Chapter 050

Potter & Perry: Fundamentals of Nursing, 7th Edition

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Chapter 50: Care of Surgical Clients

MULTIPLE CHOICE

1. A 43-year-old client is scheduled to have a gastrectomy. Which of the following is a major preoperative concern?1. The client’s brother had a tonsillectomy at age 11.2. The client smokes a pack of cigarettes a day.3. The client has an intravenous (IV) infusion.4. The client has a history of employment as a computer programmer.

ANS: 2The client who smokes is at greater risk for postoperative pulmonary complications than a client who does not. An IV should be in place for surgery so access is available to administer medications, fluids, or blood products if necessary. Keeping the client well hydrated will help prevent postoperative thrombophlebitis.

DIF: A REF: 1373 OBJ: ComprehensionTOP: Nursing Process: AssessmentMSC: NCLEX® test plan designation: Reduction of Risk Potential/Monitoring Conscious Sedation/Potential for Complications From Surgical Procedures and Health Alterations

2. An appendectomy is appropriately documented by the nurse as:1. Diagnostic surgery2. Palliative surgery3. Ablative surgery4. Reconstructive surgery

ANS: 3Ablative surgery is the excision or removal of a diseased body part, such as an appendectomy. Diagnostic surgery is surgical exploration that allows the health care provider to confirm a diagnosis. This type of surgery may involve removal of tissue for further diagnostic testing. An example would be a breast mass biopsy. Palliative surgery relieves or reduces the intensity of disease symptoms. It will not produce a cure. An example is resection of nerve roots. Reconstructive surgery restores function or appearance to traumatized or malfunctioning tissues. An example is internal fixation of a hip fracture.


Mosby items and derived items © 2009, 2005 by Mosby, Inc., an affiliate of Elsevier Inc.

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3. An obese client is admitted for abdominal surgery. The nurse recognizes that this client is more susceptible to the postoperative complication of:1. Anemia2. Seizures3. Protein loss4. Dehiscence

ANS: 4An obese client is susceptible to poor wound healing and wound infection because of the structure of fatty tissue, which contains a poor blood supply. This increases the risk for dehiscence. A client who is malnourished is more susceptible to being anemic. A client with liver disease may have altered protein metabolism.

DIF: C REF: 1372 OBJ: AnalysisTOP: Nursing Process: AssessmentMSC: NCLEX® test plan designation: Reduction of Risk Potential/Monitoring Conscious Sedation/Potential for Complications From Surgical Procedures and Health Alterations

4. The nurse is working in a postoperative care unit in an ambulatory surgery center. Of the following clients that have come to have surgery, the client at the greatest risk during surgery is a:1. 78-year-old taking an analgesic agent2. 43-year-old taking an antihypertensive agent3. 27-year-old taking an anticoagulant agent4. 10-year-old taking an antibiotic agent

ANS: 3Anticoagulants alter normal clotting factors and thus increase the risk for hemorrhaging during surgery. Aminoglycosides (a type of antibiotic) may cause mild respiratory depression from depressed neuromuscular transmission; however, the client who has beentaking anticoagulants is at greater risk during surgery.


5. A 92-year-old client is scheduled for a colectomy. Which normal physiological change that accompanies the aging process increases this client’s risk for surgery?1. An increased tactile sensation2. An increased metabolic rate3. A relaxation of arterial walls4. Reduced glomerular filtration rate

ANS: 4


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An older adult is likely to have a reduced glomerular filtration rate. This limits the body’sability to eliminate drugs or toxic substances. An older adult has reduced tactile sense, which decreases the client’s ability to respond to early warning signs of surgical complications, including sensing pressure over bony prominences. An older adult has a lower basal metabolic rate, reducing total oxygen consumption. The nurse should ensure the client obtains adequate nutritional intake when diet is resumed, but the client should avoid intake of excess calories.


6. The nurse is completing the preoperative checklist for an adult female client who is scheduled for an operative procedure later in the morning. Which of the following preoperative assessment findings for this client indicates a need to contact the surgeon?1. Hemoglobin (Hgb) 14 g/100 mL2. Blood urea nitrogen (BUN) 15 mg/100 mL3. Platelets 300,000/mm3

4. Serum creatinine 3.2 mg/100 mL

ANS: 4The normal serum creatinine in women is 0.5 to 1.1 mg/100 mL. A serum creatinine of 3.2 mg/100 mL should be reported to the health care provider, because it can be an indication of renal failure. A Hgb of 14 g/100 mL is within the normal limits of 12 to 16 g/100 mL for women. A BUN of 15 mg/100 mL is within the normal limits of 10 to 20 mg/100 mL. A platelet count of 300,000/mm3 is within the normal limits of 150,000 to 400,000/mm3.


