperative and has a Jackson-Pratt drain in place. Which of the following interventions should the nurse use to ensure proper functioning of the drain? A. Secure the drain to the clients bed sheet. B. Clam the drain when the client is ambulating C. Empty & Compress the drain reservoir as needed. D. Keep the drain higher than the surgical incision.
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D. Keep the drain higher than the surgical incision. Rationale: Compressing reservoir produces suction necessary for the drain to function properly.
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A nurse is completing an initial PACU assessment of a client who is postoperative following a total knee arthroplasty and received spinal anesthesia. Which of the following findings indicates the need to notify the provider? A. The client states having numbness to the lower extremities bilaterally. B. Spinal anesthesia is at the T10 level. C. The client rouses to tactile stimuli. D. The client reports chest pain.
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D. The client reports chest pain. Rationale: Patient who is postoperative following total knee arthroplasty is at risk for pulmonary embolism. Reports of chest pain or shortness of breathe can indicate pulmonary embolism. The nurse should report these findings to HCP immediately.
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A surgical nurse enters the surgical suite to ensure surgical asepsis is maintained. Which of the following observations requires an intervention? A. The scrub technologist is wearing a watch under his scrubs. B. The circulating nurse opens dressing packages before applying sterile gloves. C. The surgeon has her hands folded 5 cm (2 inches) above the waist. D. The holding area nurse is performing client education.
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A. The scrub technologist is wearing a watch under his scrubs. Rationale: Scrub technologist should remove finger and wrist jewelry, which can harbor bacteria.
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A nurse is caring for a client who is postoperative. To prevent formation of thrombi in the postoperative period, the nurse should do which of the following? A. Change the clients position every four hours. B. Have the client perform dorsal and plantar flexion of the feet every hour. C. Place the client in bed with a pillow under the knees. D. Assess pedal and posterior tibial pulses every two hours.
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B. Have the client perform dorsal and plantar flexion of the feet every hour.
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A nurse is caring for a client who is 2 days postoperative following a cholecystectomy. The client has been vomiting for the past 24 hr and reports a pain level of 8 on a scale from 0 to 10. The nurse notes a hard, distended abdomen and absent bowel sounds. After conferring with the provider, which of the following actions should the nurse take first? A. Draw the client's blood for electrolytes B. Insert an NG tube. C. Administer pain medication. D. Initiate I&O.
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B. Insert an NG tube to begin decompression of the bowel. Rationale: The greatest risk to the client is fluid and electrolyte imbalance as a result of gas in GI tract.
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A nurse is assessing a client who is 2 hr postoperative following an appendectomy. Which of the following findings should the nurse report to the provider? A. Urine output 20 mL/hr B. Temperature 36.5 C (97.7 F) C. A 2 cmx2cm (0.79 x 0.79) area of bloody drainage on the dressing D. Jackson-Pratt drainage 30 mL/hr.
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A. Urine output 20 mL/hr Rationale: Patient should have at least 30 mL/hr of urine output. Decreased output may indicate dehydration and poor perfusion to kidneys.
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A nurse is completing a preoperative assessment for a client who is a Jehovah's Witness. Which of the following should the nurse recognize as a situation that could pose special care needs for this client? A. Having preoperative blood drawn. B. Giving information about sexual history C. Providing informed consent to receive blood products D. Receiving care from a nurse of the opposite gender.
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C. Providing informed consent to receive blood products Rationale: Patients in this religious group are not allowed to accept blood or blood products from other persons.
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A nurse is receiving afternoon report on four clients who have returned from the PACU this morning. The nurse should assess which of the following clients first? A. A client who is postoperative following a thoracotomy has a chest tube with 150 mL bright red-blood in the collection chamber from the past hour. B. A client who is postoperative following a small bowel resection and has a temporary colostomy has absent bowel sounds in all four quadrants. C. A client who is postoperative following a tonsillectomy has had one episode of coffee ground emesis. D. A client who is postoperative following a total knee arthroplasty and has a PCA pump is reporting a knee pain level of 7 out of 10
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A. A client who is postoperative following a thoracotomy has a chest tube with 150 mL bright red-blood in the collection chamber from the past hour. Rationale: Using ABC approach (airway, breathing, circulation) to client care. Nurse should assess this client first because 150mL is unexpected and can indicate hemorrhage.
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A nurse is providing discharge instructions for a client who is postoperative following abdominal surgery. Which of the following client statements indicates a need for further teaching? A. "I will call my Dr. if I have an increase in temperature or wound drainage." B. "I will eat foods high in protein and vitamin C during my recovery" C. "I will complete the entire course of antibiotics." D. "I will remain on bed rest until my follow up appointment with my doctor."
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D. "I will remain on bed rest until my follow up appointment with my doctor." Rationale: Remaining on bed rest places the client at risk for development of venous thrombosis. The nurse should encourage ambulation and activity.
