Ramont2e Rev TIF Ch29

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Ramont, Niedringhous, Comprehensive Nursing Care 2nd Edition Update Test

Bank

Chapter 29Question 1

Type: MCSA

When the nurse cares for the client in the holding area prior to surgery, the client is in what phase of the surgical

process?

1. Preoperative

2. Intraoperative

. Postoperative

!. Perioperative

Corre"t #ns$er: 1

Rationa%e 1: he client is in the preoperative phase of the surgical process until he is wheeled into the operating

roo!, when the intraoperative phase "egins# When the client leaves the operating roo! to go to the post$

anesthesia recovery roo!, he enters the postoperative phase# ogether, these three phases are the perioperative period#

Rationa%e 2: he client is in the preoperative phase of the surgical process until he is wheeled into the operating



Rationa%e : he client is in the preoperative phase of the surgical process until he is wheeled into the operating



Rationa%e !: he client is in the preoperative phase of the surgical process until he is wheeled into the operating


anesthesia recovery roo!, he enters the postoperative phase# ogether, these three phases are the perioperative

period#

&%o'a% Rationa%e:

Cogniti(e )e(e%: %e!e!"ering

C%ient Need:

C%ient Need *u':

Nursing+ntegrated Con"epts:

%a!ont, &iedringhous, Comprehensive Nursing Care 'nd (dition )pdate est *an+

Copyright '1' "y Pearson (ducation, Inc#



)earning -ut"ome: -escri"e the phases of the perioperative period#

Question 2

Type: MCSA

he nurse is preparing the client for a "reast "iopsy to deter!ine if a lu!p found is cancerous# he nurse e.plains

that the surgery is what type?

1. A"lative

2. Palliative

. -iagnostic

!. (!ergency

Corre"t #ns$er: /

Rationa%e 1: he purpose of the surgery is to diagnose the cause of the "reast lu!p, so this is diagnostic in nature

It is not an e!ergency surgery "ecause the client0s life is not at ris+ if it is not done i!!ediately and is usually

scheduled within a few days of discovering the lu!p# A"lative surgery re!oves a diseased "ody part, which is no planned at this ti!e, although a !astecto!y !ight "e planned if the lu!p is cancerous, "ut that will not occur at

this ti!e# Palliative surgery is planned to relieve pain or sy!pto!s of a disease without curing it, such as re!oval

of a tu!or "loc+ing the "owel caused "y !etastatic cancer#

Rationa%e 2: he purpose of the surgery is to diagnose the cause of the "reast lu!p, so this is diagnostic in natureIt is not an e!ergency surgery "ecause the client0s life is not at ris+ if it is not done i!!ediately and is usually

scheduled within a few days of discovering the lu!p# A"lative surgery re!oves a diseased "ody part, which is no

planned at this ti!e, although a !astecto!y !ight "e planned if the lu!p is cancerous, "ut that will not occur atthis ti!e# Palliative surgery is planned to relieve pain or sy!pto!s of a disease without curing it, such as re!oval


Rationa%e : he purpose of the surgery is to diagnose the cause of the "reast lu!p, so this is diagnostic in nature

It is not an e!ergency surgery "ecause the client0s life is not at ris+ if it is not done i!!ediately and is usuallyscheduled within a few days of discovering the lu!p# A"lative surgery re!oves a diseased "ody part, which is no

planned at this ti!e, although a !astecto!y !ight "e planned if the lu!p is cancerous, "ut that will not occur at

this ti!e# Palliative surgery is planned to relieve pain or sy!pto!s of a disease without curing it, such as re!ovalof a tu!or "loc+ing the "owel caused "y !etastatic cancer#

Rationa%e !: he purpose of the surgery is to diagnose the cause of the "reast lu!p, so this is diagnostic in natureIt is not an e!ergency surgery "ecause the client0s life is not at ris+ if it is not done i!!ediately and is usually

scheduled within a few days of discovering the lu!p# A"lative surgery re!oves a diseased "ody part, which is no planned at this ti!e, although a !astecto!y !ight "e planned if the lu!p is cancerous, "ut that will not occur at

this ti!e# Palliative surgery is planned to relieve pain or sy!pto!s of a disease without curing it, such as re!oval


&%o'a% Rationa%e:





Cogniti(e )e(e%: Applying

C%ient Need: Physiological Integrity

C%ient Need *u':

Nursing+ntegrated Con"epts: &ursing Process: Planning

)earning -ut"ome: -iscuss various types of surgery according to the purpose, degree of urgency, and degree of

ris+#

Question

Type: MCSA

he nurse is caring for a client who had a"do!inal surgery and has a sutured wound that is healing well without

signs of infection# he nurse descri"es the wound as an:

1. Intentional closed wound#

2. )nintentional open wound#

. Intentional conta!inated wound#

!. pen unconta!inated wound#

Corre"t #ns$er: 1

Rationa%e 1: he wound was created intentionally "y a surgeon, and it is closed "ecause it is sutured, allowing th

wound to heal "y pri!ary intention# A conta!inated wound is one that has pathogens or de"ris, which this doesnot#

Rationa%e 2: he wound was created intentionally "y a surgeon, and it is closed "ecause it is sutured, allowing th

wound to heal "y pri!ary intention# A conta!inated wound is one that has pathogens or de"ris, which this doesnot#

Rationa%e : he wound was created intentionally "y a surgeon, and it is closed "ecause it is sutured, allowing th

wound to heal "y pri!ary intention# A conta!inated wound is one that has pathogens or de"ris, which this does

not#

Rationa%e !: he wound was created intentionally "y a surgeon, and it is closed "ecause it is sutured, allowing thwound to heal "y pri!ary intention# A conta!inated wound is one that has pathogens or de"ris, which this does

not#

&%o'a% Rationa%e:



C%ient Need *u':

Nursing+ntegrated Con"epts: &ursing Process: Assess!ent

)earning -ut"ome: 2ist the types of wounds and their potential co!plications#





Question !

Type: MCMA

he nurse is caring for a 34$year$old client with a history of s!o+ing one pac+ of cigarettes per day diagnosed

with early stages of e!physe!a# What preoperative screening tests would the nurse anticipate this client will

re5uire? Select all that apply#

*tandard Tet: Select all that apply#

1. Co!plete "lood count

2. Chest .$ray

. (lectrocardiogra!

!. )rine culture and sensitivity

/. A2, AS, 2-6, and "iliru"in

Corre"t #ns$er: 1,',/

Rationa%e 1: his client is at increased ris+ for respiratory infections and polycythe!ia secondary to s!o+ing, so

a C*C would "e indicated# A chest .$ray is needed "y anesthesiology in order to deter!ine the safety of

ad!inistering inhaled anesthetics# (C7 is indicated due to ris+ of cardiac da!age secondary to s!o+ing# A urine

culture and liver en8y!es are not indicated "y this client0s condition unless secondary pro"le!s e.ist#

Rationa%e 2: his client is at increased ris+ for respiratory infections and polycythe!ia secondary to s!o+ing, so


ad!inistering inhaled anesthetics# (C7 is indicated due to ris+ of cardiac da!age secondary to s!o+ing# A urineculture and liver en8y!es are not indicated "y this client0s condition unless secondary pro"le!s e.ist#

Rationa%e : his client is at increased ris+ for respiratory infections and polycythe!ia secondary to s!o+ing, so



Rationa%e !: his client is at increased ris+ for respiratory infections and polycythe!ia secondary to s!o+ing, so


ad!inistering inhaled anesthetics# (C7 is indicated due to ris+ of cardiac da!age secondary to s!o+ing# A urine

culture and liver en8y!es are not indicated "y this client0s condition unless secondary pro"le!s e.ist#

Rationa%e /: his client is at increased ris+ for respiratory infections and polycythe!ia secondary to s!o+ing, so



&%o'a% Rationa%e:





Cogniti(e )e(e%: Analy8ing


C%ient Need *u':


)earning -ut"ome: Identify tests that !ay occur and overall nursing responsi"ilities in the perioperative period

