NR 443 CHAPTER 17: SURGICAL CARE
Chapter 17: Surgical Care
Linton: Introduction to Medical-Surgical Nursing, 6th Edition
MULTIPLE CHOICE
1. A postoperative patient is complaining of incisional pain. An order has been given for morphine
every 4 to 6 hours as needed (PRN). What should the nurse assess first?
a. Assess for the presence of bowel sounds.
b. Assess pupillary reaction.
c. Ask the patient’s family if she is having pain.
d. Determine when the patient last received pain medication.
ANS: D
Verifying the time of the last dose decreases the risk of a dose of medication being given too soon.
DIF: Cognitive Level: Application REF: p. 277 OBJ: 9
TOP: Acute Pain KEY: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity: Basic Care and Comfort
2. A nurse is caring for a postoperative patient. What should the nurse ask when assessing for the
complication of malignant hyperthermia?
a. “Do you think you might have a fever?”
b. “Do you currently have an infection?”
c. “Has anyone in your family ever had problems with general anesthesia?”
d. “Have you ever had any type of malignancy?”
ANS: C
Malignant hyperthermia is a life-threatening complication that occurs in response to certain drugs.
Susceptibility to this response is inherited.
DIF: Cognitive Level: Application REF: p. 268 OBJ: 7
TOP: General Anesthesia KEY: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity: Reduction of Risk
3. A patient who had a hysterectomy yesterday has not been allowed food or drink by mouth (NPO).
The physician has now ordered the patient’s diet to be clear liquids. What should the nurse assess
prior to providing this patient with clear liquids?
a. Feelings of hunger
b. Bowel sounds
c. Positive Homans sign
d. Gag reflex
ANS: B
The absence of bowel sounds would contraindicate a diet of clear liquids.
DIF: Cognitive Level: Application REF: p. 283 OBJ: 7 | 8
TOP: Postoperative Nursing Implementations
KEY: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity: Basic Care and Comfort
, 4. Which technique should a nurse implement when changing a postoperative dressing?
a. Enteric isolation
b. Aseptic technique
c. Clean technique
d. Respiratory isolation
ANS: B
The aseptic technique is important to reduce the risk of infection.
DIF: Cognitive Level: Comprehension REF: p. 281 OBJ: 9
TOP: Postoperative Risk for Infection KEY: Nursing Process Step: Planning
MSC: NCLEX: Safe, Effective Care Environment: Safety and Infection Control
5. A nurse is caring for a postoperative patient who has had spinal anesthesia. Which assessment is
a priority for this patient?
a. Complaints of a headache
b. Pulse rate of 78 beats/min
c. Voided 300 mL
d. Blood pressure of 126/78 mm Hg
ANS: A
One complication of spinal anesthesia is postspinal headache, which is caused by the leaking of
cerebrospinal fluid at the puncture site.
DIF: Cognitive Level: Application REF: p. 267 OBJ: 7
TOP: Regional Anesthesia KEY: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
6. What should a nurse ensure that a postoperative patient implement to best prevent deep vein
thrombosis (DVT)?
a. Splint the incision.
b. Cough and deep breathe every 2 hours.
c. Regularly remove antiembolism stockings.
d. Ambulate frequently.
ANS: D
DVT is best prevented by early and frequent ambulation of the patient.
DIF: Cognitive Level: Application REF: p. 272 OBJ: 7
TOP: Postoperative Complications KEY: Nursing Process Step: Planning
MSC: NCLEX: Physiological Integrity: Basic Care and Comfort
7. During a nurse’s preoperative assessment, the nurse notices that a patient is extremely anxious.
The patient’s blood pressure is 142/92 mm Hg, the heart rate is 104 beats/min, and respirations are
32 breaths/min. What nursing action should be implemented?
a. Give the preoperative medicine early to help calm the patient.
b. Call the surgical department and cancel the surgery.
c. Notify the anesthesiologist or surgeon.
d. Instruct the patient on possible postoperative complications.
ANS: C
When significant fear is associated with surgical complications, sometimes surgery is postponed
until the anxiety level is reduced.