7. The nurse is evaluating the outcome “Client describes surgical procedures and postoperative treatment” and determines that the client has not achieved this outcome. The nurse should:1. Obtain the consent, because this is expected with preoperative anxiety2. Teach the client all about the procedure3. Ask the unit manager to assist with a teaching plan4. Inform the surgeon so that information can be provided

ANS: 4


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When the client has little or no understanding about the surgery, the health care provider will need to be notified to reinform the client. If the client does not understand the surgical procedure, the client would not be giving informed consent. It is the surgeon’s responsibility to explain the procedure and obtain the informed consent. The nurse can augment the health care provider’s explanations, but it is the health care provider’s responsibility to teach the client about the procedure. This teaching includes the need for the procedure, steps involved, risks, expected results, and alternative treatments.

DIF: A REF: 1378 OBJ: ComprehensionTOP: Nursing Process: ImplementationMSC: NCLEX® test plan designation: Reduction of Risk Potential/Monitoring Conscious Sedation/Potential for Complications From Surgical Procedures and Health Alterations

8. Which of the following statements most accurately reflects nursing accountability in the intraoperative phase?1. “I would like to see the client have a regional anesthetic rather than a general

anesthetic.”2. “There seems to be a missing sponge, so a recount should be done of all the

sponges that have been removed.”3. “Did the client receive the medications and sign the consent?”4. “The client looks to be reactive and stable.”

ANS: 2The scrub nurse counts the sponges and instruments, and the circulating nurse verifies thecounts. This statement by the nurse reflects accountability in the intraoperative phase.

DIF: C REF: 1390-1391 OBJ: AnalysisTOP: Nursing Process: EvaluationMSC: NCLEX® test plan designation: Reduction of Risk Potential/Monitoring Conscious Sedation/Potential for Complications From Surgical Procedures and Health Alterations

9. The client will have an incision in the lower left abdomen. Which of the following measures by the nurse will help decrease discomfort in the incisional area when the clientcoughs postoperatively?1. Applying a splint directly over the lower abdomen2. Keeping the client flat with her feet flexed3. Turning the client onto the right side4. Applying pressure above and below the incision

ANS: 1


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Deep-breathing and coughing exercises place additional stress on the suture line and cause discomfort. Splinting the incision with hands or a pillow provides firm support and reduces incisional pulling. Keeping the client flat will not decrease discomfort in the incisional area when the client coughs. Having the knees bent slightly will aid in relaxing the abdominal muscles, causing less discomfort. Turning the client onto the right side willnot decrease discomfort in the incisional area when the client coughs. The client should turn from side to side at least every 2 hours and may splint the incision to decrease discomfort when doing so. Splinting should be done directly over the incision to provide firm support and reduce incisional pulling as the client coughs postoperatively.

DIF: A REF: 1400-1401 OBJ: ComprehensionTOP: Nursing Process: PlanningMSC: NCLEX® test plan designation: Reduction of Risk Potential/Monitoring Conscious Sedation/Potential for Complications From Surgical Procedures and Health Alterations

10. The nurse is evaluating the client in the hospital’s postanesthesia care unit (PACU) and determines that the Aldrete score is 8. Based on this assessment, the nurse anticipates thatthe client will:1. Be sent to the intensive care unit2. Be discharged back to his or her room on the nursing unit3. Remain in the PACU until the score improves4. Return to the operating room for surgical evaluation

ANS: 2The client must receive a composite Aldrete score of 8 to 10 before being discharged from the PACU. The nurse may anticipate that the client with an Aldrete score of 8 will be discharged back to his or her room on the nursing unit. If the client’s condition is still poor 2 to 3 hours after surgery (an Aldrete score below 8), the health care provider may transfer the client to an intensive care unit. If the client’s condition is still poor 2 to 3 hours after surgery (an Aldrete score below 8), the health care provider may lengthen the client’s stay in the PACU until the score improves. A client with an Aldrete score of 8 is unlikely to return to the operating room for surgical evaluation.


11. A client is in the postanesthesia care unit (PACU) recovering from a vagotomy and pyloroplasty. Which of the following is a normal expectation of the client in this stage of recovery?1. Returned normal bowel sounds on auscultation2. Pain that is relieved with noninvasive comfort measures3. Voluntary bladder control and function4. A subdued level of consciousness and neurological function


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ANS: 4In the PACU the client is often drowsy. The effects of anesthetic agents subdue the client’s level of consciousness and neurological function. Normally during the immediate recovery phase in the PACU, faint or absent bowel sounds are auscultated in all four quadrants. Clients who have had abdominal surgery may develop paralytic ileus, with a return of bowel sounds 24 to 48 hours later. The acute incisional pain experienced in this stage of recovery is usually not relieved with noninvasive comfort measures but will require pharmacological measures of pain relief. Depending on the surgery, a client may not regain voluntary control over urinary function for 6 to 8 hours after anesthesia.