Question /

Type: MCMA

he nurse ad!its a client who will have surgery in the !orning# &ursing interventions prior to surgery will

address: Select all that apply#


1. Altered gas e.change#

2. 9luid volu!e deficit#

. An.iety#

!. nowledge deficit#

/. Ineffective coping#

Corre"t #ns$er: /,4

Rationa%e 1: his client0s nursing plan of care during the preoperative phase will "e directed at reducing an.iety

and +nowledge deficit# Insufficient infor!ation is supplied regarding the need for surgery or physiologicalcondition to +now whether the client has altered gas e.change, fluid volu!e i!"alance, or insufficient coping

s+ills#

Rationa%e 2: his client0s nursing plan of care during the preoperative phase will "e directed at reducing an.iety


s+ills#

Rationa%e : his client0s nursing plan of care during the preoperative phase will "e directed at reducing an.iety

and +nowledge deficit# Insufficient infor!ation is supplied regarding the need for surgery or physiological

condition to +now whether the client has altered gas e.change, fluid volu!e i!"alance, or insufficient copings+ills#

Rationa%e !: his client0s nursing plan of care during the preoperative phase will "e directed at reducing an.iety


s+ills#





Rationa%e /: his client0s nursing plan of care during the preoperative phase will "e directed at reducing an.ietyand +nowledge deficit# Insufficient infor!ation is supplied regarding the need for surgery or physiological

condition to +now whether the client has altered gas e.change, fluid volu!e i!"alance, or insufficient coping

s+ills#

&%o'a% Rationa%e:

Cogniti(e )e(e%: Analy8ingC%ient Need: Psychosocial Integrity

C%ient Need *u':


)earning -ut"ome: Identify tests that !ay occur and overall nursing responsi"ilities in the perioperative period

Question 0

Type: MCSA

he nurse has provided preoperative teaching, and deter!ines that further teaching is needed when the client

states:

1. ;nce I receive the preoperative !edication, I will need to re!ain in "ed#;

2. ;I can wait until <ust "efore leaving for the operating roo! to re!ove !y wedding ring and false teeth#;

. ;My fa!ily will wait for !e in the holding area while I a! in surgery#;

!. ;I should not eat or drin+ anything for eight hours "efore surgery#;

Corre"t #ns$er: /

Rationa%e 1: he client0s fa!ily !ay "e allowed in the holding area, depending on facility policy, to stay with the

client until she leaves for surgery# nce the client has "een ta+en to the %, the fa!ily will go to the waiting

roo!, and will "e infor!ed of the client0s condition when the surgery is co!pleted, or occasionally, throughout ane.tended procedure# he re!aining state!ents are correct#

Rationa%e 2: he client0s fa!ily !ay "e allowed in the holding area, depending on facility policy, to stay with the



Rationa%e : he client0s fa!ily !ay "e allowed in the holding area, depending on facility policy, to stay with theclient until she leaves for surgery# nce the client has "een ta+en to the %, the fa!ily will go to the waiting


Rationa%e !: he client0s fa!ily !ay "e allowed in the holding area, depending on facility policy, to stay with the







&%o'a% Rationa%e:


C%ient Need: Psychosocial Integrity

C%ient Need *u':

Nursing+ntegrated Con"epts: &ursing Process: (valuation

)earning -ut"ome: -escri"e essential preoperative teaching#

Question

Type: MCSA

he nurse teaches the client to cough and deep$"reathe, and deter!ines that the client understood teaching when

which of the following state!ents is !ade?

1. ;I should "reathe in slowly through !y !outh and out through !y nose#;

2. ;I should "reathe in and cough as soon as I0! done inhaling#;

. ;I should hold a rolled pillow against !y a"do!en when I cough, to splint the incision#;

!. ;I will "egin coughing and deep$"reathing the day after surgery#;

Corre"t #ns$er: /

Rationa%e 1: he client should "reathe in through the nose and out through the !outh# After inhaling, the client

should hold the "reath for a few seconds "efore coughing# (.ercises should "egin as soon as possi"le aftersurgery#

Rationa%e 2: he client should "reathe in through the nose and out through the !outh# After inhaling, the client

should hold the "reath for a few seconds "efore coughing# (.ercises should "egin as soon as possi"le after

surgery#

Rationa%e : he client should "reathe in through the nose and out through the !outh# After inhaling, the client

should hold the "reath for a few seconds "efore coughing# (.ercises should "egin as soon as possi"le after

surgery#

Rationa%e !: he client should "reathe in through the nose and out through the !outh# After inhaling, the clientshould hold the "reath for a few seconds "efore coughing# (.ercises should "egin as soon as possi"le after

surgery#

&%o'a% Rationa%e:







C%ient Need *u':

Nursing+ntegrated Con"epts: &ursing Process: (valuation

)earning -ut"ome: -escri"e essential preoperative teaching#

Question

Type: MCSA

he nurse is preparing a client for surgery who will leave for the operating roo! in = !inutes# Prior to

ad!inistering the preoperative !edication, the nurse instructs the client to:

1. >oid#

2. *athe#

. %eview the signed preoperative consent#

!. -eep$"reathe and cough#

Corre"t #ns$er: 1

Rationa%e 1: Prior to ad!inistering the preoperative !edication, the nurse should instruct the client to e!pty the

"ladder# he "ath should have "een perfor!ed "efore the ti!e for preoperative !edication is due# here is no

need for the client to review the operative consent if it has already "een signed, and e.ercises "egin after surgery#

Rationa%e 2: Prior to ad!inistering the preoperative !edication, the nurse should instruct the client to e!pty the "ladder# he "ath should have "een perfor!ed "efore the ti!e for preoperative !edication is due# here is no


Rationa%e : Prior to ad!inistering the preoperative !edication, the nurse should instruct the client to e!pty the "ladder# he "ath should have "een perfor!ed "efore the ti!e for preoperative !edication is due# here is noneed for the client to review the operative consent if it has already "een signed, and e.ercises "egin after surgery#

Rationa%e !: Prior to ad!inistering the preoperative !edication, the nurse should instruct the client to e!pty the

"ladder# he "ath should have "een perfor!ed "efore the ti!e for preoperative !edication is due# here is no


&%o'a% Rationa%e:


C%ient Need: Physiological IntegrityC%ient Need *u':

Nursing+ntegrated Con"epts: &ursing Process: I!ple!entation

)earning -ut"ome: &a!e essential aspects of nursing care when preparing a client for surgery#

Question 9

Type: MCSA





he nurse wor+ing in the (!ergency -epart!ent ad!its a client re5uiring surgical repair of a laceration on the

hand, and anticipates what type of anesthesia?

1. Spinal

2. 7eneral

. opical

!. 2ocal

Corre"t #ns$er: 4

Rationa%e 1: he client re5uiring suturing of a laceration in the hand would re5uire local anesthetic# opical

anesthetic eli!inates surface sensation, "ut would not "e deep enough for surgical repair# Spinal or generalanesthetic would not "e re5uired for a s!all, locali8ed surgical procedure of the hand#

Rationa%e 2: he client re5uiring suturing of a laceration in the hand would re5uire local anesthetic# opical

anesthetic eli!inates surface sensation, "ut would not "e deep enough for surgical repair# Spinal or generalanesthetic would not "e re5uired for a s!all, locali8ed surgical procedure of the hand#

Rationa%e : he client re5uiring suturing of a laceration in the hand would re5uire local anesthetic# opical

anesthetic eli!inates surface sensation, "ut would not "e deep enough for surgical repair# Spinal or general

anesthetic would not "e re5uired for a s!all, locali8ed surgical procedure of the hand#

Rationa%e !: he client re5uiring suturing of a laceration in the hand would re5uire local anesthetic# opicalanesthetic eli!inates surface sensation, "ut would not "e deep enough for surgical repair# Spinal or general

anesthetic would not "e re5uired for a s!all, locali8ed surgical procedure of the hand#

&%o'a% Rationa%e:



C%ient Need *u':


)earning -ut"ome: -escri"e the types of anesthesia that !ay "e used intraoperatively#

Question 13

Type: MCSA

he nurse is caring for a client who received spinal anesthesia# he client calls the nurse into the roo!, saying,

;Co!e 5uic+ I can0t feel !y legs; he nurse0s "est response is:

1. ;I will call the doctor i!!ediately#;

2. ;2oss of feeling is nor!al, and will su"side as the anesthesia wears off#;





. ;6ave you fallen or in<ured yourself in any way since surgery?;

