Chapter 37: Perioperative Nursing Care
Yoost & Crawford: Fundamentals of Nursing: Active Learning for Collaborative
Practice, 2nd Edition
MULTIPLE CHOICE
1. The nurse is caring for a patient who is about to have surgery. Which intervention will be
included in the patient’s care to meet the goals for risk for perioperative positioning injury
related to immobilization during surgical procedure?
a. Use adequate assistance to move patient onto the OR table.
b. Watch for early signs of hypovolemia caused by patient’s NPO status since
midnight.
c. Use therapeutic touch and guided imagery to allay patient’s fears of surgery.
d. Pad all bony prominences and avoid hyperextension of extremities.
ANS: D
Risk for perioperative positioning injury is addressed by ensuring that the patient’s skin and
bony prominences are well padded during the surgery. In addition, hyperextension of
extremities may lead to joint damage, so this should be avoided as well. The other
interventions are appropriate for perioperative care but do not relate directly to the Nursing
diagnosis of positioning injury potential.
DIF: Applying OBJ: 37.7 TOP: Planning
MSC: NCLEX Client Needs Category: Reduction of Risk Potential: Potential for Complications from
Surgical Procedures NOT: Concepts: Safety
2. The nurse is caring for a male patient who is having open heart surgery. The patient’s chest is
covered with thick hair, so the surgical technician begins to shave the patient’s skin near the
operative site. Which action by the technician requires intervention by the nurse to correct the
technique?
a. A straight safety razor and antibiotic foam is used.
b. Disposable electric trimmers are used to trim the hair.
c. Antibacterial soap is used prior to hair removal.
d. Only the hair directly around the surgical site is removed.
ANS: A
Disposable electric trimmers should be used to remove excess hair from operative sites.
Antibacterial soap is commonly used to clean the skin before surgical procedures. Only the
hair around the surgical site is removed. A straight safety razor would never be used because
small nicks in the skin can occur, increasing infection risk.
DIF: Remembering OBJ: 37.3 TOP: Implementation
MSC: NCLEX Client Needs Category: Safety and Infection Control: Safe Use of Equipment
NOT: Concepts: Infection
3. The nurse is caring for a patient who has just been brought to the postoperative unit following
major surgery and notes that the patient has many tubes and monitors in place. Which will the
nurse assess first?
a. The patient’s intravenous lines
b. The patient’s urinary catheter
This study source was downloaded by 100000869267694 from CourseHero.com on 10-24-2023 08:35:56 GMT -05:00
https://www.coursehero.com/file/85312511/37rtf/
, c. The patient’s nasogastric tube
d. The patient’s endotracheal tube
ANS: D
Airway maintenance and protection is the highest priority for this patient, so the nurse should
assess the endotracheal tube first to ensure that it is patent and positioned correctly. The other
tubes may be assessed afterward.
DIF: Applying OBJ: 37.5 TOP: Assessment
MSC: NCLEX Client Needs Category: Management of Care: Establishing Priorities
NOT: Concepts: Clinical Judgment
4. The nurse is caring for a patient who has a family history of reactions to general anesthesia.
Which medication will the nurse anesthetist have ready as a precautionary measure before the
patient’s surgery is started?
a. Protamine sulfate
b. Dantrolene sodium (Dantrium)
c. Activated charcoal with sorbitol
d. Folinic acid (Leucovorin)
ANS: B
Malignant hyperthermia is a dangerous anesthesia reaction caused by a genetic defect that
may be passed down via family history. Knowing this, the anesthesiologist would have
dantrolene ready as a precaution because it is a mainstay of treatment for malignant
hyperthermia. The other medications are not related.
DIF: Applying OBJ: 37.4 TOP: Implementation
MSC: NCLEX Client Needs Category: Reduction of Risk Potential: Potential for Complications from
Surgical Procedures NOT: Concepts: Clinical Judgment
5. Which action by the nurse best demonstrates accountability in the operating room?
a. Applying warm blankets when the patient reports feeling chilly
b. Holding the patient’s hand to allay anxiety before anesthesia is administered
c. Double-checking that the surgical site is clearly marked and visible after draping
d. Using calming speech with a reassuring tone of voice when speaking with the
patient
ANS: C
Accountability is accomplished by ensuring that proper precautions are taken to prevent errors
from happening. The nurse can prevent wrong-site surgery by making sure that the surgical
site is clearly marked and visible after the draping is completed. The surgeon could
inadvertently operate on the incorrect site if the markings are covered by the surgical drapes.
The other actions of the nurse are appropriate but do not demonstrate accountability and error
prevention.
DIF: Applying OBJ: 37.3 TOP: Implementation
MSC: NCLEX Client Needs Category: Safety and Infection Control: Error Prevention
NOT: Concepts: Safety
6. The nurse is caring for a patient who will be having surgery. The patient has just signed the
consent form for the operation. What does the patient’s signature indicate?
a. The patient agrees with the doctor’s diagnosis.