12. The client is scheduled for abdominal surgery and has just received the preoperative medications. The nurse should:1. Keep the client quiet2. Obtain the consent3. Prepare the skin at the surgical site4. Place the side rails up on the bed or stretcher

ANS: 4After administering preoperative medications, the nurse should raise the side rails on the bed or stretcher and keep the bed or stretcher in low position. Preanesthetic medications will help reduce the client’s anxiety. Consent must be obtained before preoperative medications are administered or the consent is invalid. Preparing the skin at the surgical site is often done in the operating room.


13. The nurse is completing the preoperative checklist for an adult client who is scheduled for an operative procedure later in the morning. Which of the following preoperative assessment findings for this client indicates a need to contact the anesthesiologist?1. Temperature is 100° F.2. Pulse is 90 beats per minute.3. Respiratory rate is 20 breaths per minute.4. Blood pressure is 130/74 mm Hg.

ANS: 1


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An elevated temperature before surgery is a cause for concern. If the client has an underlying infection, the surgeon may choose to postpone surgery until the infection has been treated. An elevated body temperature increases the risk for fluid and electrolyte imbalance after surgery. Anxiety and fear commonly cause elevations in heart rate and blood pressure. A pulse rate of 90 beats per minute is not a concern. A respiratory rate of 20 breaths per minute is normal for an adult. A blood pressure of 130/74 mm Hg is not excessively elevated.


14. In the postoperative period, the nurse recognizes that an early sign of malignant hyperthermia is:1. Fever2. Tachycardia3. Muscle relaxation4. Skin pallor

ANS: 2Malignant hyperthermia should be suspected when there is unexpected tachycardia and tachypnea; jaw muscle rigidity; body rigidity of limbs, abdomen, and chest; or hyperkalemia. Temperature elevation is a late sign of malignant hyperthermia. Muscle rigidity, not relaxation, is an early sign of malignant hyperthermia. Skin pallor is not an early sign of malignant hyperthermia. Skin pallor may be seen in the immediate postoperative period, because the body is cool.


15. The client tells the nurse that “blowing into this tube thing (incentive spirometer) is a ridiculous waste of time.” The nurse explains that the specific purpose of the therapy is to:1. Directly remove excess secretions from the lungs2. Increase pulmonary circulation3. Promote lung expansion4. Stimulate the cough reflex

ANS: 3


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The primary purpose of using an incentive spirometer is to promote lung expansion. Coughing exercises are used to remove excess secretions from the lungs. Ambulation helps increase pulmonary circulation as the respiratory rate increases. The primary purpose of incentive spirometry is not to stimulate the cough reflex, but to promote lung expansion.


16. The female client on the surgical unit is being prepared for abdominal surgery with general anesthesia. In preparing this client for surgery, the nurse should:1. Leave all of her jewelry intact2. Provide her with sips of water for a dry mouth3. Remove her makeup and nail polish4. Remove her hearing aid before transport to the operating room

ANS: 3All makeup, including nail polish, should be removed to expose normal skin and nail color to determine the client’s level of oxygenation and circulation during and after surgery. Jewelry and other valuables should be given to family members or secured for safekeeping. A wedding band can be taped in place unless there is a risk that the client will experience swelling of the hand or fingers. For safety, metal items, such as for pierced areas, should be removed. The client should be allowed nothing by mouth (NPO) before surgery to prevent vomiting and aspiration with general anesthesia. Clients may beallowed to keep personal items such as a hearing aid until they reach the preoperative area.


17. The client asks the nurse the purpose of having medications (Demerol and Vistaril) given before surgery. The nurse should inform the client that these particular medications:1. Reduce preoperative fear2. Promote emptying of the stomach3. Reduce body secretions4. Ease the induction of the anesthesia

ANS: 4


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Preoperative medications such as Demerol and Vistaril help reduce the client’s anxiety, the amount of general anesthesia required, the risk for nausea and vomiting and resulting aspiration, and the amount of respiratory secretions. They may also help the client feel drowsy and lessen his or her anxiety associated with fear. Vistaril (hydroxyzine pamoate) is often given to control nausea and vomiting by suppressing the central nervous system (CNS). Vistaril will have an anticholinergic effect, reducing body secretions. These medications given together will ease the induction of anesthesia.