Chapter 17: Surgical Care
Linton: Introduction to Medical-Surgical Nursing, 6th Edition
MULTIPLE CHOICE
1. A postoperative patient is complaining of incisional pain. An order has been given for morphine
every 4 to 6 hours as needed (PRN). What should the nurse assess first?
a. Assess for the presence of bowel sounds.
b. Assess pupillary reaction.
c. Ask the patient’s family if she is having pain.
d. Determine when the patient last received pain medication.
ANS: D
Verifying the time of the last dose decreases the risk of a dose of medication being given too soon.
DIF: Cognitive Level: Application REF: p. 277 OBJ: 9
TOP: Acute Pain KEY: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity: Basic Care and Comfort
2. A nurse is caring for a postoperative patient. What should the nurse ask when assessing for the
complication of malignant hyperthermia?
a. “Do you think you might have a fever?”
b. “Do you currently have an infection?”
c. “Has anyone in your family ever had problems with general anesthesia?”
d. “Have you ever had any type of malignancy?”
ANS: C
Malignant hyperthermia is a life-threatening complication that occurs in response to certain drugs.
Susceptibility to this response is inherited.
DIF: Cognitive Level: Application REF: p. 268 OBJ: 7
TOP: General Anesthesia KEY: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity: Reduction of Risk
3. A patient who had a hysterectomy yesterday has not been allowed food or drink by mouth (NPO).
The physician has now ordered the patient’s diet to be clear liquids. What should the nurse assess
prior to providing this patient with clear liquids?
a. Feelings of hunger
b. Bowel sounds
c. Positive Homans sign
d. Gag reflex
ANS: B
The absence of bowel sounds would contraindicate a diet of clear liquids.
DIF: Cognitive Level: Application REF: p. 283 OBJ: 7 | 8
TOP: Postoperative Nursing Implementations
KEY: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity: Basic Care and Comfort
, 4. Which technique should a nurse implement when changing a postoperative dressing?
a. Enteric isolation
b. Aseptic technique
c. Clean technique
d. Respiratory isolation
ANS: B
The aseptic technique is important to reduce the risk of infection.
DIF: Cognitive Level: Comprehension REF: p. 281 OBJ: 9
TOP: Postoperative Risk for Infection KEY: Nursing Process Step: Planning
MSC: NCLEX: Safe, Effective Care Environment: Safety and Infection Control
5. A nurse is caring for a postoperative patient who has had spinal anesthesia. Which assessment is
a priority for this patient?
a. Complaints of a headache
b. Pulse rate of 78 beats/min
c. Voided 300 mL
d. Blood pressure of 126/78 mm Hg
ANS: A
One complication of spinal anesthesia is postspinal headache, which is caused by the leaking of
cerebrospinal fluid at the puncture site.
DIF: Cognitive Level: Application REF: p. 267 OBJ: 7
TOP: Regional Anesthesia KEY: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
6. What should a nurse ensure that a postoperative patient implement to best prevent deep vein
thrombosis (DVT)?
a. Splint the incision.
b. Cough and deep breathe every 2 hours.
c. Regularly remove antiembolism stockings.
d. Ambulate frequently.
ANS: D
DVT is best prevented by early and frequent ambulation of the patient.
DIF: Cognitive Level: Application REF: p. 272 OBJ: 7
TOP: Postoperative Complications KEY: Nursing Process Step: Planning
MSC: NCLEX: Physiological Integrity: Basic Care and Comfort
7. During a nurse’s preoperative assessment, the nurse notices that a patient is extremely anxious.
The patient’s blood pressure is 142/92 mm Hg, the heart rate is 104 beats/min, and respirations are
32 breaths/min. What nursing action should be implemented?
a. Give the preoperative medicine early to help calm the patient.
b. Call the surgical department and cancel the surgery.
c. Notify the anesthesiologist or surgeon.
d. Instruct the patient on possible postoperative complications.
ANS: C
When significant fear is associated with surgical complications, sometimes surgery is postponed
until the anxiety level is reduced.