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A nurse is preparing a client for surgery. The client appears apprehensive and asks multiple questions about the risks of the procedure. Which of the following actions should the nurse take before witnessing the client's signing of the informed consent form? A. Explain the risks and benefits of the surgery to the client B. Ask the surgeon to speak to the client for clarification. C. Reassure the client that the procedure is necessary for recovery D. Document the clients lace of preoperative teaching.
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B. Ask the surgeon to speak to the client for clarification. Rationale: The surgeon is responsible for explaining the surgery and its risk and benefits.
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A nurse is assessing a client who is 2 days postoperative following a total prostatectomy. The nurse notes the client's right calf is red, edematous, and warm to the touch. Which of the following actions should the nurse take? A. Apply an ice pack to the clients right calf. B. Elevate the clients right extremity. C. Administer testosterone to the client. D. Gently massage the clients right calf.
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B. Elevate the clients right extremity. Rationale: Findings suggest client has DVT. Nurse should keep right extremity elevated to promote venous return.
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A nurse is providing preoperative teaching for a client who is scheduled to have a mastectomy. Which of the following statements by the client indicates a need for further teaching? A. "I should wait 3-4 weeks after surgery to do water aerobics" B. "I'll wait until a week after surgery to start hand strengthening exercises." C. "I should avoid having blood drawn from the arm on the side I had mastectomy" D. "I'll be able to shower after the doctor removes the drain."
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B. "I'll wait until a week after surgery to start hand strengthening exercises." Rationale: Nurse should encourage client to start doing exercises, such as squeezing a ball, after surgery.
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A nurse is providing teaching for a client who is scheduled to undergo moderate (conscious) sedation for a bronchoscopy. The nurse should verify that the client understands the procedure when the client states which of the following? A. "I will need to complete a bowel prep the day before the procedure." B. "I will drink plenty of fluids the morning of the procedure." C. "I can eat as soon as the procedure is over." D. "I can expect to feel sleepy for several hours after the procedure."
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D. "I can expect to feel sleepy for several hours after the procedure." Rationale: Following moderate sedation, the client should expect to feel drowsy for several hours and should avoid all activities requiring concentration.
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A nurse is caring for a client who is postoperative following abdominal surgery. Which of the following nursing interventions should the nurse perform to prevent respiratory complications? A. Instruct the client to ehale into the incentive spirometer every 1 to 2 hours. B. Minimize the amount of pain medication the client receives to prevent sedation. C. Advise the client to splint the surgical incision when coughing and deep breathing. D. Reposition the client every 8 hours for the first 48 hours.
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C. Advise the client to splint the surgical incision when coughing and deep breathing. Rationale: Splinting the incision supports the surgical site and decreases pain during coughing and deep breathing.
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A nurse is monitoring a client receiving succinylcholine during a surgical procedure. Which of the following actions should the nurse take if the client develops malignant hyperthermia? A. Administer dantrolene. B. Institute seizure precautions C. Measure blood glucose D. Give IV atropine.
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A. Administer dantrolene. Rationale: Nurse should administer dantrolene by IV bolus at 2 to 3 mg/kg to reverse malignant hyperthermia.
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A nurse is caring for a client who has an NG tube set to continuous low suction following a gastrectomy. Which of the following findings should the nurse report to the provider? A. Gastric distention B. Absent bowel sounds C. Incisional pain of 9 on a scale form 0 to 10. D. Small amount of bloody drainage in the NG tube.
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A. Gastric distention Rationale: Gastric distention is an indication that the NG is not patent. Nurse should report to HCP to prevent complications at the anastomosis.
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A nurse is providing teaching for a client who is in the immediate postoperative period and has a PCA pump. Which of the following statements should the nurse include in the teaching? A. "You will receive a dose of medication every time you push the button." B. "Do not allow your family to push the PCA button if you are sleeping." C. "You cannot receive too much medication by pushing the button." D. Do not push the PCA button until your pain reaches a severe level."
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B. "Do not allow your family to push the PCA button if you are sleeping." Rationale:
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A nurse is caring for a client during surgery. To help prevent neuromuscular complications during the surgical procedure, the nurse should take which of the following actions? A. Administer an IV bolus of normal saline. B. Massage the clients lower extremities during the procedure. C. Support the client's bony prominences with foam padding. D. Extend the clients joints and maintain position with padded straps.
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C. Support the client's bony prominences with foam padding. Rationale: Padding on bony prominences helps prevent pressure on nerves and blood vessels and reduces the potential for neuromuscular complications.
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A nurse is assessing a client's recovery from spinal anesthesia. Which of the following sensations should the nurse expect to return to the client first? A. Pain B. Cold C. Touch D. Warmth
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C. Touch Rationale: Following spinal anesthesia, the first sensation the client will feel is the sense of touch.