18. A client who receives general or regional anesthesia in an ambulatory surgery center:1. Has to meet identified criteria in order to be discharged home2. Will remain in the phase I recovery area longer than a hospitalized client3. Is allowed to ambulate as soon as being admitted to the recovery area4. Is immediately given liberal amounts of fluid to promote the excretion of the

anesthesia

ANS: 1Ambulatory surgical clients are discharged to home when they meet certain criteria. With new anesthetic agents and techniques, many ambulatory surgery clients are able to bypassphase I. However, if the client is in need of close monitoring, the client is assessed and cared for in the same fashion as inpatient clients in phase I. Whether the client will be able to ambulate as soon as being admitted to the recovery area depends upon the ambulatory client’s condition, type of surgery, and anesthesia. This is not a true statementfor all ambulatory surgery clients. The administration of fluids is dependent upon the client’s condition and type of surgery. The excretion of anesthetic depends on many factors, including the route of administration (e.g., fluids will not promote the excretion of anesthetic gases). Oral fluids cannot be given until it is determined the client has a gag reflex and bowel sounds. Fluids are often given to prevent circulatory complications.


19. Following abdominal surgery, the nurse suspects that the client may be having internal bleeding. Which of the following findings is indicative of this complication?1. Increased blood pressure2. Incisional pain3. Abdominal distention4. Increased urinary output


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ANS: 3Signs of internal bleeding following abdominal surgery may include abdominal distention; swelling or bruising around the incision; increased pain; a drop in blood pressure; elevated heart and respiratory rates; thready pulse; cool, clammy, pale skin; and restlessness. The client who is hemorrhaging will have a decreased blood pressure. Incisional pain may occur as a result of surgery. A continuous increase in pain in conjunction with other symptoms of bleeding may indicate internal hemorrhaging. A client who is bleeding will have a decreased urinary output.


20. After discharge from the postanesthesia care unit (PACU), the client returned to the surgical nursing unit at 10:00 AM. It is now 11:30 AM, and the client is not experiencing any complications or difficulties. The nurse will plan to measure the client’s vital signs:1. Every 15 minutes2. Every 30 minutes3. Every 1 hour4. Every 4 hours

ANS: 3Vital sign monitoring on the postoperative nursing unit should initially be hourly for 4 hours and then every 4 hours. As the client’s condition stabilizes, the frequency of assessment will usually decrease to once a shift until discharge. Upon the client’s arrival to recovery, the nurse repeats measurement of vital signs every 15 minutes, not for the client who is stable on the surgical nursing unit. The client who is not experiencing any complications or difficulties does not require vital sign measurement every 30 minutes. After the client’s vital signs are obtained hourly for 4 hours and remain stable, the client may have his or her vital signs measured every 4 hours.

DIF: A REF: 1396 OBJ: ComprehensionTOP: Nursing Process: PlanningMSC: NCLEX® test plan designation: Reduction of Risk Potential/Monitoring Conscious Sedation/Potential for Complications From Surgical Procedures and Health Alterations

21. The client had surgery in the morning that involved the right femoral artery. To assess theclient’s circulation status to the right leg, the nurse will make sure to check the pulse at the:1. Radial artery2. Ulnar artery3. Brachial artery4. Dorsalis pedis artery


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ANS: 4The nurse should assess peripheral pulses and capillary refill distal to the site of surgery. After surgery to the femoral artery, the nurse assesses posterior tibial and dorsalis pedis pulses. The nurse also compares pulses in the affected extremity with those in the nonaffected extremity.


22. Upon admission to the postanesthesia care unit (PACU), the client who has no orthopedicor neurological restrictions is positioned with the:1. Bed flat and the client’s arms to the sides2. Client’s neck flexed and body positioned laterally3. Head of the bed slightly elevated with the client’s head to the side4. Client’s arms crossed over the chest and the bed in high-Fowler’s position

ANS: 3To promote a patent airway, the head of the bed may be slightly elevated and the client’s neck slightly extended, with the client’s head turned to the side. The client’s head should not be flexed as this may occlude the airway. The client’s arms should never be positioned over or across the chest, because this reduces maximal chest expansion.


23. A client who is scheduled for surgery is found to have thrombocytopenia. A specific postoperative concern for the nurse for this client is:1. Hemorrhage2. Wound infection3. Fluid imbalance4. Respiratory depression

ANS: 1A client with thrombocytopenia is at risk for hemorrhaging during and after surgery. Clients with immunological disorders or diabetes mellitus have an increased risk for wound infection after surgery. A client who has a fever is at risk for fluid imbalance. A client who has chronic respiratory disease may be at increased risk for respiratory depression, not the client with thrombocytopenia.