!. ;-id this occur suddenly, or have you noticed this ever since surgery?;

Corre"t #ns$er: '

Rationa%e 1: Spinal anesthesia di!inishes sensation "elow the level of the in<ection, and can co!pletely eli!inat

sensation, depending on what !edication is used and how !uch is ad!inistered# he nurse will reassure the clienthat the sensation loss is nor!al and te!porary, and that he will regain full function within a few hours postoperatively# here is no need to notify the doctor or assess for in<ury#

Rationa%e 2: Spinal anesthesia di!inishes sensation "elow the level of the in<ection, and can co!pletely eli!inat

sensation, depending on what !edication is used and how !uch is ad!inistered# he nurse will reassure the clien

that the sensation loss is nor!al and te!porary, and that he will regain full function within a few hours postoperatively# here is no need to notify the doctor or assess for in<ury#

Rationa%e : Spinal anesthesia di!inishes sensation "elow the level of the in<ection, and can co!pletely eli!inat



Rationa%e !: Spinal anesthesia di!inishes sensation "elow the level of the in<ection, and can co!pletely eli!inat



&%o'a% Rationa%e:


C%ient Need: Psychosocial IntegrityC%ient Need *u':


)earning -ut"ome: -escri"e the types of anesthesia that !ay "e used intraoperatively#

Question 11

Type: MCSA

he nurse is caring for a postoperative client and gathers the following data: te!perature /=#'@C, pulse 14,

respirations , o.ygen saturation B', pain level of ', dressing is clean and dry, "reath sounds reveal fine rales in

the "ases "ilaterally# What is the nurse0s priority intervention?

1. As+ the client to deep$"reathe and cough#

2. Ad!inister narcotic analgesic for pain#

. &otify the doctor of the client0s need for increased fluids#





!. Ad!inister o.ygen#

Corre"t #ns$er: 1

Rationa%e 1: he client0s respiratory rate is low, possi"ly secondary to narcotic analgesics# As+ing the client to

deep$"reathe and cough will help to i!prove o.ygenation and clear secretions fro! the airways# If, after coughin

and deep$"reathing, the client returns to the sa!e level of sedation and respiratory depression, the nurse will

infor! the %&# here is no need to increase fluids or ad!inister o.ygen, as the elevated pulse rate is notunco!!on after surgery, and is not significantly elevated to re5uire treat!ent#

Rationa%e 2: he client0s respiratory rate is low, possi"ly secondary to narcotic analgesics# As+ing the client to


and deep$"reathing, the client returns to the sa!e level of sedation and respiratory depression, the nurse willinfor! the %&# here is no need to increase fluids or ad!inister o.ygen, as the elevated pulse rate is not

unco!!on after surgery, and is not significantly elevated to re5uire treat!ent#

Rationa%e : he client0s respiratory rate is low, possi"ly secondary to narcotic analgesics# As+ing the client todeep$"reathe and cough will help to i!prove o.ygenation and clear secretions fro! the airways# If, after coughin

and deep$"reathing, the client returns to the sa!e level of sedation and respiratory depression, the nurse willinfor! the %&# here is no need to increase fluids or ad!inister o.ygen, as the elevated pulse rate is not

unco!!on after surgery, and is not significantly elevated to re5uire treat!ent#

Rationa%e !: he client0s respiratory rate is low, possi"ly secondary to narcotic analgesics# As+ing the client to


and deep$"reathing, the client returns to the sa!e level of sedation and respiratory depression, the nurse will

infor! the %&# here is no need to increase fluids or ad!inister o.ygen, as the elevated pulse rate is notunco!!on after surgery, and is not significantly elevated to re5uire treat!ent#

&%o'a% Rationa%e:



C%ient Need *u':


)earning -ut"ome: -iscuss the nurse0s role in the care of the postoperative client#

Question 12

Type: MCSA

he nurse is caring for an o"ese client who is postoperative gastric "ypass surgery# he nurse plans care directedat the client0s specific ris+s for postoperative co!plications "y e.cluding which i!ple!entation?

1. (levating the head of the "ed and holding food and fluids until gag refle. returns

2. urning and repositioning the client until she can !ove independently

. (ncouraging coughing and deep$"reathing e.ercises





!. Applying and !aintaining antie!"olis! stoc+ings

Corre"t #ns$er: 1

Rationa%e 1: his client will "e n#p#o# until peristalsis returns and initial healing of the internal suture lines "egins

he gag refle. will return long "efore this client is allowed to eat# *ecause the client is o"ese, she is at ris+ for

respiratory co!plications, thro!"ophle"itis, and poor wound healing that can result in he!orrhage, dehiscence,

and infection#

Rationa%e 2: his client will "e n#p#o# until peristalsis returns and initial healing of the internal suture lines "egins


respiratory co!plications, thro!"ophle"itis, and poor wound healing that can result in he!orrhage, dehiscence,

and infection#

Rationa%e : his client will "e n#p#o# until peristalsis returns and initial healing of the internal suture lines "egins


respiratory co!plications, thro!"ophle"itis, and poor wound healing that can result in he!orrhage, dehiscence,and infection#

Rationa%e !: his client will "e n#p#o# until peristalsis returns and initial healing of the internal suture lines "egins


respiratory co!plications, thro!"ophle"itis, and poor wound healing that can result in he!orrhage, dehiscence,and infection#

&%o'a% Rationa%e:



C%ient Need *u':


)earning -ut"ome: Identify potential postoperative pro"le!s and preventive !easures#

Question 1

Type: MCSA

When does the nurse re!ove the postoperative client0s sutures?

1. When the wound is closed and scar tissue is seen

2. When the wound has visi"le sca"s and is no longer ede!atous

. When all drainage fro! the wound ceases

!. When the physician orders re!oval of sutures

Corre"t #ns$er: 4





Rationa%e 1: Sutures are not re!oved until an order is received fro! the physician# Prior to re!oving sutures, thenurse assesses that the wound is appro.i!ated, healing has "egun, and there are no open areas or drainage# If the

wound does not appear ready for suture re!oval, the nurse would notify the physician and as+ that the provider

assess the wound "efore sutures are re!oved# Waiting until scar tissue appears would leave the sutures in placefor too long a period of ti!e and increase the ris+ of infection#

Rationa%e 2: Sutures are not re!oved until an order is received fro! the physician# Prior to re!oving sutures, the

nurse assesses that the wound is appro.i!ated, healing has "egun, and there are no open areas or drainage# If thewound does not appear ready for suture re!oval, the nurse would notify the physician and as+ that the providerassess the wound "efore sutures are re!oved# Waiting until scar tissue appears would leave the sutures in place

for too long a period of ti!e and increase the ris+ of infection#

Rationa%e : Sutures are not re!oved until an order is received fro! the physician# Prior to re!oving sutures, the

nurse assesses that the wound is appro.i!ated, healing has "egun, and there are no open areas or drainage# If thewound does not appear ready for suture re!oval, the nurse would notify the physician and as+ that the provider

assess the wound "efore sutures are re!oved# Waiting until scar tissue appears would leave the sutures in place

for too long a period of ti!e and increase the ris+ of infection#

Rationa%e !: Sutures are not re!oved until an order is received fro! the physician# Prior to re!oving sutures, thenurse assesses that the wound is appro.i!ated, healing has "egun, and there are no open areas or drainage# If the

wound does not appear ready for suture re!oval, the nurse would notify the physician and as+ that the provider

assess the wound "efore sutures are re!oved# Waiting until scar tissue appears would leave the sutures in placefor too long a period of ti!e and increase the ris+ of infection#

&%o'a% Rationa%e:



C%ient Need *u':


)earning -ut"ome: -escri"e ongoing care of the surgical client, including suture and staple re!oval and

discharge considerations#

Question 1!

Type: MCSA

he client tells the nurse, ;I had surgery four days ago, and !y dressing has never "een changed#; What is the

nurse0s priority intervention?

