Terms in this set (61)
Which nursing action would avoid pressure on the popliteal nerve when applying the safety strap across the client's legs on the operating table?
Apply the safety strap 2 inches above the knees.
A nurse is caring for a client following an abdominal hysterectomy performed 1 day ago. An intravenous (IV) line is infusing and a nasogastric (NG) tube is in place and attached to low intermittent suction. The nurse monitors the client and notes that the bowel sounds are absent. The nurse should appropriately:
Document the finding and continue to check for bowel sounds.
A nurse is monitoring the status of the postoperative client. The nurse would become most concerned with which of the following signs, which could indicate an evolving complication?
When positioning for a surgical procedure, the nurse understands that the client's respiratory system is most at risk for dysfunction when in which position?
A nurse is explaining the universal protocol for preventing wrong site, wrong procedure, and wrong person surgery to a group of nursing students. The nurse explains that site marking involves:
The surgeon marking the area of the operative procedure
A nurse obtains the vital signs on a postoperative client who just returned to the nursing unit. The client's blood pressure (BP) is 100/60 mm Hg, the pulse is 90 beats per minute, and the respiration rate is 20 breaths per minute. On the basis of these findings, which of the following nursing actions should be performed?
Continue to monitor the vital signs.
A nurse checks the sternotomy incision of a client on the second postoperative day after cardiac surgery. The incision shows some slight "puffiness" along the edges and is non-reddened with no apparent drainage. The client's temperature is 99° F (37.2° C) orally. The white blood cell (WBC) count is 7500 cells/mm3. The nurse interprets that the incision line:
Is slightly edematous but shows no active signs of infection
When performing a surgical dressing change of a client's abdominal dressing, a nurse notes an increase in the amount of drainage and separation of the incision line. The underlying tissue is visible to the nurse. The nurse should plan to do which of the following in the initial care of this wound?
Apply a sterile dressing soaked with normal saline.
A nurse checks the client's surgical incision for signs of infection. Which of the following would be indicative of a potential infection?
The presence of purulent drainage
A client arrives to the surgical nursing unit after surgery. The initial nursing action is to check the:
Patency of the airway
A nurse has admitted a client to the clinical nursing unit following a right mastectomy. The nurse plans to place the right arm in which of the following positions?
Elevated on one or two pillows
A nurse is reviewing the preoperative orders of a client with a colon tumor who is scheduled for abdominal perineal resection. The nurse notes that the health care provider has prescribed neomycin sulfate (Mycifradin) for the client. The nurse determines that this medication has been prescribed:
To decrease the bacteria in the bowel
A nurse is collecting data from a client who is scheduled for surgery in 1 week in the ambulatory care surgical center. The nurse notes that the client has a history of arthritis and has been taking acetylsalicylic acid (aspirin). The nurse reports the information to the surgeon and anticipates that the surgeon will prescribe which of the following?
Discontinue the aspirin 48 hours before the scheduled surgery.
A nurse is assisting in caring for a client immediately following an abdominal surgical procedure who lost a significant amount of blood during surgery. Which finding would indicate a sign of a potential complication?
A nurse is caring for a client who is scheduled for surgery. The client is concerned about the surgical procedure. To alleviate the client's fears and misconceptions about surgery, the nurse should:
Ask the client to discuss information known about the planned surgery.
During a surgical procedure a nurse prevents a client's extremities from dangling over the sides of the table, knowing that this action may cause:
Nerve and muscle damage
A client's preoperative vital signs are temperature 98.6° F orally, apical pulse 80 beats per minute with a regular rhythm, respiration rate 22 breaths per minute, and blood pressure 168/94 mm Hg in the right arm. Based on the interpretation of these findings, which action should the nurse take first?
Compare these values to those recorded previously.
A nurse is teaching a client about the use of an incentive spirometer in the postoperative period. The nurse should include which of the following pieces of information in discussions with the client?
The best results are achieved when sitting at least halfway or fully upright.
What equipment should the nurse plan to have at the bedside when initiating a clear liquid diet in a postoperative client who has had general anesthesia?
A nurse just reassessed the condition of a postoperative client who was admitted 1 hour ago to the surgical unit. The nurse plans to most carefully monitor which of the following parameters during the next hour?