DIF: A REF: 1370 OBJ: ComprehensionTOP: Nursing Process: Planning


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MSC: NCLEX® test plan designation: Reduction of Risk Potential/Monitoring Conscious Sedation/Potential for Complications From Surgical Procedures and Health Alterations

24. A prostate biopsy is an acceptable procedure to be performed as an ambulatory surgery on an otherwise healthy adult male because the American Society of Anesthesiologists (ASA) considers that a: 1. Physical status class 12. Physical status class 23. Physical status class 44. Physical status class 5

ANS: 1ASA physical status classes 1 and 2 and also stable class 3 are now acceptable for ambulatory surgery. Classes 4 and 5 require inpatient surgery.


25. Which of the following statements made by a nurse reflects the greatest insight into the responsibility an ambulatory care nurse has to the client’s family? 1. “A client’s family deserves the attention of the nursing staff.” 2. “Family is important to my client, and so family is important to me.” 3. “I consider myself as having several clients: the surgical client and all the family

that’s present.”4. “I am responsible for keeping the family informed of the status of their loved one

both during and after the procedure.”

ANS: 3Family members attempt to provide support through their presence but face many of the same stressors as the client. You need to effectively communicate with the client and family; they are clients as well.

DIF: C REF: 1386 OBJ: AnalysisTOP: Nursing Process: PlanningMSC: NCLEX® test plan designation: Reduction of Risk Potential/Monitoring Conscious Sedation/Potential for Complications From Surgical Procedures and Health Alterations

26. Which of the following statements made by a nurse reflects the greatest insight into the planning needs of a same-day surgical experience? 1. “Time is a precious resource in same-day surgery units; being organized allows for

the best utilization of time.”2. “Everything must be checked and verified as being ready before the client is


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admitted into the surgical area.”3. “With only a few hours from time of admission to the beginning of the procedure,

things have to be effectively organized.”4. “I take the time to review the client’s preadmission and preoperative data in order

to formulate the most individualized plan of care possible.”

ANS: 4Ambulatory and same-day surgical programs offer challenges in gathering a complete assessment in a limited time. Clients are admitted only hours before the surgical event, soit is important for you to organize and verify data obtained preoperatively and implement a perioperative plan of care. Although the remaining options are not incorrect, they do notstress the importance of effective organization of the client’s plan of care.


27. The perioperative nurse realizes that the most effective means of evaluating the client’s understanding of previous teaching is to: 1. Provide written material on the subject to be reviewed after discharge2. Reinforce the material with family as the procedure is being performed3. Discuss it with the client and family in the immediate preoperative period4. Offer to answer any questions that the client or family have just before discharge

ANS: 3In the immediate preoperative period, assess the client’s understanding of previous teaching. The other options are not truly evaluations of the client’s knowledge.


28. Which of the following preoperative assessment findings would most likely delay a planned procedure requiring general anesthetic?1. A cough and low-grade fever2. The pulse oximetry reading of 97% on room air3. A blood pressure that is 10 systolic points higher than baseline4. The client’s report of “being so nervous about this procedure”

ANS: 1Preoperative assessment occasionally reveals an abnormality that delays or cancels surgery. A client who presents with a cough and low-grade fever on admission would require the nurse to notify the surgeon immediately. The other options do not necessarily warrant delay or cancellation of a procedure.


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29. A 74-year-old is accompanied by his daughter to the ambulatory surgery department for the surgical removal of a suspicious skin lesion. The client has experienced dysphasia since a cerebral vascular accident 3 years ago. The most effective way for the nurse to secure the necessary preoperative interview information is to: 1. Question the client’s daughter2. Review the client’s past medical records3. Present the questions in a simple format4. Rely on the client’s preadmission survey

ANS: 1If a client is unable to relate all of the necessary information, rely on family members as resources. The remaining options are not reliable, effective methods of securing information regarding this client.


30. A client who has type 2 diabetes is scheduled for the removal of a skin lesion on his right shoulder at an ambulatory surgery unit. The nursing diagnosis the client is at greatest risk for postoperatively is: 1. Risk for injury2. Risk for infection3. Impaired wound healing4. Imbalanced nutrition: less than body requirements

ANS: 3Diabetes increases susceptibility to infection and impairs wound healing from altered glucose metabolism and associated circulatory impairment. The stress of surgery often causes increases in blood glucose levels. Although all the options present with possible nursing diagnoses, the remaining options are not of primary concern because steps can betaken (e.g., antibiotic, intravenous fluids) to minimize the risk. Impaired wound healing isnot as easily managed.