1. Change the dressing i!!ediately#

2. Consult the physician#

. Call the nursing supervisor and co!plete an incident report#

!. Consult the !edical record and review the physician0s orders#





Corre"t #ns$er: 4

Rationa%e 1: he nurse should consult the physician0s orders to deter!ine how the dressing is to "e treated#ccasionally a dressing !ight "e applied that does not re5uire changing until sutures are to "e re!oved# he

nurse should return to the client and e.plain that the physician has ordered the dressing to re!ain in place#

Rationa%e 2: he nurse should consult the physician0s orders to deter!ine how the dressing is to "e treated#

ccasionally a dressing !ight "e applied that does not re5uire changing until sutures are to "e re!oved# henurse should return to the client and e.plain that the physician has ordered the dressing to re!ain in place#

Rationa%e : he nurse should consult the physician0s orders to deter!ine how the dressing is to "e treated#

ccasionally a dressing !ight "e applied that does not re5uire changing until sutures are to "e re!oved# he


Rationa%e !: he nurse should consult the physician0s orders to deter!ine how the dressing is to "e treated#

ccasionally a dressing !ight "e applied that does not re5uire changing until sutures are to "e re!oved# he


&%o'a% Rationa%e:



C%ient Need *u':


)earning -ut"ome: (.plain ways that 2P&sD2>&s can provide wound care and support healing#

Question 1/

Type: MCMA

he 2P&D2>& is preparing a client for surgery# he following ite!s are reviewed with the client prior to

ad!inistration of !edications:ESelect all that applyF


1. Procedure site

2. -enture location

. 2a" results

!. G$ray results

/. *lood consent

Corre"t #ns$er: 1,',3





Rationa%e 1: he nurse verifies with the client as well as the consent for! to ensure that the surgical site isverified

Rationa%e 2: he nurse verifies with the client as well as the consent for! to ensure that the surgical site is

verified

Rationa%e : he nurse verifies with the client as well as the consent for! to ensure that the surgical site is

verified

Rationa%e !: he nurse verifies with the client as well as the consent for! to ensure that the surgical site is

verified

Rationa%e /: he nurse verifies with the client as well as the consent for! to ensure that the surgical site is

verified

&%o'a% Rationa%e:

Cogniti(e )e(e%: )nderstanding



)earning -ut"ome:

Question 10

Type: MCMA

he nurse is preparing the client for surgery# Identification of ris+ factors associated with delayed wound healing

is done during a preoperative assess!ent, and can include:ESelect all that applyF


1. -ia"etes

2. Cardiac conditions

. CP-

!. Steroid therapy

/. (pilepsy

Corre"t #ns$er: 1,4

Rationa%e 1: -ia"etes !ellitus predisposes the client to wound infection and delayed healing

Rationa%e 2: Cardiac conditions wea+en the heartH well$controlled cardiac pro"le!s generally pose !ini!aloperative ris+





Rationa%e : CP- adversely affects pul!onary function, especially when e.acer"ated "y the effects of generalanesthesiaH they also predispose clients to postoperative lung infections

Rationa%e !: Steroid therapy can delay or slow wound healingH steroid !edication needs to "e withdrawn

gradually

Rationa%e /: )ncontrolled neurologic disease such as epilepsy !ay result in sei8ures during surgery or recovery

&%o'a% Rationa%e:



C%ient Need *u':


)earning -ut"ome:

Question 1

Type: MCSA

he 2P&D2>& is preparing a client for surgery# he 2P&D2>& has the following responsi"ility with the

preoperative consent:

1. Witnessing the clients signature

2. Medicating the client prior to signing the for!

. (ncouraging the client to read a"out the procedure so it is understood

!. Signing the consent for the client who is not clear a"out the procedure

Corre"t #ns$er: 1

Rationa%e 1: he 2P&D2>& !ay witness the clients signature

Rationa%e 2: he 2P&D2>& !ay witness the clients signature

Rationa%e : he 2P&D2>& !ay witness the clients signature

Rationa%e !: he 2P&D2>& !ay witness the clients signature

&%o'a% Rationa%e:



C%ient Need *u':


)earning -ut"ome:





Question 1

Type: MCMA

Prior to the clients surgery, the nurse is responsi"le for:Select all that apply


1. Asse!"ling all !edical records

2. Scru""ing the surgical site

. 9acilitating the clients "ath or shower

!. 6aving the client void prior to anesthesia

/. %ecording vital signs

Corre"t #ns$er: /,4,3

Rationa%e 1: he nurse is responsi"le for asse!"ling pertinent records

Rationa%e 2: he nurse is responsi"le for asse!"ling pertinent records

Rationa%e : he nurse is responsi"le for asse!"ling pertinent records

Rationa%e !: he nurse is responsi"le for asse!"ling pertinent records

Rationa%e /: he nurse is responsi"le for asse!"ling pertinent records

&%o'a% Rationa%e:



C%ient Need *u':


)earning -ut"ome:

Question 19

Type: MCSA

-uring preparation for surgery, the nurse applies which of the following to facilitate venous "lood return?

1. Se5uential co!pression devices

2. 6ista!ine$receptor antihista!ines





. Anticholinergics

!. Cleansing ene!a

Corre"t #ns$er: 1

Rationa%e 1: SC-s are used to pro!ote venous return fro! the legsH they inflate and deflate plastic sleeves

wrapped around the legs to pro!ote venous flow



Rationa%e : SC-s are used to pro!ote venous return fro! the legsH they inflate and deflate plastic sleeves


Rationa%e !: SC-s are used to pro!ote venous return fro! the legsH they inflate and deflate plastic sleeves


&%o'a% Rationa%e:



C%ient Need *u':


)earning -ut"ome:

Question 23

Type: MCSA

he nurse is preparing a client for a palliative procedure# Which of the following is an appropriate description for

the nurse to use to descri"e the purpose of the surgery?

1. his procedure will esta"lish the diagnosis for further treat!ent

2. his procedure will relieve pressure on the nerve causing the pain

. his procedure will restore function fro! the previous procedure

!. his procedure will replace the !alfunctioning nerve

Corre"t #ns$er: '

Rationa%e 1: -iagnostic procedures confir! or esta"lish a diagnosis, such as a "iopsy of a !ass in a "reast

Rationa%e 2: Palliative procedures do not cure, "ut relieve or reduce pain or sy!pto!s of a disease

Rationa%e : %econstructive procedures restore function or appearance that has "een lost or reduced





Rationa%e !: ransplant surgery replaces !alfunctioning structures, such as a live transplant or hip replace!ent

&%o'a% Rationa%e:



C%ient Need *u':


)earning -ut"ome:

Question 21

Type: MCSA

he nurse is preparing a client for elective surgery# he appropriate description for this type of surgery is

1. Surgery that involves a high degree of ris+

2. Surgery that nor!ally involves little ris+

. Surgery that is perfor!ed i!!ediately to preserve function

!. Surgery that is perfor!ed to i!prove the clients life

Corre"t #ns$er: 4

Rationa%e 1: Ma<or surgery involves a high degree of ris+

Rationa%e 2: Ma<or surgery involves a high degree of ris+

Rationa%e : Ma<or surgery involves a high degree of ris+

Rationa%e !: Ma<or surgery involves a high degree of ris+

&%o'a% Rationa%e:



C%ient Need *u':


)earning -ut"ome:

Question 22

Type: MCMA

he nurse is caring for a client who had a laparoscopic cholecyctecto!y three days ago# his phase of surgery is

+nown as:ESelect all that applyF






1. Preoperative phase

2. Intraoperative phase

. Postoperative phase

!. Perioperative period

/. (!ergency phase

Corre"t #ns$er: /,4

Rationa%e 1: he preoperative phase occurs "efore surgery

Rationa%e 2: he preoperative phase occurs "efore surgery

Rationa%e : he preoperative phase occurs "efore surgery

Rationa%e !: he preoperative phase occurs "efore surgery

Rationa%e /: he preoperative phase occurs "efore surgery

&%o'a% Rationa%e:



C%ient Need *u':


)earning -ut"ome:

Question 2

Type: MCMA

he nurse is caring for a client in the preoperative phase of surgery# &ursing interventions include:ESelect all that

applyF


1. Chec+ing to "e sure ordered test results or place in the !edical record

2. Perfor!ing preoperative teaching

. Assessing vital signs and pain

!. (ncouraging deep "reathing





/. (ncouraging client to turn fro! side to side

Corre"t #ns$er: 1,'

Rationa%e 1: Preparing the clients chart with the results fro! preoperative diagnostic or screening tests and

e.a!inations is a preoperative nursing responsi"ility

Rationa%e 2: Preparing the clients chart with the results fro! preoperative diagnostic or screening tests ande.a!inations is a preoperative nursing responsi"ility

Rationa%e : Preparing the clients chart with the results fro! preoperative diagnostic or screening tests ande.a!inations is a preoperative nursing responsi"ility

Rationa%e !: Preparing the clients chart with the results fro! preoperative diagnostic or screening tests and

e.a!inations is a preoperative nursing responsi"ility

Rationa%e /: Preparing the clients chart with the results fro! preoperative diagnostic or screening tests ande.a!inations is a preoperative nursing responsi"ility

&%o'a% Rationa%e:



C%ient Need *u':


)earning -ut"ome:

Question 2!