This study source was downloaded by 100000869267694 from CourseHero.com on 10-24-2023 08:35:56 GMT -05:00
https://www.coursehero.com/file/85312511/37rtf/
Yoost & Crawford: Fundamentals of Nursing: Active Learning for Collaborative
Practice, 2nd Edition
MULTIPLE CHOICE
1. The nurse is caring for a patient who is about to have surgery. Which intervention will be
included in the patient’s care to meet the goals for risk for perioperative positioning injury
related to immobilization during surgical procedure?
a. Use adequate assistance to move patient onto the OR table.
b. Watch for early signs of hypovolemia caused by patient’s NPO status since
midnight.
c. Use therapeutic touch and guided imagery to allay patient’s fears of surgery.
d. Pad all bony prominences and avoid hyperextension of extremities.
ANS: D
Risk for perioperative positioning injury is addressed by ensuring that the patient’s skin and
bony prominences are well padded during the surgery. In addition, hyperextension of
extremities may lead to joint damage, so this should be avoided as well. The other
interventions are appropriate for perioperative care but do not relate directly to the Nursing
diagnosis of positioning injury potential.
DIF: Applying OBJ: 37.7 TOP: Planning
MSC: NCLEX Client Needs Category: Reduction of Risk Potential: Potential for Complications from
Surgical Procedures NOT: Concepts: Safety
2. The nurse is caring for a male patient who is having open heart surgery. The patient’s chest is
covered with thick hair, so the surgical technician begins to shave the patient’s skin near the
operative site. Which action by the technician requires intervention by the nurse to correct the
technique?
a. A straight safety razor and antibiotic foam is used.
b. Disposable electric trimmers are used to trim the hair.
c. Antibacterial soap is used prior to hair removal.
d. Only the hair directly around the surgical site is removed.
ANS: A
Disposable electric trimmers should be used to remove excess hair from operative sites.
Antibacterial soap is commonly used to clean the skin before surgical procedures. Only the
hair around the surgical site is removed. A straight safety razor would never be used because
small nicks in the skin can occur, increasing infection risk.
DIF: Remembering OBJ: 37.3 TOP: Implementation
MSC: NCLEX Client Needs Category: Safety and Infection Control: Safe Use of Equipment
NOT: Concepts: Infection
3. The nurse is caring for a patient who has just been brought to the postoperative unit following
major surgery and notes that the patient has many tubes and monitors in place. Which will the
nurse assess first?
a. The patient’s intravenous lines
b. The patient’s urinary catheter
This study source was downloaded by 100000869267694 from CourseHero.com on 10-24-2023 08:35:56 GMT -05:00
https://www.coursehero.com/file/85312511/37rtf/
, c. The patient’s nasogastric tube
d. The patient’s endotracheal tube
ANS: D
Airway maintenance and protection is the highest priority for this patient, so the nurse should
assess the endotracheal tube first to ensure that it is patent and positioned correctly. The other
tubes may be assessed afterward.
DIF: Applying OBJ: 37.5 TOP: Assessment
MSC: NCLEX Client Needs Category: Management of Care: Establishing Priorities
NOT: Concepts: Clinical Judgment
4. The nurse is caring for a patient who has a family history of reactions to general anesthesia.
Which medication will the nurse anesthetist have ready as a precautionary measure before the
patient’s surgery is started?
a. Protamine sulfate
b. Dantrolene sodium (Dantrium)
c. Activated charcoal with sorbitol
d. Folinic acid (Leucovorin)
ANS: B
Malignant hyperthermia is a dangerous anesthesia reaction caused by a genetic defect that
may be passed down via family history. Knowing this, the anesthesiologist would have
dantrolene ready as a precaution because it is a mainstay of treatment for malignant
hyperthermia. The other medications are not related.
DIF: Applying OBJ: 37.4 TOP: Implementation
MSC: NCLEX Client Needs Category: Reduction of Risk Potential: Potential for Complications from
Surgical Procedures NOT: Concepts: Clinical Judgment
5. Which action by the nurse best demonstrates accountability in the operating room?
a. Applying warm blankets when the patient reports feeling chilly
b. Holding the patient’s hand to allay anxiety before anesthesia is administered
c. Double-checking that the surgical site is clearly marked and visible after draping
d. Using calming speech with a reassuring tone of voice when speaking with the
patient
ANS: C
Accountability is accomplished by ensuring that proper precautions are taken to prevent errors
from happening. The nurse can prevent wrong-site surgery by making sure that the surgical
site is clearly marked and visible after the draping is completed. The surgeon could
inadvertently operate on the incorrect site if the markings are covered by the surgical drapes.
The other actions of the nurse are appropriate but do not demonstrate accountability and error
prevention.
DIF: Applying OBJ: 37.3 TOP: Implementation
MSC: NCLEX Client Needs Category: Safety and Infection Control: Error Prevention
NOT: Concepts: Safety
6. The nurse is caring for a patient who will be having surgery. The patient has just signed the
consent form for the operation. What does the patient’s signature indicate?
a. The patient agrees with the doctor’s diagnosis.
This study source was downloaded by 100000869267694 from CourseHero.com on 10-24-2023 08:35:56 GMT -05:00
https://www.coursehero.com/file/85312511/37rtf/