Urinary output of 20 mL/hr
A nurse in the health care provider's office is measuring vital signs on a postoperative client who underwent mastectomy of her right breast 2 weeks ago. The client tells the nurse that she is very concerned because she has numbness in the area of the surgery and along the inner side of the arm from the armpit to the elbow. The nurse should tell the client that:
These sensations dissipate over several months and usually resolve after 1 year.
A client has an intravenous infusion (IV) started before surgery for a right below-the-knee amputation. In addition to the intravenous infusion, blood is drawn and a surgical skin preparation is done. The nurse anticipates that the client is likely to experience which psychosocial problem in the preoperative period?
A nurse is caring for a postoperative client who has been NPO, and the health care provider has prescribed a clear liquid diet. In planning to initiate this diet, which priority item should the nurse place at the client's bedside?
A nurse receives a client in the surgical unit who was transferred from the postanesthesia care unit. The nurse checks the client for which of the following first
A patent airway
The skin surrounding a postoperative client's abdominal wound is becoming irritated in the area where the dressing tape is being reapplied with each dressing change. Which of the following is the appropriate nursing action?
Apply Montgomery ties
A client who had knee surgery 4 days ago reports to the home health nurse that he has not had a bowel movement since before the surgery. Which question would assist the nurse in the collection of data regarding the client's problem?
"What have you been eating and drinking since the surgery?"
A nurse is assisting in caring for a client in transfer from the post-anesthesia care unit following nasal surgery. Nasal packing and a mustache dressing are in place. The nurse places the client in which position to best reduce swelling?
A nurse provides preoperative teaching to a client who will wear an abdominal binder postoperatively following abdominal surgery. Which should the nurse include in the preoperative teaching plan?
Sit up for coughing while splinting the incision
A nurse is caring for a postoperative client who is being monitored by pulse oximetry. Which of the following is an expected measurement determined by the pulse oximeter?
Oxygen saturation 95% to 100%
The nurse is assessing a client's postoperative pain using the PQRSTU method. Using this method, which of the following questions would the nurse ask the client? Select all that apply.
"What makes your pain better or worse?"
"What does the pain feel like?"
"Where is the pain located?"
"How does the pain affect you?"
A nurse is caring for a client immediately following a total abdominal hysterectomy. The nurse anticipates that which of the following will be the priority in the first 24 hours following surgery?
A client with arthritis is scheduled for a surgical knee joint replacement. The client will be admitted to the hospital on the day of the surgical procedure, and the nurse is providing instructions to the client regarding preparation for the surgical procedure. Which statement by the client indicates an understanding of the preoperative instructions?
"I cannot drink or eat anything after midnight on the night before surgery."
A nurse is caring for a postoperative client who had a pelvic exenteration. The health care provider has changed the client's diet from nothing by mouth (NPO) to clear liquids. The nurse checks which of the following before administering the clear liquids?
A client who currently underwent abdominal surgery experiences an evisceration. Which statement made by the client supports this diagnosis?
"It felt like something just slit me wide open."
A client has returned to the nursing unit following abdominal hysterectomy. To most effectively gather data on the client's postoperative bleeding, the nurse will implement which intervention?
Rolling the client to one side to view bedding
A nurse is changing an abdominal dressing on a client with an open incision and notes the presence of sanguineous drainage. Which nursing action would be appropriate?
Notify the registered nurse.
A nurse is providing instructions to a client following mastectomy who will be discharged with an axillary drain in place. The client will be receiving home care visits from a registered nurse to monitor drainage and perform dressing changes. Which statement by the client indicates a need for further instructions?
"I need to begin full range-of-motion (ROM) exercises to my upper arm as soon as I get home."
A client returns from the recovery room following an abdominal surgical procedure. Following the arrival of the client to the nursing unit, the initial nursing action is to check the:
A client who had abdominal surgery complains of feeling as though "something gave way" in the incisional site. The nurse removes the dressing and notes the presence of a loop of bowel protruding through the incision. Which nursing intervention(s) would the nurse take? Select all that apply.
Notify the registered nurse.
Document the client's complaint.
Instruct the client to remain quiet.
Prepare the client for wound closure.
A nurse is caring for a postoperative client who has a drain inserted into the surgical wound. Which of the following actions would the nurse avoid in the care of the drain?
Secure the drain by curling or folding it and taping it firmly to the body.