Type: MCMA

he 2P&D2>& will "e responsi"le for collecting data on the postoperative client# Priority assess!ents include:

ESelect all that applyF


1. "serving the clients orientation to ti!e, person, and place

2. a+ing the clients vital signs every hour until the client is sta"le

. Indicators of tissue perfusion

!. Patency of drains

/. 9luid "alance

Corre"t #ns$er: 1,/,4,3





Rationa%e 1: Assessing the clients level of consciousness is a priority assess!entD this will affect the clientsrespiratory status

Rationa%e 2: Assessing the clients level of consciousness is a priority assess!entD this will affect the clients

respiratory status

Rationa%e : Assessing the clients level of consciousness is a priority assess!entD this will affect the clients

respiratory status

Rationa%e !: Assessing the clients level of consciousness is a priority assess!entD this will affect the clients

respiratory status

Rationa%e /: Assessing the clients level of consciousness is a priority assess!entD this will affect the clients

respiratory status

&%o'a% Rationa%e:




)earning -ut"ome:

Question 2/

Type: MCSA

he nurse is preparing a client for surgery# Preoperative teaching has "een shown to have which of the following

functions?

1. Increases postoperative co!plications

2. Increases the relationship "etween the nurse and the clients fa!ily

. -ecrease an.iety

!. Ma+e client aware of need for e.tended assistance

Corre"t #ns$er: /

Rationa%e 1: Preoperative teaching has "een shown to decrease postoperative co!plications

Rationa%e 2: Preoperative teaching has "een shown to decrease postoperative co!plications

Rationa%e : Preoperative teaching has "een shown to decrease postoperative co!plications

Rationa%e !: Preoperative teaching has "een shown to decrease postoperative co!plications





&%o'a% Rationa%e:



C%ient Need *u':


)earning -ut"ome:

Question 20

Type: MCMA

he nurse is preparing a client for surgery# Which of the following physical preparations instructions !ay "e

necessary to include for the client scheduled for colon surgery?ESelect all that applyF


1. Avoiding coughing

2. S+in preparation

. Avoiding food prior to surgery

!. (.plaining the procedure

/. Infor!ing client of the location of the waiting roo!

Corre"t #ns$er: ',/

Rationa%e 1: he client scheduled for colon surgery will need to cough and deep "reathe to !aintain goodo.ygenation in the postoperative period

Rationa%e 2: he client scheduled for colon surgery will need to cough and deep "reathe to !aintain goodo.ygenation in the postoperative period

Rationa%e : he client scheduled for colon surgery will need to cough and deep "reathe to !aintain good

o.ygenation in the postoperative period

Rationa%e !: he client scheduled for colon surgery will need to cough and deep "reathe to !aintain goodo.ygenation in the postoperative period

Rationa%e /: he client scheduled for colon surgery will need to cough and deep "reathe to !aintain good

o.ygenation in the postoperative period

&%o'a% Rationa%e:







C%ient Need *u':


)earning -ut"ome:

Question 2

Type: MCSA

he nurse is caring for a client scheduled for colon surgery# Appropriate infor!ation to provide the client

regarding general anesthesia includes:

1. It is ad!inistered directly to the s+in, or in<ected into a specific area

2. It produces !ini!al depression of the level of consciousness

. It allows the client to retain the a"ility to consciously !aintain a patent airway

!. It "loc+s awareness centers in the "rain

Corre"t #ns$er: 4

Rationa%e 1: %egional anesthesia, specifically topical or local anesthesias, are applied directly to the s+in or

in<ected into a specific area and is used for !inor surgical procedures

Rationa%e 2: %egional anesthesia, specifically topical or local anesthesias, are applied directly to the s+in or


Rationa%e : %egional anesthesia, specifically topical or local anesthesias, are applied directly to the s+in orin<ected into a specific area and is used for !inor surgical procedures

Rationa%e !: %egional anesthesia, specifically topical or local anesthesias, are applied directly to the s+in or


&%o'a% Rationa%e:



C%ient Need *u':


)earning -ut"ome:

Question 2

Type: MCMA

he nurse is preparing a client for surgery# Appropriate leg e.ercises to include in preoperative teaching include:







1. Alternating dorsifle.ion and plantar fle.ion

2. %aise and lower the legs alternately fro! the surface of the "ed

. %otate the an+les to right and to left

!. -iaphrag!atic e.ercises

/. Incision splinting


Rationa%e 1: his e.ercise, also +now as calf pu!ping, alternately contracts and rela.es the gastrocne!ius!uscles, and is do to decrease the li+elihood of thro!"us for!ation

Rationa%e 2: his e.ercise, also +now as calf pu!ping, alternately contracts and rela.es the gastrocne!ius

!uscles, and is do to decrease the li+elihood of thro!"us for!ation

Rationa%e : his e.ercise, also +now as calf pu!ping, alternately contracts and rela.es the gastrocne!ius


Rationa%e !: his e.ercise, also +now as calf pu!ping, alternately contracts and rela.es the gastrocne!ius


Rationa%e /: his e.ercise, also +now as calf pu!ping, alternately contracts and rela.es the gastrocne!ius


&%o'a% Rationa%e:



C%ient Need *u':


)earning -ut"ome:

Question 29

Type: MCMA

he nurse is preparing a client for "ac+ surgery# Infor!ation to include related to postoperative activity includes:



1. -eep "reathing and coughing e.ercises





2. 2eg e.ercises

. Ways to turn and !ove

!. Methods of analgesia that will "e used

/. he need to deep "reath "ut not to cough

Corre"t #ns$er: 1,',/,4

Rationa%e 1: Coughing and deep "reathing e.ercises are an i!portant part of postoperative activity

Rationa%e 2: Coughing and deep "reathing e.ercises are an i!portant part of postoperative activity

Rationa%e : Coughing and deep "reathing e.ercises are an i!portant part of postoperative activity

Rationa%e !: Coughing and deep "reathing e.ercises are an i!portant part of postoperative activity

Rationa%e /: Coughing and deep "reathing e.ercises are an i!portant part of postoperative activity

&%o'a% Rationa%e:



C%ient Need *u':


)earning -ut"ome:

Question 3Type: MCSA

he nurse is caring for a /B year old client who is 4 hours postoperative fro! general anesthesia# he clients

spouse as+s why it is i!portant for the client to cough and deep "reath# he !ost appropriate response fro! the

nurse would "e:

1. It is i!portant in order to prevent a pul!onary e!"olis!

2. It is i!portant in order to reduce the incidence of postoperative depression

. It is i!portant in order to reduce the chance of aspiration pneu!onia

!. It is i!portant in order to reduce the incidence of !ucous plugs

Corre"t #ns$er: 4

Rationa%e 1: A pul!onary e!"olis! is cause "y a "lood clot that has !oved to the lungs which "loc+s a pul!onary arteryH turning, a!"ulation, antie!"olic stoc+ings and SC-s are preventive interventions





Rationa%e 2: A pul!onary e!"olis! is cause "y a "lood clot that has !oved to the lungs which "loc+s a pul!onary arteryH turning, a!"ulation, antie!"olic stoc+ings and SC-s are preventive interventions

Rationa%e : A pul!onary e!"olis! is cause "y a "lood clot that has !oved to the lungs which "loc+s a

pul!onary arteryH turning, a!"ulation, antie!"olic stoc+ings and SC-s are preventive interventions

Rationa%e !: A pul!onary e!"olis! is cause "y a "lood clot that has !oved to the lungs which "loc+s a

pul!onary arteryH turning, a!"ulation, antie!"olic stoc+ings and SC-s are preventive interventions