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A nurse is taking a preoperative medication history on a client who is scheduled for surgery. Which of the following medications should the nurse recognize as placing the client at risk for complications due to interaction with anesthetic agents? A. Captopril B. Atorvastatin C. Ranitidine D. Ciprofloxacin
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A. Captopril Rationale: Antihypertensive agents, such as captopril, can cause hypotensive crisis for a client who is receiving anesthetic agents.
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A nurse is providing preoperative teaching for a client. Which of the following prescribed medications should the nurse instruct the client to discontinue 48 hr prior to the surgery? A. Furosemide B. Digoxin C. Prednisone D. Warfarin
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D. Warfarin Rationale: Warfarin is an anticoagulant and increases the likelihood of bleeding during and following surgery. The nurse should instruct client to discontinue med 36 to 48 hours prior to surgery. This is the amount of time it will take for the client to resynthesizes enough clotting factors to reverse effects of warfarin.
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A nurse who is working in the surgical suite should check that the rooms are maintained at a cool temperature with low humidity to decrease which of the following? A. Risk for malignant hyperthermia B. Amount of anesthetic agents clients need C. Risk of infection D. Amount of oxygen clients need.
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C. Risk for infection Rationale: Cool room temp with humidity between 30-60%, along with proper air exchange and filtering system, reduces the risk of infection for clients during surgery.
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A nurse is caring for a client receiving moderate (conscious) sedation with midazolam and fentanyl. The client's respirations decrease from 16/min to 6/min, and the oxygen saturation decreases from 92% to 85%. Which of the following actions should the nurse take first? A. Gather suction equipment. B. Obtain equipment necessary for CPR. C. Administer reversal agents D. Start an additional IV line.
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C. Administer reversal agents Rationale: Greatest risk to client is respiratory depression. The first action nurse should take is to administer reversal agents to block the effects of midazolam and fentanyl.
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A nurse is caring for a client who is postoperative following a total hip arthroplasty. Which of the following assessment data indicates the client is at an increased risk for infection? A. Use of herbal remedies B. Long-term use of corticosteroids C. Excessive exposure to sunlight D. Diet high in cholesterol.
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B. Long-term use of corticosteroids Rationale: Use of corticosteroids inhibits leukocyte response, increasing the clients risk for infection.
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A nurse is reviewing the medical record of a client who is to undergo general anesthesia for surgery. The nurse should report which of the following findings to the provider? A. Potassium level 2.8 mEq/L B. Sodium level 140 mEq/L INR 1.5 BUN 12 mg/dL
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A. Potassium level 2.8 mEq/L Rationale: This potassium level is below the expected reference range and places the client at risk for cardiac dysrhythmias.
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A nurse is caring for a client who has a surgical wound with a Penrose drain in place. Which of the following interventions should the nurse plan to perform? A. Cut a slit 4-inch square gauze pad to place around the drain. B. Use sterile technique when performing dressing changes. C. Establish a clamping schedule prior to removal. D. Apply negative pressure when emptying the drain.
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B. Use sterile technique when performing dressing changes. Rationale: Nurse should change Penrose drain using surgical asepsis technique.
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A nurse is assessing a client in the PACU to determine if he is ready for discharge. Which of the following assessment findings indicates that the client is ready for discharge? A. The clients preoperative BP was 140/90 mmHg, and her postoperative BP is now 100/65 mmHg. B. The client rates her pain at 4, on a 0 to 10 scale. C. The client is able to move all four extremities on command. D. The client requires tactile stimulation to awaken.
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C. The client is able to move all four extremities on command. Rationale: Client should be able to move all four extremities on command prior to discharge from PACU
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A client is transferred from the surgical suite to the PACU following oral surgery. While monitoring the client's vital signs, the nurse finds that the tongue has become swollen and is obstructing the airway. Which of the following actions should the nurse take first? A. Contact the anesthesiologist B. Assist with endotracheal intubation C. Increase the client's flow of oxygen D. Use the head-tilt, chin-lift method to open the airway.
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D. Use the head-tilt, chin-lift method to open the airway. Rationale: Priority of nurse should take is using the ABC approach (airway, breathing, circulation) to establish patient airway. This maneuver pulls the tongue forward and opens the air passage.
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A nurse is providing preoperative teaching to a client who is scheduled for a gastrectomy in 1 week. The client is anxious about the upcoming surgery. Which of the following is an appropriate action for the nurse to take? A. Sympathize with the clients feelings. B. Reassure the client that the surgery will go fine. C. Change the topic of discussion. D. Provide concise, factual information.
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D. Provide concise, factual information. Rationale: Providing concise, factual information allows for open communication and gives the nurse the opportunity to dispel the clients fears.
