Exam 1 Practice Questions: Adult 1 With Complete
Solutions
. Data obtained during the peri-operative nurse's assessment of a
patient in the preoperative holding area that would indicate a
need for special protection techniques during surgery include
a. a history of spinal and hip arthritis.
b. verbalization of anxiety by the patient.
c. a stated allergy to cats and dogs.
d. having a sip of water 2 hours previously. Correct Answers a.
history of spinal and hip arthritis
(
The patient with arthritis may require special positioning to
avoid injury and postoperative discomfort. Preoperative anxiety
and having a sip of water 2 to 3 hours before surgery are not
unusual for the preoperative patient. An allergy to cats and dogs
will not impact the care needed during the intraoperative phase.)
1.The nurse from the general surgical unit is asked to bring the
patient's hearing aid to the surgical suite. The nurse will take the
hearing aid to the
a. clean core.
b. scrub sink areas.
c. nursing station or information desk.
d. corridors of the operating room area. Correct Answers c.
nursing station or information desk
,(C. The nurse from the general unit would not be wearing
surgical scrub attire or a head covering and would be restricted
to the nursing station or information desk, which are unrestricted
areas. The clean core, scrub sink area, and corridors are semi-
restricted areas and require that staff members wear surgical
scrub attire and head coverings.)
3. A surgical patient received a volatile liquid as an inhalation
anesthetic during surgery. Postoperatively the nurse should
monitor the patient for
a. incisional pain.
b. hypertension.
c. tachypnea.
d. myoclonia. Correct Answers a. incisional pain
(Because volatile liquid inhalation agents are rapidly
metabolized, postoperative pain occurs soon after surgery.
Hypertension and tachypnea are not associated with general
anesthetics. Myoclonia may occur with nonbarbiturate hypnotics
but not with the inhaled inhalation agents.)
A 39-yr-old woman with a history of smoking and oral
contraceptive use is admitted with a venous thromboembolism
(VTE) and prescribed unfractionated heparin. What laboratory
test should the nurse review to evaluate the expected effect of
the heparin?
a. Platelet count
b. Activated clotting time (ACT)
,c. International normalized ratio (INR)
d. Activated partial thromboplastin time (APTT) Correct
Answers d. Activated partial thromboplastin time (APTT)
(Unfractionated heparin can be given by continuous IV for VTE
treatment. When given IV, heparin requires frequent laboratory
monitoring of clotting status as measured by activated partial
thromboplastin time (aPTT). Platelet counts can decrease as an
adverse reaction to heparin.)
A circulating nurse is monitoring the temperature in a surgical
suite. The nurse should identify that cool temperatures reduce a
client's risk for which of the following potential complications
of surgery?
a. malignant hyperthermia
b. blood clots
c. infection
d. hypoxia Correct Answers c. infection
(The nurse should identify that a cool room temperature with
humidity between 30% and 60%, along with a proper air
exchange and filtering system, reduces the risk of infection for
clients during surgery.)
A client had an open transverse colectomy 5 days ago. The nurse
enters the client's room and recognizes that the wound has
eviscerated. After covering the wound with a sterile, saline-
, soaked dressing, which of the following actions should the nurse
take?
a. go to the nurses' station to seek assistance
b. reinsert the organs into the abdominal cavity
c. place the client in a reverse trendelenburg position
d. obtain vital signs to assess for shock Correct Answers d.
obtain vital signs to assess for shock
(The nurse should place the client in a supine position with hips
and knees bent and the head of the bed elevated 15° to 20°. The
nurse should make no attempt to reinsert the eviscerated
contents. The nurse should stay with a client who has
experienced a wound evisceration. The nurse should press the
call light to seek assistance)
A client is transferred from the surgical suite to the PACU
following oral surgery. While monitoring the client's vital signs,
the nurse finds that the client's tongue has become swollen and
is obstructing the airway. Which of the following actions should
the nurse take first?
a. contact the anesthesiologist
b. assist with ET intubation
c. increase the client's flow of oxygen
d. use the head-tilt, chin-lift method to open the airway Correct
Answers d. use the head-tilt, chin-lift method to open the
airway
(The first action the nurse should take when using the airway,
breathing, circulation approach to client care is to establish a
Solutions
. Data obtained during the peri-operative nurse's assessment of a
patient in the preoperative holding area that would indicate a
need for special protection techniques during surgery include
a. a history of spinal and hip arthritis.