&%o'a% Rationa%e:



C%ient Need *u':


)earning -ut"ome:

Question 1

Type: MCMA

he nurse is e.plaining the causes of several potential gastrointestinal co!plications of surgery to a client# Which

of the following gastrointestinal co!plications can "e prevented "y ad!inistering I> fluids instead of oral fluids

until peristalsis returns?ESelect all that applyF


1. &ausea and vo!iting

2. Constipation

. y!panites

!. Paralytic ileus

/. Infection

Corre"t #ns$er: 1,4

Rationa%e 1: &ausea and vo!iting can "e reduced or prevented if the client ta+es in I> fluids until peristalsis

returns, then ta+es in clear fluids, then full fluids, then to regular diet

Rationa%e 2: &ausea and vo!iting can "e reduced or prevented if the client ta+es in I> fluids until peristalsisreturns, then ta+es in clear fluids, then full fluids, then to regular diet

Rationa%e : &ausea and vo!iting can "e reduced or prevented if the client ta+es in I> fluids until peristalsis






Rationa%e !: &ausea and vo!iting can "e reduced or prevented if the client ta+es in I> fluids until peristalsisreturns, then ta+es in clear fluids, then full fluids, then to regular diet

Rationa%e /: &ausea and vo!iting can "e reduced or prevented if the client ta+es in I> fluids until peristalsis


&%o'a% Rationa%e:

Cogniti(e )e(e%:


C%ient Need *u':


)earning -ut"ome:

Question 2

Type: MCSA

he client calls the nurse to loo+ at his surgical wound, which has increased drainage, and has underlying tissuesvisi"le# he nurse identifies this as:

1. Wound evisceration

2. Wound infection

. Wound dehiscence

!. 6e!orrhage

Corre"t #ns$er: /

Rationa%e 1: Wound evisceration is the e.trusion of internal organs and tissues through the incision, and presents

as an opening of the incision and visi"le protrusion of organs


as an opening of the incision and visi"le protrusion of organs

Rationa%e : Wound evisceration is the e.trusion of internal organs and tissues through the incision, and presentsas an opening of the incision and visi"le protrusion of organs

Rationa%e !: Wound evisceration is the e.trusion of internal organs and tissues through the incision, and presentsas an opening of the incision and visi"le protrusion of organs

&%o'a% Rationa%e:

Cogniti(e )e(e%:


C%ient Need *u':






)earning -ut"ome:

Question

Type: MCMA

he nurse is caring for a client who is ' days postop whose vital signs show the following: pulse of 11', "lood

pressure of B=D3', with a urine output of 13 ccDhour# Which of the following postoperative pro"le!s could presen

with those signs?ESelect all that applyF


1. )I

2. (!"olus

. 6ypovole!ia

!. 6e!orrhage

/. 6ypovole!ic shoc+


Rationa%e 1: A urinary tract infection presents clinically as cloudy andDor foul s!elling urine, with the clientco!plaining of "urning with voiding, or lower a"do!inal pain

Rationa%e 2: A urinary tract infection presents clinically as cloudy andDor foul s!elling urine, with the client

co!plaining of "urning with voiding, or lower a"do!inal pain

Rationa%e : A urinary tract infection presents clinically as cloudy andDor foul s!elling urine, with the clientco!plaining of "urning with voiding, or lower a"do!inal pain

Rationa%e !: A urinary tract infection presents clinically as cloudy andDor foul s!elling urine, with the client

co!plaining of "urning with voiding, or lower a"do!inal pain

Rationa%e /: A urinary tract infection presents clinically as cloudy andDor foul s!elling urine, with the clientco!plaining of "urning with voiding, or lower a"do!inal pain

&%o'a% Rationa%e:

Cogniti(e )e(e%:


C%ient Need *u':


)earning -ut"ome:





Question !

Type: MCMA

he nurse is assisting a client to a!"ulate on postop day 1# (arly a!"ulation helps to prevent which of the

following postoperative pro"le!s?ESelect all that applyF


1. hro!"ophle"itis

2. 6ypostatic pneu!onia

. )rinary retention

!. )rinary tract infection

/. Wound infection


Rationa%e 1: hro!"ophle"itis is prevented with early a!"ulation, leg e.ercises, antie!"olic stoc+ings, SC-s

and ade5uate fluid inta+e



Rationa%e : hro!"ophle"itis is prevented with early a!"ulation, leg e.ercises, antie!"olic stoc+ings, SC-s


Rationa%e !: hro!"ophle"itis is prevented with early a!"ulation, leg e.ercises, antie!"olic stoc+ings, SC-s


Rationa%e /: hro!"ophle"itis is prevented with early a!"ulation, leg e.ercises, antie!"olic stoc+ings, SC-sand ade5uate fluid inta+e

&%o'a% Rationa%e:

Cogniti(e )e(e%:


C%ient Need *u':Nursing+ntegrated Con"epts: &ursing Process: I!ple!entation

)earning -ut"ome:

Question /

Type: MCMA

he 2P&D2>& is preparing a client for surgery# he following ite!s are reviewed with the client prior to

ad!inistration of !edications:






1. Procedure site

2. -enture location

. 2a" results

!. G$ray results

/. *lood consent


Rationa%e 1: he nurse verifies with the client as well as the consent for! to ensure that the surgical site isverified#

Rationa%e 2: he nurse verifies with the client as well as the consent for! to ensure that the surgical site is

verified#

Rationa%e : he nurse verifies with the client as well as the consent for! to ensure that the surgical site is

verified#

Rationa%e !: he nurse verifies with the client as well as the consent for! to ensure that the surgical site is

verified#

Rationa%e /: he nurse verifies with the client as well as the consent for! to ensure that the surgical site is

verified#

&%o'a% Rationa%e:



C%ient Need *u':


)earning -ut"ome:

Question 0

Type: MCMA

he nurse is preparing the client for surgery# Identification of ris+ factors associated with delayed wound healingis done during a preoperative assess!ent, and can include:


1. -ia"etes#

2. Cardiac conditions#





. CP-#

!. Steroid therapy#

/. (pilepsy#

Corre"t #ns$er: 1,4

Rationa%e 1: -ia"etes !ellitus predisposes the client to wound infection and delayed healing#

Rationa%e 2: Cardiac conditions wea+en the heartH well$controlled cardiac pro"le!s generally pose !ini!al

operative ris+#

Rationa%e : CP- adversely affects pul!onary function, especially when e.acer"ated "y the effects of generalanesthesiaH they also predispose clients to postoperative lung infections#

Rationa%e !: Steroid therapy can delay or slow wound healingH steroid !edication needs to "e withdrawn

gradually#

Rationa%e /: )ncontrolled neurologic disease such as epilepsy can result in sei8ures during surgery or recovery#

&%o'a% Rationa%e:



C%ient Need *u':


)earning -ut"ome:

Question

Type: MCSA

he 2P&D2>& is preparing a client for surgery# he 2P&D2>& has the following responsi"ility with the

preoperative consent:

1. Witnessing the clients signature

2. Medicating the client prior to signing the for!

. (ncouraging the client to read a"out the procedure so it is understood

!. Signing the consent for the client who is not clear a"out the procedure

Corre"t #ns$er: 1

Rationa%e 1: he 2P&D2>& !ay witness the clients signature#

Rationa%e 2: he 2P&D2>& !ay witness the clients signature#





Rationa%e : he 2P&D2>& !ay witness the clients signature#

Rationa%e !: he 2P&D2>& !ay witness the clients signature#

&%o'a% Rationa%e:




)earning -ut"ome:

Question

Type: MCMA

Prior to the clients surgery, the nurse is responsi"le for:


1. Asse!"ling all !edical records#

2. Scru""ing the surgical site#

. 9acilitating the clients "ath or shower#

!. 6aving the client void prior to anesthesia#

/. %ecording vital signs#


Rationa%e 1: he nurse is responsi"le for asse!"ling pertinent records#

Rationa%e 2: he nurse is responsi"le for asse!"ling pertinent records#

Rationa%e : he nurse is responsi"le for asse!"ling pertinent records#

Rationa%e !: he nurse is responsi"le for asse!"ling pertinent records#

Rationa%e /: he nurse is responsi"le for asse!"ling pertinent records#

&%o'a% Rationa%e:



C%ient Need *u':


)earning -ut"ome:





Question 9

Type: MCSA

-uring preparation for surgery, the nurse applies which of the following to facilitate venous "lood return?

