Intro to Perioperative - Med Surg Questions and Answers With Verified
Solutions 2025
A client had an open transverse colectomy 5 days ago. The nurse enters the client's room and recognizes
that the wound has eviscerated. After covering the wound with a sterile, saline-soaked dressing, which
of the following actions should the nurse take?
A. Go to nurses' station to seek assistance
B. Reinsert the organs into the abdominal cavity.
C. Place client in reverse Trendelenburg position
D. Obtain V/S to assess for shock. - ✔✔D. Obtain V/S to assess for shock.
Rationale: Nurse should obtain V/S to assess pts current status.
A nurse is caring for a client who is postoperative and has a Jackson-Pratt drain in place. Which of the
following interventions should the nurse use to ensure proper functioning of the drain?
A. Secure the drain to the clients bed sheet.
B. Clam the drain when the client is ambulating
C. Empty & Compress the drain reservoir as needed.
D. Keep the drain higher than the surgical incision. - ✔✔D. Keep the drain higher than the surgical
incision.
Rationale: Compressing reservoir produces suction necessary for the drain to function properly.
A nurse is completing an initial PACU assessment of a client who is postoperative following a total knee
arthroplasty and received spinal anesthesia. Which of the following findings indicates the need to notify
the provider?
A. The client states having numbness to the lower extremities bilaterally.
B. Spinal anesthesia is at the T10 level.
, C. The client rouses to tactile stimuli.
D. The client reports chest pain. - ✔✔D. The client reports chest pain.
Rationale: Patient who is postoperative following total knee arthroplasty is at risk for pulmonary
embolism. Reports of chest pain or shortness of breathe can indicate pulmonary embolism. The nurse
should report these findings to HCP immediately.
A surgical nurse enters the surgical suite to ensure surgical asepsis is maintained. Which of the following
observations requires an intervention?
A. The scrub technologist is wearing a watch under his scrubs.
B. The circulating nurse opens dressing packages before applying sterile gloves.
C. The surgeon has her hands folded 5 cm (2 inches) above the waist.
D. The holding area nurse is performing client education. - ✔✔A. The scrub technologist is wearing a
watch under his scrubs.
Rationale: Scrub technologist should remove finger and wrist jewelry, which can harbor bacteria.
A nurse is caring for a client who is postoperative. To prevent formation of thrombi in the postoperative
period, the nurse should do which of the following?
A. Change the clients position every four hours.
B. Have the client perform dorsal and plantar flexion of the feet every hour.
C. Place the client in bed with a pillow under the knees.
D. Assess pedal and posterior tibial pulses every two hours. - ✔✔B. Have the client perform dorsal and
plantar flexion of the feet every hour.
A nurse is caring for a client who is 2 days postoperative following a cholecystectomy. The client has
been vomiting for the past 24 hr and reports a pain level of 8 on a scale from 0 to 10. The nurse notes a
hard, distended abdomen and absent bowel sounds. After conferring with the provider, which of the
following actions should the nurse take first?
Solutions 2025
A client had an open transverse colectomy 5 days ago. The nurse enters the client's room and recognizes
that the wound has eviscerated. After covering the wound with a sterile, saline-soaked dressing, which
of the following actions should the nurse take?
A. Go to nurses' station to seek assistance
B. Reinsert the organs into the abdominal cavity.
C. Place client in reverse Trendelenburg position
D. Obtain V/S to assess for shock. - ✔✔D. Obtain V/S to assess for shock.
Rationale: Nurse should obtain V/S to assess pts current status.
A nurse is caring for a client who is postoperative and has a Jackson-Pratt drain in place. Which of the
following interventions should the nurse use to ensure proper functioning of the drain?
A. Secure the drain to the clients bed sheet.
B. Clam the drain when the client is ambulating
C. Empty & Compress the drain reservoir as needed.
D. Keep the drain higher than the surgical incision. - ✔✔D. Keep the drain higher than the surgical
incision.
Rationale: Compressing reservoir produces suction necessary for the drain to function properly.
A nurse is completing an initial PACU assessment of a client who is postoperative following a total knee
arthroplasty and received spinal anesthesia. Which of the following findings indicates the need to notify
the provider?
A. The client states having numbness to the lower extremities bilaterally.
B. Spinal anesthesia is at the T10 level.
, C. The client rouses to tactile stimuli.
D. The client reports chest pain. - ✔✔D. The client reports chest pain.
Rationale: Patient who is postoperative following total knee arthroplasty is at risk for pulmonary
embolism. Reports of chest pain or shortness of breathe can indicate pulmonary embolism. The nurse
should report these findings to HCP immediately.
A surgical nurse enters the surgical suite to ensure surgical asepsis is maintained. Which of the following
observations requires an intervention?
A. The scrub technologist is wearing a watch under his scrubs.
B. The circulating nurse opens dressing packages before applying sterile gloves.
C. The surgeon has her hands folded 5 cm (2 inches) above the waist.
D. The holding area nurse is performing client education. - ✔✔A. The scrub technologist is wearing a
watch under his scrubs.
Rationale: Scrub technologist should remove finger and wrist jewelry, which can harbor bacteria.
A nurse is caring for a client who is postoperative. To prevent formation of thrombi in the postoperative
period, the nurse should do which of the following?
A. Change the clients position every four hours.
B. Have the client perform dorsal and plantar flexion of the feet every hour.
C. Place the client in bed with a pillow under the knees.
D. Assess pedal and posterior tibial pulses every two hours. - ✔✔B. Have the client perform dorsal and
plantar flexion of the feet every hour.
A nurse is caring for a client who is 2 days postoperative following a cholecystectomy. The client has
been vomiting for the past 24 hr and reports a pain level of 8 on a scale from 0 to 10. The nurse notes a
hard, distended abdomen and absent bowel sounds. After conferring with the provider, which of the
following actions should the nurse take first?