DIF: C REF: 1370 OBJ: AnalysisTOP: Nursing Process: PlanningMSC: NCLEX® test plan designation: Reduction of Risk Potential/Monitoring Conscious Sedation/Potential for Complications From Surgical Procedures and Health


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Alterations

31. A client with a history of sleep apnea has had a same-day surgery procedure that will require the administration of morphine postoperatively to manage pain. This client will beassessed most appropriately by the perioperative nurse for the risk for respiratory complications by frequently:1. Listening to breath sounds2. Monitoring pulse oximetry3. Evaluating spirometer use4. Counting respirations per minute

ANS: 1Administration of opioids increases risk for airway obstruction postoperatively. Clients will desaturate as revealed by a drop in oxygen saturation by pulse oximetry. The remaining options are not as specific for this particular client’s risk.

DIF: C REF: 1372 OBJ: AnalysisTOP: Nursing Process: ImplementationMSC: NCLEX® test plan designation: Reduction of Risk Potential/Monitoring Conscious Sedation/Potential for Complications From Surgical Procedures and Health Alterations

32. A client scheduled for an ambulatory surgery procedure requiring anesthetics arrives witha low-grade fever and a productive sough. The postponement of the procedure is most likely a result of the: 1. Client’s increased risk for a respiratory tract infection2. Possibility of a respiratory complication during anesthesia3. Increased risk for the client's infecting staff and other clients4. Client’s impaired resistance as a result of a respiratory tract infection

ANS: 2Cough and low-grade fever increases the risk for respiratory complications during anesthesia (e.g., pneumonia and spasm of laryngeal muscles). Although the other options are not incorrect, they do not represent the most likely risk factor that would result in the cancellation of the procedure.

DIF: C REF: 1388 OBJ: AnalysisTOP: Nursing Process: EvaluationMSC: NCLEX® test plan designation: Reduction of Risk Potential/Monitoring Conscious Sedation/Potential for Complications From Surgical Procedures and Health Alterations

33. Which of the following goals is most appropriate for a preoperative client with a nursing diagnosis of deficient knowledge regarding preoperative requirements related to lack of exposure to information?1. Client will understand the need for scheduled surgery before leaving the provider’s

office.


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2. Client will understand the preoperative routines of surgical care before leaving provider’s office.

3. Client will present for drawing of preoperative laboratory blood at least 48 hours before scheduled surgery.

4. Client will be able to successfully accomplish the preoperative bowel preparation by morning of scheduled surgery.

ANS: 2Understanding the need for the surgery is not as directly related to preoperative requirements as is the understanding of preoperative routines. The remaining options are client outcomes.


34. Which of the following client outcomes is most therapeutic for a preoperative client with a nursing diagnosis of deficient knowledge regarding preoperative requirements related to lack of exposure to information?1. Client will share the preoperative routines of surgical care with family to facilitate

compliance.2. Client will understand the preoperative routines of surgical care before leaving

provider’s office.3. Client will call laboratory to schedule appointment for preoperative blood draw for

required testing. 4. Client will present for drawing of preoperative laboratory blood at least 48 hours

before scheduled surgery.

ANS: 4The answer provides for behavior that is measurable and pertinent to the preoperative goals. Sharing the information and calling for the appointment are appropriate outcomes, but they are not the most therapeutic because they not related to actual compliance with the preoperative routine. The remaining option is a client goal.

DIF: C REF: 1376-1377 OBJ: AnalysisTOP: Nursing Process: PlanningMSC: NCLEX® test plan designation: Reduction of Risk Potential/Monitoring Conscious Sedation/Potential for Complications From Surgical Procedures and Health Alterations

35. Which of the following client evaluations is most reflective of compliance for a preoperative client with a nursing diagnosis of deficient knowledge regarding preoperative requirements related to lack of exposure to information?1. Client will present for scheduled blood laboratory work 48 hours before surgery.2. Client’s preoperative blood laboratory work results are present on preoperative


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chart.3. Client will share the preoperative routines of surgical care with family to facilitate

compliance.4. Client will understand the preoperative routines of surgical care before leaving

provider’s office.

ANS: 2The answer shows proof of the client’s compliance, whereas the remaining options are either goals or outcomes.

DIF: C REF: 1376-1377 OBJ: AnalysisTOP: Nursing Process: EvaluationMSC: NCLEX® test plan designation: Reduction of Risk Potential/Monitoring Conscious Sedation/Potential for Complications From Surgical Procedures and Health Alterations

36. Which of the following best describes the primary nursing role regarding a client’s consent to surgery immediately before surgery?1. Explaining the procedure to the client in a fashion that is easily understood2. Placing the signed consent in the client’s medical record3. Ensuring that the client understands the possible risks of the procedure before

signing the consent4. Reviewing the client’s surgical consent as a part of the routine preoperative

checklist

ANS: 4It is the surgeon’s responsibility to explain the procedure and obtain the informed consent. After the client completes the consent form, place it in the medical record. The record goes to the operating room with the client after the nurse confirms all required information has been included.