1. Se5uential co!pression devices

2. 6ista!ine$receptor antihista!ines

. Anticholinergics

!. Cleansing ene!a

Corre"t #ns$er: 1

Rationa%e 1: SC-s are used to pro!ote venous return fro! the legsH they inflate and deflate plastic sleeveswrapped around the legs to pro!ote venous flow#


wrapped around the legs to pro!ote venous flow#

Rationa%e : SC-s are used to pro!ote venous return fro! the legsH they inflate and deflate plastic sleeveswrapped around the legs to pro!ote venous flow#

Rationa%e !: SC-s are used to pro!ote venous return fro! the legsH they inflate and deflate plastic sleeves

wrapped around the legs to pro!ote venous flow#

&%o'a% Rationa%e:



C%ient Need *u':


)earning -ut"ome:

Question !3

Type: MCSA

he nurse is preparing a client for a palliative procedure# Which of the following is appropriate for the nurse to

use to descri"e the purpose of the surgery?

1. his procedure will esta"lish the diagnosis for further treat!ent#

2. his procedure will relieve pressure on the nerve causing the pain#

. his procedure will restore function fro! the previous procedure#

!. his procedure will replace the !alfunctioning nerve#





Corre"t #ns$er: '

Rationa%e 1: -iagnostic procedures confir! or esta"lish a diagnosis, such as a "iopsy of a !ass in a "reast#

Rationa%e 2: Palliative procedures do not cure "ut relieve or reduce pain or sy!pto!s of a disease#

Rationa%e : %econstructive procedures restore function or appearance that has "een lost or reduced#

Rationa%e !: ransplant surgery replaces !alfunctioning structures, as with a live transplant or hip replace!ent#

&%o'a% Rationa%e:



C%ient Need *u':


)earning -ut"ome:

Question !1

Type: MCSA

he nurse is preparing a client for elective surgery# he appropriate description for this type of surgery is:

1. Surgery that involves a high degree of ris+#

2. Surgery that nor!ally involves little ris+#

. Surgery that is perfor!ed i!!ediately to preserve function#

!. Surgery that is perfor!ed to i!prove the clients life#

Corre"t #ns$er: 4

Rationa%e 1: Ma<or surgery involves a high degree of ris+#

Rationa%e 2: Ma<or surgery involves a high degree of ris+#

Rationa%e : Ma<or surgery involves a high degree of ris+#

Rationa%e !: Ma<or surgery involves a high degree of ris+#

&%o'a% Rationa%e:

Cogniti(e )e(e%:


C%ient Need *u':


)earning -ut"ome:





Question !2

Type: MCMA

he nurse is caring for a client who had a laparoscopic cholecystecto!y / days ago# his phase of surgery is

+nown as the:


1. Preoperative phase#

2. Intraoperative phase#

. Postoperative phase#

!. Perioperative period#

/. (!ergency phase#

Corre"t #ns$er: /,4

Rationa%e 1: he preoperative phase occurs "efore surgery#

Rationa%e 2: he preoperative phase occurs "efore surgery#

Rationa%e : he preoperative phase occurs "efore surgery#

Rationa%e !: he preoperative phase occurs "efore surgery#

Rationa%e /: he preoperative phase occurs "efore surgery#

&%o'a% Rationa%e:

Cogniti(e )e(e%: nowledge


C%ient Need *u':


)earning -ut"ome:

Question !

Type: MCMAhe nurse is caring for a client in the preoperative phase of surgery# &ursing interventions include:


1. Chec+ing to "e sure ordered test results are place in the !edical record#

2. Perfor!ing preoperative teaching#





. Assessing vital signs and pain#

!. (ncouraging deep "reathing#

/. (ncouraging the client to turn fro! side to side#

Corre"t #ns$er: 1,'

Rationa%e 1: Preparing the clients chart with the results fro! preoperative diagnostic or screening tests and

e.a!inations is a preoperative nursing responsi"ility#

Rationa%e 2: Preparing the clients chart with the results fro! preoperative diagnostic or screening tests ande.a!inations is a preoperative nursing responsi"ility#

Rationa%e : Preparing the clients chart with the results fro! preoperative diagnostic or screening tests and


Rationa%e !: Preparing the clients chart with the results fro! preoperative diagnostic or screening tests and


Rationa%e /: Preparing the clients chart with the results fro! preoperative diagnostic or screening tests and


&%o'a% Rationa%e:



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Question !!

Type: MCMA

he 2P&D2>& will "e responsi"le for collecting data on the postoperative client# Priority assess!ents include:


1. "serving the clients orientation to ti!e, person, and place#

2. a+ing the clients vital signs every hour until the client is sta"le#

. Indicators of tissue perfusion#

!. Patency of drains#

/. 9luid "alance#





Corre"t #ns$er: 1,/,4,3

Rationa%e 1: Assessing the clients level of consciousness is a priority assess!entH this will affect the clientsrespiratory status#

Rationa%e 2: Assessing the clients level of consciousness is a priority assess!entH this will affect the clients

respiratory status#

Rationa%e : Assessing the clients level of consciousness is a priority assess!entH this will affect the clientsrespiratory status#

Rationa%e !: Assessing the clients level of consciousness is a priority assess!entH this will affect the clients

respiratory status#

Rationa%e /: Assessing the clients level of consciousness is a priority assess!entH this will affect the clients

respiratory status#

&%o'a% Rationa%e:



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Question !/

Type: MCSA

he nurse is preparing a client for surgery# Preoperative teaching has "een shown to have which of the following

functions?

1. Increases postoperative co!plications#

2. (nhances the relationship "etween the nurse and the clients fa!ily#

. -ecreases an.iety#

!. Ma+es the client aware of the need for e.tended assistance#

Corre"t #ns$er: /

Rationa%e 1: Preoperative teaching has "een shown to decrease postoperative co!plications#

Rationa%e 2: Preoperative teaching has "een shown to decrease postoperative co!plications#

Rationa%e : Preoperative teaching has "een shown to decrease postoperative co!plications#

Rationa%e !: Preoperative teaching has "een shown to decrease postoperative co!plications#





&%o'a% Rationa%e:



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Question !0

Type: MCMA

he nurse is preparing a client for surgery# Which of the following physical preparations instructions !ight "enecessary to include for the client scheduled for colon surgery?


1. Avoiding coughing

2. S+in preparation

. Avoiding food prior to surgery

!. (.plaining the procedure

/. Infor!ing the client of the location of the waiting roo!

Corre"t #ns$er: ',/

Rationa%e 1: he client scheduled for colon surgery will need to cough and deep$"reathe to !aintain good

o.ygenation in the postoperative period#

Rationa%e 2: he client scheduled for colon surgery will need to cough and deep$"reathe to !aintain good


Rationa%e : he client scheduled for colon surgery will need to cough and deep$"reathe to !aintain good


Rationa%e !: he client scheduled for colon surgery will need to cough and deep$"reathe to !aintain good


Rationa%e /: he client scheduled for colon surgery will need to cough and deep$"reathe to !aintain goodo.ygenation in the postoperative period#

&%o'a% Rationa%e:



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Question !

Type: MCSA

he nurse is caring for a client scheduled for colon surgery# Appropriate infor!ation to provide the client

regarding general anesthesia includes:

1. It is ad!inistered directly to the s+in, or in<ected into a specific area#

2. It produces !ini!al depression of the level of consciousness#

. It allows the client to retain the a"ility to consciously !aintain a patent airway#

!. It "loc+s awareness centers in the "rain#

Corre"t #ns$er: 4

Rationa%e 1: %egional anesthesia, specifically topical or local anesthesia, are applied directly to the s+in or

in<ected into a specific area, and is used for !inor surgical procedures#

Rationa%e 2: %egional anesthesia, specifically topical or local anesthesia, are applied directly to the s+in orin<ected into a specific area, and is used for !inor surgical procedures#

Rationa%e : %egional anesthesia, specifically topical or local anesthesia, are applied directly to the s+in or

in<ected into a specific area, and is used for !inor surgical procedures#

Rationa%e !: %egional anesthesia, specifically topical or local anesthesia, are applied directly to the s+in orin<ected into a specific area, and is used for !inor surgical procedures#

&%o'a% Rationa%e:



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Question !