b. verbalization of anxiety by the patient.
c. a stated allergy to cats and dogs.
d. having a sip of water 2 hours previously. Correct Answers a.
history of spinal and hip arthritis
(
The patient with arthritis may require special positioning to
avoid injury and postoperative discomfort. Preoperative anxiety
and having a sip of water 2 to 3 hours before surgery are not
unusual for the preoperative patient. An allergy to cats and dogs
will not impact the care needed during the intraoperative phase.)
1.The nurse from the general surgical unit is asked to bring the
patient's hearing aid to the surgical suite. The nurse will take the
hearing aid to the
a. clean core.
b. scrub sink areas.
c. nursing station or information desk.
d. corridors of the operating room area. Correct Answers c.
nursing station or information desk
,(C. The nurse from the general unit would not be wearing
surgical scrub attire or a head covering and would be restricted
to the nursing station or information desk, which are unrestricted
areas. The clean core, scrub sink area, and corridors are semi-
restricted areas and require that staff members wear surgical
scrub attire and head coverings.)
3. A surgical patient received a volatile liquid as an inhalation
anesthetic during surgery. Postoperatively the nurse should
monitor the patient for
a. incisional pain.
b. hypertension.
c. tachypnea.
d. myoclonia. Correct Answers a. incisional pain
(Because volatile liquid inhalation agents are rapidly
metabolized, postoperative pain occurs soon after surgery.
Hypertension and tachypnea are not associated with general
anesthetics. Myoclonia may occur with nonbarbiturate hypnotics
but not with the inhaled inhalation agents.)
A 39-yr-old woman with a history of smoking and oral
contraceptive use is admitted with a venous thromboembolism
(VTE) and prescribed unfractionated heparin. What laboratory
test should the nurse review to evaluate the expected effect of
the heparin?
a. Platelet count
b. Activated clotting time (ACT)
,c. International normalized ratio (INR)
d. Activated partial thromboplastin time (APTT) Correct
Answers d. Activated partial thromboplastin time (APTT)
(Unfractionated heparin can be given by continuous IV for VTE
treatment. When given IV, heparin requires frequent laboratory
monitoring of clotting status as measured by activated partial
thromboplastin time (aPTT). Platelet counts can decrease as an
adverse reaction to heparin.)
A circulating nurse is monitoring the temperature in a surgical
suite. The nurse should identify that cool temperatures reduce a
client's risk for which of the following potential complications
of surgery?
a. malignant hyperthermia
b. blood clots
c. infection
d. hypoxia Correct Answers c. infection
(The nurse should identify that a cool room temperature with
humidity between 30% and 60%, along with a proper air
exchange and filtering system, reduces the risk of infection for
clients during surgery.)
A client had an open transverse colectomy 5 days ago. The nurse
enters the client's room and recognizes that the wound has
eviscerated. After covering the wound with a sterile, saline-
, soaked dressing, which of the following actions should the nurse
take?
a. go to the nurses' station to seek assistance
b. reinsert the organs into the abdominal cavity
c. place the client in a reverse trendelenburg position
d. obtain vital signs to assess for shock Correct Answers d.
obtain vital signs to assess for shock
(The nurse should place the client in a supine position with hips
and knees bent and the head of the bed elevated 15° to 20°. The
nurse should make no attempt to reinsert the eviscerated
contents. The nurse should stay with a client who has
experienced a wound evisceration. The nurse should press the
call light to seek assistance)
A client is transferred from the surgical suite to the PACU
following oral surgery. While monitoring the client's vital signs,
the nurse finds that the client's tongue has become swollen and
is obstructing the airway. Which of the following actions should
the nurse take first?
a. contact the anesthesiologist
b. assist with ET intubation
c. increase the client's flow of oxygen
d. use the head-tilt, chin-lift method to open the airway Correct
Answers d. use the head-tilt, chin-lift method to open the
airway
(The first action the nurse should take when using the airway,
breathing, circulation approach to client care is to establish a