37. The initial client education–related nursing action by the preadmission nurse is to:1. Respond to questions presented by the family regarding the client’s surgery2. Call the client before the surgery to restate presurgery routine3. Provide the client with a list of preoperative requirements4. Arrange a time for presurgical blood work to be drawn

ANS: 2Preadmission nurses call clients up to 1 week before surgery to clarify questions and reinforce explanations. The remaining options are directed toward either facilitating compliance with preoperative requirements or addressing the needs of the client’s family.


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38. Which of the following statements made by the nurse shows the most informed understanding of the role of family in the client’s postoperative recovery? 1. "The family will be the ones you will be dealing with regarding postoperative

needs."2. "When the family is more relaxed about caring for the client, the client is more

relaxed."3. "The more the family understands what to expect during recovery, the more

comfortable they are in caring for the client."4. "Teaching the family what they need to know before the surgery will maximize

their effectiveness regarding the client’s postoperative care."

ANS: 4Often a family member is the caregiver when the client recovers from surgery. Perioperative preparation of family members before surgery helps to maximize effective caregiving while minimizing anxiety and misunderstanding.


39. The nurse recognizes which of the following as the greatest barrier to meeting a preoperative client’s nursing diagnosis of deficient knowledge regarding surgical procedure? 1. Effects of preoperative medication2. Complicated nature of the information3. Fear or anxiety regarding the procedure4. Emotional denial regarding surgical outcomes

ANS: 3Anxiety and fear are barriers to learning, and both emotions heighten as surgery approaches. Education should be provided before any preoperative sedation is administered; the information should be introduced in terms that the client can understand. The presence of denial is an assumption that is not necessarily correct.



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40. The nurse knows that the client is most likely going to arrive for the surgical procedure having adhered to the required bowel preparation if:1. The client understands the need for the laxative2. The laxative ordered is pleasant tasting3. The bowel preparation is an uncomplicated process4. The client has the appropriate support at home

ANS: 1Given a rationale for preoperative and postoperative procedures, the client is better prepared to participate in care. The remaining options may have an effect on compliance but not to the degree that understanding the need and purpose of the bowel preparation.


41. Which surgical classification would be the most appropriate for a cardiac catheterization scheduled on a 44-year-old male client who is in the hospital with chest pain?1. Major 2. Minor3. Ablative 4. Elective

ANS: 1Major surgery involves extensive reconstruction or alteration in body parts and poses great risks to well-being. Minor surgery involves minimal alteration in body parts, is often designed to correct deformities, and involves minimal risks compared with major procedures. Ablative surgery is the excision or removal of a diseased body part. Elective surgery is performed on the basis of client’s choice, is not essential, and is not always necessary for health.

DIF: B REF: 1366 OBJ: ApplicationTOP: Nursing Process: PlanningMSC: NCLEX® test plan designation: Psychosocial Integrity/Sensory/Perceptual Alterations Systems

42. A 36-year-old female diabetic client is having an elective breast augmentation procedure done. Which of the following tests must be done on the day of surgery?1. Complete blood count (CBC) 2. Blood glucose3. Serum electrolytes4. Coagulation studies

ANS: 2


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Blood glucose level can be obtained by either a finger stick or peripheral blood sample. Clients often require treatment of low or high levels preoperatively and postoperatively.

DIF: A REF: 1367 OBJ: ComprehensionTOP: Nursing Process: PlanningMSC: NCLEX® test plan designation: Psychosocial Integrity/Sensory/Perceptual Alterations Systems

43. A 48-year-old male client with a history of chronic obstructive pulmonary disease (COPD) is scheduled for an inguinal hernia repair. The nurse instructs that client that he can expect the health care provider to order which of the following tests before surgery?1. Human immunodeficiency virus (HIV) antibody 2. Prolactin level3. Pulmonary function test4. Glucose tolerance test

ANS: 3Pulmonary function testing and occasionally arterial blood gas analysis are often performed before surgery on clients with preexisting lung disease. An HIV-antibody test diagnoses HIV. It is not a test that is normally ordered before surgery. Prolactin levels are used to diagnose and monitor prolactin-secreting pituitary adenomas. A glucose tolerance test is used to assist in the diagnosis of diabetes mellitus and is also used in the evaluationof hypoglycemia. It is not a test that is normally ordered before surgery.


44. A 64-year-old male client has been scheduled to undergo surgery for a total knee replacement. The client would like to be able to use his own blood for the surgery, if needed. The nurse explains that there are several advantages to the client's having an autologous infusion, but there are some drawbacks as well. Which of the following wouldbe considered a drawback to an autologous infusion?1. The client has a decreased risk for contracting HIV.2. There is an decreased risk for infection.3. The client has less risk for a transfusion reaction.4. The client may have a decreased hemoglobin and hematocrit level on the day of

surgery.