Type: MCMAhe nurse is preparing a client for surgery# Appropriate leg e.ercises to include in preoperative teaching include:


1. Alternate dorsifle.ion and plantar fle.ion#

2. %aise and lower the legs alternately fro! the surface of the "ed#





. %otate the an+les to the right and to the left#

!. -iaphrag!atic e.ercises#

/. Incision splinting#


Rationa%e 1: his e.ercise, also +nown as calf pu!ping, alternately contracts and rela.es the gastrocne!ius

!uscles, and is done to decrease the li+elihood of thro!"us for!ation#

Rationa%e 2: his e.ercise, also +nown as calf pu!ping, alternately contracts and rela.es the gastrocne!ius!uscles, and is done to decrease the li+elihood of thro!"us for!ation#

Rationa%e : his e.ercise, also +nown as calf pu!ping, alternately contracts and rela.es the gastrocne!ius


Rationa%e !: his e.ercise, also +nown as calf pu!ping, alternately contracts and rela.es the gastrocne!ius


Rationa%e /: his e.ercise, also +nown as calf pu!ping, alternately contracts and rela.es the gastrocne!ius


&%o'a% Rationa%e:



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Question !9

Type: MCMA

he nurse is preparing a client for "ac+ surgery# Infor!ation to relay related to postoperative activity includes:


1. -eep "reathing and coughing e.ercises#

2. 2eg e.ercises#

. Ways to turn and !ove#

!. Methods of analgesia that will "e used#

/. he need to deep$"reathe "ut not to cough#





Corre"t #ns$er: 1,',/,4

Rationa%e 1: Coughing and deep "reathing e.ercises are i!portant parts of postoperative activity#

Rationa%e 2: Coughing and deep "reathing e.ercises are i!portant parts of postoperative activity#

Rationa%e : Coughing and deep "reathing e.ercises are i!portant parts of postoperative activity#

Rationa%e !: Coughing and deep "reathing e.ercises are i!portant parts of postoperative activity#

Rationa%e /: Coughing and deep "reathing e.ercises are i!portant parts of postoperative activity#

&%o'a% Rationa%e:



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Question /3

Type: MCSA

he nurse is caring for a /B$year$old client who is 4 hours postoperative fro! general anesthesia# he clients

spouse as+s why it is i!portant for the client to cough and deep$"reathe# he !ost appropriate response fro! the

nurse would "e:

1. It is i!portant in order to prevent a pul!onary e!"olis!#

2. It is i!portant in order to reduce the incidence of postoperative depression#

. It is i!portant in order to reduce the chance of aspiration pneu!onia#

!. It is i!portant in order to reduce the incidence of !ucous plugs#

Corre"t #ns$er: 4

Rationa%e 1: A pul!onary e!"olis! is caused "y a "lood clot that has !oved to the lungs and "loc+s a

pul!onary arteryH turning, a!"ulation, antie!"olic stoc+ings, and SC-s are preventive interventions#

Rationa%e 2: A pul!onary e!"olis! is caused "y a "lood clot that has !oved to the lungs and "loc+s a pul!onary arteryH turning, a!"ulation, antie!"olic stoc+ings, and SC-s are preventive interventions#

Rationa%e : A pul!onary e!"olis! is caused "y a "lood clot that has !oved to the lungs and "loc+s a

pul!onary arteryH turning, a!"ulation, antie!"olic stoc+ings, and SC-s are preventive interventions#

Rationa%e !: A pul!onary e!"olis! is caused "y a "lood clot that has !oved to the lungs and "loc+s a pul!onary arteryH turning, a!"ulation, antie!"olic stoc+ings, and SC-s are preventive interventions#





&%o'a% Rationa%e:



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Question /1

Type: MCMA

he nurse is e.plaining the causes of several potential gastrointestinal co!plications of surgery to a client# Whichof the following gastrointestinal co!plications can "e prevented "y ad!inistering I> fluids instead of oral fluids

until peristalsis returns?


1. &ausea and vo!iting

2. Constipation

. y!panites

!. Paralytic ileus

/. Infection

Corre"t #ns$er: 1,4

Rationa%e 1: &ausea and vo!iting can "e reduced or prevented if the client ta+es in I> fluids until peristalsisreturns, then ta+es in clear fluids, then full fluids, then returns to her regular diet#

Rationa%e 2: &ausea and vo!iting can "e reduced or prevented if the client ta+es in I> fluids until peristalsis

returns, then ta+es in clear fluids, then full fluids, then returns to her regular diet#

Rationa%e : &ausea and vo!iting can "e reduced or prevented if the client ta+es in I> fluids until peristalsisreturns, then ta+es in clear fluids, then full fluids, then returns to her regular diet#

Rationa%e !: &ausea and vo!iting can "e reduced or prevented if the client ta+es in I> fluids until peristalsis

returns, then ta+es in clear fluids, then full fluids, then returns to her regular diet#

Rationa%e /: &ausea and vo!iting can "e reduced or prevented if the client ta+es in I> fluids until peristalsisreturns, then ta+es in clear fluids, then full fluids, then returns to her regular diet#

&%o'a% Rationa%e:







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Question /2

Type: MCSA

he client calls the nurse to loo+ at his surgical wound, which has increased drainage, and has underlying tissues

visi"le# he nurse identifies this as:

1. Wound evisceration#

2. Wound infection#

. Wound dehiscence#

!. 6e!orrhage#

Corre"t #ns$er: /


as an opening of the incision and visi"le protrusion of organs#

Rationa%e 2: Wound evisceration is the e.trusion of internal organs and tissues through the incision, and presentsas an opening of the incision and visi"le protrusion of organs#

Rationa%e : Wound evisceration is the e.trusion of internal organs and tissues through the incision, and presents

as an opening of the incision and visi"le protrusion of organs#

Rationa%e !: Wound evisceration is the e.trusion of internal organs and tissues through the incision, and presentsas an opening of the incision and visi"le protrusion of organs#

&%o'a% Rationa%e:



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Question /Type: MCMA

he nurse is caring for a client who is ' days postop and whose vital signs show the following: pulse of 11', "lood pressure of B=D3', and a urine output of 13 ccDhour# Which of the following postoperative pro"le!s could

present with those signs?






1. )I

2. (!"olus

. 6ypovole!ia

!. 6e!orrhage

/. 6ypovole!ic shoc+


Rationa%e 1: A urinary tract infection presents clinically as cloudy andDor foul$s!elling urine, with the client

co!plaining of "urning with voiding, or lower a"do!inal pain#

Rationa%e 2: A urinary tract infection presents clinically as cloudy andDor foul$s!elling urine, with the client


Rationa%e : A urinary tract infection presents clinically as cloudy andDor foul$s!elling urine, with the clientco!plaining of "urning with voiding, or lower a"do!inal pain#

Rationa%e !: A urinary tract infection presents clinically as cloudy andDor foul$s!elling urine, with the clientco!plaining of "urning with voiding, or lower a"do!inal pain#

Rationa%e /: A urinary tract infection presents clinically as cloudy andDor foul$s!elling urine, with the client


&%o'a% Rationa%e:



C%ient Need *u':


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Question /!

Type: MCMA

he nurse is assisting a client to a!"ulate on postop day 1# (arly a!"ulation helps to prevent which of the

following postoperative pro"le!s?


1. hro!"ophle"itis

2. 6ypostatic pneu!onia

. )rinary retention





!. )rinary tract infection

/. Wound infection



and ade5uate fluid inta+e#



Rationa%e : hro!"ophle"itis is prevented with early a!"ulation, leg e.ercises, antie!"olic stoc+ings, SC-s


Rationa%e !: hro!"ophle"itis is prevented with early a!"ulation, leg e.ercises, antie!"olic stoc+ings, SC-s


Rationa%e /: hro!"ophle"itis is prevented with early a!"ulation, leg e.ercises, antie!"olic stoc+ings, SC-sand ade5uate fluid inta+e#

&%o'a% Rationa%e:



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Documents

Ramont2e Rev TIF Ch29