A nurse is explaining The Joint Commission's (TJC's) universal protocol for preventing wrong-site, wrong-procedure, and wrong-person surgery to a group of nursing students. The nurse explains that site marking involves:
The surgeon marking the area of the operative procedure
A surgeon is performing an abdominal hysterectomy. Before the surgery is completed, the operating room nurse counts the sponges and notes that the sponge count is not correlating with the preoperative count. Which action by the nurse is important?
Informing the surgeon of the situation
A nurse is assigned to assist in caring for a client who recently returned from the operating room. On data collection, the nurse notes that the client's vital signs are as follows: blood pressure (BP) 102/62 mm Hg, pulse 91 beats per minute, respirations 16 breaths per minute. Preoperative vital signs were BP 124/78 mm Hg, pulse 74 beats per minute, respirations 20 breaths per minute. Which of the following actions should the nurse plan to take first?
Recheck the vital signs in 15 minutes.
A nurse monitors the postoperative client frequently for the presence of secretions in the lungs, knowing that accumulated secretions can lead to:
A nurse is monitoring a postoperative client on an hourly basis. The nurse notes that the client's hourly urine output is 25 mL. Based on this finding, the first action of the nurse would be to:
Check the client's overall intake and output record.
A nurse is monitoring an adult client for postoperative complications. Which of the following would be the most indicative of a potential postoperative complication that requires further observation?
A urinary output of 20 mL/hour
A nurse is providing instructions to a client and family regarding home care following cataract removal from the left eye. The nurse would provide the client with which of the following pieces of information about positioning in the postoperative period?
Do not sleep on the left side.
A nurse is preparing the client for transfer to the operating room (OR). The nurse should take which of the following actions in the care of this client at this time?
Ensure that the client has voided.
A nurse is checking a client's surgical incision and notes an increase in the amount of drainage, a separation of the incision line, and the appearance of underlying tissue. Which of the following is the initial action?
Apply a sterile dressing soaked with normal saline to the wound.
What equipment should the nurse plan to have at the bedside when initiating a clear liquid diet for a postoperative client who has had general anesthesia?
A nurse monitors a postoperative client for signs of complications. Which of the following signs would the nurse determine to be indicative of a potential complication?
A nurse is explaining the concept of time-out in the perioperative area to a group of nursing students, knowing that the purpose of time-out is:
To allow the surgical team a chance to verbally verify their agreement on the client's name, surgical procedure, and site
A client is admitted to the surgical unit postoperatively with a wound drain (Hemovac) in place. Which of the following nursing actions would the nurse avoid in the care of the drain?
Curl the drain tightly and tape it firmly to the body.
A nurse is preparing a client for surgery. Which of the following would be a component of the plan of care?
Review the results of the preoperative laboratory studies.
A nurse is changing the abdominal dressing on a client following abdominal surgery. The nurse notes that the incision line is separated and the appearance of underlying tissue is noted. Wound dehiscence is suspected. Which of the following is the appropriate initial nursing action?
Apply a sterile dressing soaked with sterile normal saline to the wound.
A nurse is assisting in providing surgical instructions to a preoperative client. Which instruction would be most appropriate to include in the preoperative plan of care?
Coughing and deep breathing exercises
A nurse is explaining the concept of a time-out in the perioperative area. The purpose of a time-out is:
To allow the surgical team a chance to verbally verify its agreement about the client's name, the surgical procedure, and the site
A client has been taking prednisone for 3 years to treat symptoms of lupus erythematosa. She is scheduled for abdominal hysterectomy because of menorrhagia. The nurse plans care realizing that postoperatively the client is at risk for which condition?
Increased likelihood of surgical site infection
A nurse is developing a plan of care for a client who is scheduled for surgery. The nurse would include which of the following activities in the nursing care plan for the client on the day of surgery?
Have the client void immediately before surgery.
A preoperative client expresses anxiety to the nurse about the upcoming surgery. Which of the following responses by the nurse is most likely to stimulate further discussion between the client and the nurse?
"Can you share with me what you've been told about your surgery?"
A nurse is getting a postoperative client out of bed for the first time since surgery. The nurse raises the head of the bed, and the client complains of dizziness. Which of the following actions should the nurse take first?
Lower the head of the bed slowly until the dizziness is relieved.