ANS: 4


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The client must plan ahead in plenty of time in order to be able to donate his own blood. In addition, the client who does self-donation sometimes exhibits a lower hemoglobin and hematocrit level on the day of surgery. Autologous infusions are an option for some clients who choose to donate their own blood before surgery to reduce the risk for transfusion-related infections. The client is at less risk for a transfusion reaction because it is his own blood. There is a lowered risk for infection because the blood is from the client.


45. A 24-year-old male client has been scheduled to undergo surgery for an ACL repair of hisright knee. The client states that he is confused about what the surgeon will be doing. Thebest response from the nurse is:1. "The surgeon went over this procedure with you in his office"2. "Let me get the surgeon to talk with you before we proceed so that you fully

understand what will be happening"3. To share with the client what he can expect in regard to the procedure4. "This is just a simple procedure—you should feel much better afterwards"

ANS: 2The surgeon is responsible for making sure that the client completely understands the procedure before the client gives informed consent. The client may not remember the conversation that the surgeon had with him regarding the procedure due to anxiety. The nurse should not discount the client’s concerns.


46. A 47-year-old female client has been scheduled to undergo surgery for removal of her gallbladder. Preoperatively the nurse is teaching the client what to expect when she wakesup in the postanesthesia care center. The nurse tells the client that her vision may be blurry due to which of the following reasons?1. The client’s blood pressure may be high from the postoperative pain.2. The client may be slow to arouse from the anesthesia, causing her vision to be

blurred upon waking.3. The anesthesia provider applies ointment to clients’ eyes to prevent corneal

damage. 4. The lighting in the postanesthesia area will be subdued, causing the client to have

blurred vision upon waking.

ANS: 3


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The anesthesia provider applies ointment to clients’ eyes to prevent corneal damage. Warning clients about sensations of blurred vision will reduce their anxiety on awakeningfrom surgery. The client’s pain should be under control and therefore will not cause her blood pressure to be raised. The more subdued lighting in the postanesthesia care area should help the client’s vision to focus upon coming out from under the anesthesia.


47. Given a rationale for preoperative and postoperative procedures, the client is better prepared to participate in care. For which of the following should the nurse provide instruction and rationale?1. Incentive spirometry 2. Specific details regarding the progression of diet3. Working the call button for the nurse4. Using the patient-controlled analgesia (PCA) pump

ANS: 1Given a rationale for preoperative and postoperative procedures, the client is better prepared to participate in care. The diet progression should be discussed with the client by the unit nurse as the postsurgical diet progresses. The call light may be specific to the unit the client is on and is best taught to the client once he or she is on the unit so that the client can demonstrate to the nurse that he or she understands how to use it. The PCA pump is best taught to the client once he or she is on the unit so that the client can demonstrate to the nurse that he or she understands how to use it.


48. The nurse is very busy and needs to delegate some tasks to the nursing assistive personnel (NAP). Which of the following would be the most appropriate task to delegate?1. Postoperative client teaching2. Demonstrating postoperative exercises3. Transporting the preoperative client from the unit to the holding area4. Reviewing the preoperative assessment to make sure that the client’s vital signs

have been documented

ANS: 3In many hospitals a nursing orderly or transporter brings a stretcher for transporting the client. The transporter checks the client’s identification bracelet for two identifiers againstthe client’s chart to be sure that the right person is going to surgery.

DIF: B REF: 1380 OBJ: Analysis


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TOP: Nursing Process: PlanningMSC: NCLEX® test plan designation: Psychosocial Integrity/Sensory/Perceptual Alterations Systems

MULTIPLE RESPONSE

1. When discussing the details of having a procedure done in a facility's ambulatory surgery department, the nurse includes which of the following as advantages? (Select all that apply.)1. Facilitates faster postsurgical recovery2. Reduces hospital-oriented expenses3. Allows for more one-on-one attention by staff4. Cuts preparation time for surgical procedures 5. Minimizes risk for acquiring a nosocomial infection6. The anesthetic drugs used result in faster "wake-up" time

ANS: 1, 2, 5, 6There are distinct benefits for the client who has ambulatory surgery. Anesthetic drugs that metabolize rapidly with few after-effects allow shorter operative times and faster recovery time. Ambulatory surgery also offers cost savings by eliminating the need for hospital stays. This reduces the possibility of acquiring health care–associated infections, which occur when normal skin flora changes from hospitalization and clients become colonized with bacteria found in the hospital setting. Preparation time and staff attention are not necessarily affected.



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